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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1108474



Case Details

VAERS ID: 1108474 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac failure, Cardiac failure congestive, Confusional state, Death, Dyspnoea, General physical health deterioration, Generalised oedema, Increased upper airway secretion, Insomnia, Nausea, Pulse absent, Respiratory arrest, Tachypnoea, Unresponsive to stimuli
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient was admitted to the ER on 12/26/20 with worsening shortness of breath and was admitted to acute care services. On 12/29/20, a hospice consult was placed for end stage CHF, EF 20%. On 12/30/20, he transferred to the facility and was a DNR. On 1/7/21, he was noted to have increased secretions in throat and was given atropine gtts sublingual and ondansetron for nausea. He also had issues with insomnia and was given trials of hydroxyzine, trazodone and melatonin. Lorazepam remained on profile as well as part of hospice care. On 1/9/21, he was noted to be more confused, tachypneic and had anasarca (furosemide was ordered). Later on that same day he began to decline rapidly to the point of unresponsiveness other than to verbal stimuli and was determined to be imminent. On 1/10/21, he remained unresponsive and not able to tolerate oral meds. That same day at 1020 when nursing did rounds, he was found to be pulseless and without respirations. An autopsy was declined.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1108474

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