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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1031767



Case Details

VAERS ID: 1031767 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-30
Onset:2021-01-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration pleural cavity, Confusional state, Death, Hypotension, Oxygen saturation decreased, Pleural effusion, Pneumonia, Septic shock, Staring
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Toxic-septic shock conditions (narrow), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Polyethylene Glycol 3350 Powder Calcium-Vitamin D Tablet 500-200 MG-UNIT (Calcium Carb-Cholecalciferol) Lidocaine Patch 4 % Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Melatonin Tablet 3 MG traMADol HCl Tablet 50 MG Ferrous Glucona
Current Illness: ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ESSENTIAL (PRIMARY) HYPERTENSION POLYNEUROPATHY, UNSPECIFIED GENERALIZED ANXIETY DISORDER LOCALIZED EDEMA GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS INSOMNIA, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE DYSPHAGIA, UNSPECIFIED DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED WEAKNESS MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING HYPERLIPIDEMIA, UNSPECIFIED AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OLD MYOCARDIAL INFARCTION HISTORY OF FALLING PERSONAL HISTORY OF PEPTIC ULCER DISEASE BARIATRIC SURGERY STATUS PRESENCE OF LEFT ARTIFICIAL KNEE JOINT PRESENCE OF RIGHT ARTIFICIAL SHOULDER JOINT PRESENCE OF LEFT ARTIFICIAL SHOULDER JOINT
Preexisting Conditions: ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ESSENTIAL (PRIMARY) HYPERTENSION POLYNEUROPATHY, UNSPECIFIED GENERALIZED ANXIETY DISORDER LOCALIZED EDEMA GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS INSOMNIA, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE DYSPHAGIA, UNSPECIFIED DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED WEAKNESS MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING HYPERLIPIDEMIA, UNSPECIFIED AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OLD MYOCARDIAL INFARCTION HISTORY OF FALLING PERSONAL HISTORY OF PEPTIC ULCER DISEASE BARIATRIC SURGERY STATUS PRESENCE OF LEFT ARTIFICIAL KNEE JOINT PRESENCE OF RIGHT ARTIFICIAL SHOULDER JOINT PRESENCE OF LEFT ARTIFICIAL SHOULDER JOINT
Allergies: Dilaudid
Diagnostic Lab Data: Resident hospitalized; Dx: pneumonia with septic shock. Thoracentesis for large pleural effusion performed in hospital. Resident expired on 2/4/2021.
CDC Split Type:

Write-up: 1/31/2021 12:50 Nursing Note Note Text: Res had low BP, low O2 sats, 30 breaths per minute, eyes open wide, making confused utterances. Started supplemental oxygen via NC, 2L, then 3L. Sats went up to 93% for a while, Sprvsr called. Unable to auscultate Left lung sounds. Called to update Res daughter. Called to page NP, writer went back to assess Res and O2 sats were 88%, turned O2 to 4LPM, called 911 for transport to Hospital ED. Left around 1030. NP called back afterwards, was updated. Family updated that Res was sent to Hospital ED. Note Text: Received phone call from daughter as well as information from hospital. Resident has pneumonia with septic shock. She is on abx and had thoracentesis performed for large pleural effusion. [linked]


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