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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1055298



Case Details

VAERS ID: 1055298 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-20
Onset:2021-02-06
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute respiratory failure, Bladder catheterisation, Blood creatinine increased, Blood glucose increased, Blood lactic acid increased, Body temperature increased, COVID-19, COVID-19 pneumonia, Cardio-respiratory arrest, Chest X-ray abnormal, Computerised tomogram abdomen, Computerised tomogram head, Computerised tomogram thorax, Culture urine, Death, Differential white blood cell count, Dyspnoea, Emphysema, Fibrin D dimer increased, Full blood count, Glycosylated haemoglobin, Hypotension, Lung opacity, Metabolic function test, Myocardial necrosis marker normal, Oxygen therapy, Physical examination, Pleural effusion, Pulmonary fibrosis, SARS-CoV-2 test positive, Scan with contrast, Sepsis, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Ordered DISCHARGE PATIENTon Discharge Date: 2/12/2021 ONE TIME 02/12/21 1617 DISCHARGE PATIENTon Discharge Date: 2/12/2021 ONE TIME 02/12/21 1618 LORazepam (ATIVAN) injection 1 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 1101 LORazepam (ATIVAN) injection 1 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 1122 morphine injection 2 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 1122 Case management to consult Hospice ONE TIME, Status: Canceled 02/12/21 1144 LORazepam (ATIVAN) injection 1 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 0839 morphine injection 2 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 0839 scopolamine (TRANSDERM-SCOP) 1 mg/3 days TD patch EVERY 72 HOURS, Status: Discontinued 02/12/21 0840 morphine injection 2 mg EVERY 2 HOURS PRN, Status: Discontinued 02/12/21 0839 LORazepam (ATIVAN) injection 1 mg EVERY 2 HOURS PRN, Status: Discontinued 02/12/21 0839 Path review, smear ONE TIME, Status: Canceled 02/12/21 0610 alum & mag hydroxide-simeth (MYLANTA) 200-200-20 MG/5ML suspension 30 mL EVERY 6 HOURS PRN, Status: Discontinued 02/12/21 0528 CBC w Auto Diff TOMORROW 0500 ONCE, Status: Canceled 02/11/21 1420 Basic metabolic panel TOMORROW 0500 ONCE 02/11/21 1420 Diet type: Full Liquid, Supplements; Nutritional Supplements: Mighty Shake; Frequency: Three times per Day DIET EFFECTIVE NOW, Status: Canceled 02/11/21 0929 Comprehensive metabolic panel ONE TIME 02/11/21 0649 furosemide (LASIX) injection 40 mg ONCE 02/10/21 1337 PREPARE CONVALESCENT PLASMA, 2 Units Blood - Once 02/10/21 1232 Transfuse Convalescent Plasma , 2 Units Transfusion, Status: Canceled 02/10/21 1232 iohexol (OMNIPAQUE) 300 MG/ML injection 80 mL ONCE 02/10/21 1210 CT Head Wo Contrast RAD ONE TIME 02/10/21 1127 CT Chest For Pulmonary Embolism w Contrast RAD ONE TIME 02/10/21 1127 venlafaxine (EFFEXOR) tablet 75 mg 3 TIMES DAILY BEFORE MEALS, Status: Discontinued Note to Pharmacy: OP SIG:Take 75 mg by mouth 3 t... 02/10/21 1014 Path review, smear ONE TIME, Status: Canceled 02/10/21 0552 CBC w Auto Diff TOMORROW 0500 ONCE 02/09/21 1045 Comprehensive metabolic panel TOMORROW 0500 ONCE 02/09/21 1045 Lactic Acid, Serum TOMORROW 0500 ONCE 02/09/21 1045 Insert Foley Catheter ONE TIME, Status: Canceled 02/09/21 1347 Activity: Up in Chair 3 TIMES DAILY, Status: Canceled 02/09/21 1031 vitamin B-1 (THIAMINE) 100 mg DAILY, Status: Discontinued 02/09/21 1031 OT EVALUATE/DEVELOP POC/IMPLEMENT Reason for OT: weakness ONE TIME, Status: Canceled 02/09/21 1031 budesonide (PULMICORT) nebulizer suspension 500 mcg RT BID (RT ONLY), Status: Discontinued 02/09/21 0910 CHG Bath DAILY, Status: Canceled 02/08/21 1820 Oxygen Therapy Maintain O2 Sat at or Greater: 88% (titrate to maintain 88% or higher); Liter Per Minute: 6 LPM; Device: Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/09/21 0714 Oxygen Therapy Maintain O2 Sat at or Greater: 88% (titrate to maintain 88% or higher); Liter Per Minute: 6 LPM; Device: Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/09/21 0714 Oxygen Therapy Maintain O2 Sat at or Greater: 88% (titrate to maintain 88% or higher); Liter Per Minute: 4 LPM; Device: Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/09/21 0646 CBC W AUTO DIFF EVERY 3 DAYS, Status: Canceled Comments: Low molecular weight heparin o... 02/06/21 1711 CBC w Auto Diff TOMORROW 0500 ONCE, Status: Canceled 02/08/21 1141 Comprehensive metabolic panel TOMORROW 0500 ONCE 02/08/21 1141 Lactic Acid, Serum TOMORROW 0500 ONCE 02/08/21 1141 XR Chest 1 View RAD ONE TIME 02/08/21 2224 melatonin tablet 5 mg AT BEDTIME, Status: Discontinued 02/08/21 1129 LORazepam (ATIVAN) injection 1 mg ONCE 02/08/21 1810 INCENTIVE SPIROMETER Q2H While awake EVERY 2 HOURS WHILE AWAKE, Status: Canceled 02/08/21 1831 May use PICC Line ONE TIME, Status: Canceled 02/08/21 1820 Measure picc line every shift and document., Change Picc dressing in 24 hours from placement., Change Picc line every 7 days on Tuesday and prn. ONE TIME, Status: Canceled 02/08/21 1820 Have Consent Signed For: Picc line ONE TIME, Status: Canceled 02/08/21 1820 Obtain Consent For: PICC line ONE TIME, Status: Canceled 02/08/21 1811 Central line insertion ONE TIME, Status: Canceled 02/08/21 1811 levoFLOXacin (LEVAQUIN) IVPB 750 mg EVERY 48 HOURS, Status: Discontinued 02/08/21 1152 zinc sulfate (ZINCATE) capsule 220 mg DAILY, Status: Discontinued 02/08/21 1129 vitamin D3 tablet 2,000 Units DAILY, Status: Discontinued 02/08/21 1129 doxycycline (VIBRAMYCIN) 100 mg in dextrose 5 % 250 mL IVPB EVERY 12 HOURS, Status: Discontinued 02/08/21 1114 Diet type: Full Liquid DIET EFFECTIVE NOW, Status: Canceled 02/08/21 1110 Hemoglobin A1c ONE TIME 02/08/21 1111 ipratropium-albuterol (DUO-NEB) 0.5-2.5 (3) MG/3ML nebulizer solution 3 mL RT QID (RT ONLY), Status: Discontinued 02/08/21 1041 CBC w Auto Diff ONE TIME 02/08/21 0934 Comprehensive metabolic panel ONE TIME 02/08/21 0934 Lactic Acid, Serum ONE TIME 02/08/21 0934 iohexol (OMNIPAQUE) 300 MG/ML injection 80 mL ONCE 02/08/21 0750 CT Abdomen Pelvis W Contrast RAD ONE TIME 02/08/21 0619 remdesivir 100 mg in sodium chloride 0.9 % 100 mL infusion EVERY 24 HOURS, Status: Discontinued 02/06/21 1711 remdesivir 100 mg in sodium chloride 0.9 % 100 mL infusion EVERY 24 HOURS 02/07/21 1348 Oxygen Therapy Maintain O2 Sat at or Greater: 88%; Liter Per Minute: 5 LPM; Device: High Flow Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/07/21 1715 morphine injection 2 mg EVERY 3 HOURS PRN, Status: Discontinued 02/07/21 1011 ferrous sulfate tablet 325 mg DAILY WITH BREAKFAST, Status: Discontinued Note to Pharmacy: OP SIG:Take 325 mg by mouth da... 02/06/21 1301 Basic metabolic panel TOMORROW 0500 ONCE 02/06/21 1711 CBC with Auto Diff TOMORROW 0500 ONCE 02/06/21 1711 meperidine (DEMEROL) injection 25 mg EVERY 3 HOURS PRN, Status: Discontinued 02/07/21 0032 ipratropium-albuterol (DUO-NEB) 0.5-2.5 (3) MG/3ML nebulizer solution 3 mL EVERY 6 HOURS PRN, Status: Discontinued 02/06/21 2046 LORazepam (ATIVAN) injection 1 mg EVERY 6 HOURS PRN, Status: Discontinued 02/06/21 2046 budesonide-formoterol (SYMBICORT) 160-4.5 MCG/ACT inhaler 2 puff 2 TIMES DAILY, Status: Discontinued Note to Pharmacy: OP SIG:Inhale 2 puffs by mouth... 02/06/21 1301 alcohol (NOZIN) nasal sanitizer 2 TIMES DAILY, Status: Discontinued 02/06/21 1700 venlafaxine (EFFEXOR) tablet 75 mg 3 TIMES DAILY WITH MEALS, Status: Discontinued Note to Pharmacy: OP SIG:Take 75 mg by mouth 3 t... 02/06/21 1301
CDC Split Type:

Write-up: Emergency Room HPI: The patient is a 71 y.o. female with a PMH notable for COPD, hypertension and anxiety and depression who presented on 2/6/2021 for evaluation of shortness of breath. Patient presented to our emergency room yesterday morning from local nursing facility rehab nursing staff reported that she had had a increased shortness of breath for the last 3 days she has been diagnosed with COVID-19 on 2-2-2021. Patient has also received both COVID-19 vaccines. Patient presented to the emergency room with labored respirations conscious awake and was on a non-rebreather at 15 L. upon arrival to our emergency room patient''s temperature 101.6?, pulse 169, respirations 40 to blood pressure 142/91 and oxygen saturation 100% on 15 L non-rebreather. Patient received a chest x-ray that showed chronic emphysema and fibrotic changes in the lung no acute processes identified. Patient''s white count 12.8, glucose 197, creatinine 1.2, lactic acid 4.6, cardiac enzymes negative, D-dimer 1180, patient has urine culture pending. Patient has received about 3 L normal saline boluses patient was having hypotension 86/52. Patient also received IV acetaminophen a 1000 mg IV in the emergency room along with Decadron 10 mg IV piggyback. Patient was admitted acute care for the need of IV fluids and IV antibiotics for COVID-19 and sepsis 2/12 admit Brief history and initial physical exam: Patient is a 71 year old long-term resident of Rehab and Healthcare. Unfortunately, she contracted coronavirus (COVID-19) at the nursing home. Her respiratory status started to decompensate and so she was brought into the hospital. Initial workup showed significant bilateral pleural effusions and ground-glass opacity of both lungs. She had a significant supplemental oxygen requirement. She was admitted for further evaluation and treatment. Hospital course: The patient was admitted and started on IV Remdesivir. She was given IV Decadron. She was given immune support vitamins. Despite this, her sepsis worsened. When it became apparent that the patient was not going to recover, her daughter did make her comfort care only and hospice was consulted. The patient was found to be appropriate for general inpatient hospice and was made comfort care. Her requirement for morphine and Ativan did slowly rise. Eventually, the patient did succumb to her respiratory failure. Time of death was called at 10:00 p.m. on February 15, 2021 Discharge Condition: expired. Presume cause of death with cardiopulmonary arrest secondary to acute respiratory failure secondary to coronavirus (COVID-19) pneumonia Disposition: Deceased


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