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

This is VAERS ID 1102443

Case Details

VAERS ID: 1102443 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Colorado  
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood lactic acid normal, Brain natriuretic peptide increased, Computerised tomogram thorax, Cough, Death, Fibrin D dimer increased, Lung opacity, Oxygen saturation decreased, Pyrexia, Troponin normal, Urine analysis normal, Vomiting
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Abilify Tablet 5 MG (ARIPiprazole), Donepezil 10 mg HCl Tablet, Finasteride 5 mg Tablet, Levothyroxine Sodium Tablet 75 MCG, Lidoderm Patch 5 % (Lidocaine), Loratadine Tablet 10 MG, MiraLax Powder (PolyethyleneGlycol 3350) 17 gram, Omeprazo
Current Illness: The resident had dementia and was requiring increase assistance. The resident had been experiencing weight loss over the past few months. The resident was medicated for chronic pain.
Preexisting Conditions: The resident was wheelchair bound and dependent on staff for care.
Allergies: Pregabalin
Diagnostic Lab Data: 2/18/2021- CTA-PE of Chest performed at the hospital. Results- no evidence of pulmonary embolism. Scattered centrilobular nodules and groundglass opacities in the right lower lobe, right middle lobe and left lower lobe. Appearance is concerning for endobronchial infectious/inflammatory process such as aspiration pneumonia. The appearance is not compatible with covid pneumonia. 2/18/2021- UA - negative 2/18/2021- D-Dimer 1.55 (High) 2/18/2021- BNP 862 (High) 2/18/2021- Troponin WNL, Lactic Acid WNL,
CDC Split Type:

Write-up: On 2/18/2021 the resident spiked a fever of 101.7 and had decrease oxygen saturation down to 86% with a cough. The resident was transferred to the ER for evaluation. Per Advanced Directives resident was not treated with antibiotics and returned to the Nursing Home on 2/19/2021. The resident had several episodes of emesis and was placed on comfort measures. He dised on 2/25/2021.

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