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

This is VAERS ID 1152977



Case Details

VAERS ID: 1152977 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-02-23
Onset:2021-02-27
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: C-reactive protein, Cardiac murmur, Chest pain, Dyspnoea, Oxygen saturation, Troponin
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COPD; Dementia; Diabetes mellitus; Heart failure; Hypertension
Allergies:
Diagnostic Lab Data: Test Name: Souffle grade 3; Result Unstructured Data: Test Result:souffle grade 3; Test Name: CRP; Result Unstructured Data: Test Result:50; Test Name: saturatie; Test Result: 95 %; Test Name: troponine; Result Unstructured Data: Test Result:366
CDC Split Type: NLPFIZER INC2021311622

Write-up: Dyspnoea; Chest pain; This is a spontaneous report from a contactable physician downloaded from the Agency Regulatory Authority-WEB, regulatory authority number NL-LRB-00474154. A 90-year-old male patient received bnt162b2 (COMIRNATY), via an unspecified route of administration on 23Feb2021 as a single dose (at the age of 90-years-old) for covid-19 immunisation. Medical history included chronic obstructive pulmonary disease (COPD), dementia, heart failure, diabetes mellitus, and hypertension; all from an unknown date and unknown if ongoing. The patient''s concomitant medications were not reported. On 27Feb2021, the patient experienced chest pain and dyspnoea. The patient was admitted to the hospital for his dyspnoea and they could not find the cause of his dyspnoea. No diagnosis was made. The patient underwent lab tests and procedures which included cardiac murmur: souffle grade 3, c-reactive protein: 50, oxygen saturation: 95 %, and troponin: 366; all on an unspecified date. The outcome of the events was fatal. The cause of death was chest pain and dyspnoea. The patient died on 28Feb2021. It was unknown if an autopsy was performed. Case Summary and Reporter''s Comments Text: Past drug therapy BioNTech/Pfizer vaccin (Comirnaty): no Additional information ADR: the patient became increasingly dyspnoeic. Demented gentleman, copd, smoker, tendency to the cordis. Admission: PRIVACY 27Feb21. work diagnosis; copd, / dec cordis / pneumonia / acs ?? no exact diagnosis has been established. 28fb died No follow-up attempts are possible, information about lot number cannot be obtained.; Reporter''s Comments: Past drug therapy BioNTech/Pfizer vaccin (Comirnaty): no Additional information ADR: the patient became increasingly dyspnoeic. Demented gentleman, copd, smoker, tendency to the cordis. Admission: PRIVACY 27Feb21. work diagnosis; copd, / dec cordis / pneumonia / acs ?? no exact diagnosis has been established. 28fb died; Reported Cause(s) of Death: Chest pain; Dyspnoea


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