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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1012703

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Case Details

VAERS ID: 1012703 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New Hampshire  
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium normal, Blood sodium normal, Blood urea increased, COVID-19, Carbon dioxide normal, Confusional state, Cough, Differential white blood cell count normal, Ear haemorrhage, Fibrin D dimer increased, Full blood count, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin normal, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Metabolic function test, Nucleated red cells, Platelet count normal, Rales, Red blood cell count decreased, Red cell distribution width normal, SARS-CoV-2 test positive, Thrombosis, Vomiting, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin Tablet 81 MG clonazePAM Tablet 0.5 MG Colace Capsule 100 MG DULoxetine HCL Furosemide Tablet 20 MG Norvasc Tablet 10 MG Potassium Chloride ER CapsulE QUEtiapine Fumarate Tablet Galantamine Hydrobromide Tablet
Current Illness: Intermittent delusional periods-followed by Generations Mental Health.1/6 Increased BLE edema, BP trending up. Acute visit with APRN, N.O. started Lasix & KCL. CBC and BMP ordered for 1/8 with elevation in BMP/Creatinine. Lasix and KCL placed on hold. On palliative services presently.
Preexisting Conditions: Alzheimer?s Disease/Depression; HTN; CAD, CKD, AAA w/o Rupture, no surgical intervention per ADPOA, Dyslipidemia, GERD.
Diagnostic Lab Data: 1/14-Covid Antigen test positive 1/14-11:49 am D-DIMER-32.33 WBC 8.71 RBC 4.55 HGB 12.9 HCT 41.4 MCV 91.0 MCH 28.4 MCHC 31.2 RDW-CV 12.6 MPV 10.1 Platelet Count 225 NRBC Automated 0.0 RDW-SD 41.7 Glucose 125 BUN 29 Creatinine 2.34 Calcium 9.4 Sodium 140 Potassium 4.2 Chloride 107 CO2 24 BUN/Creatinine Ratio 12.39 GFR 27
CDC Split Type:

Write-up: 1/14/2021-0545, blood noted left and right ear. 0715, vomited x 1. Covid Antigen positive. Acute MD visit-basilar crackles right and coughing. Increased confusion.

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