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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1759111

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Case Details

VAERS ID: 1759111 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-04-05
Onset:2021-09-13
   Days after vaccination:161
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0150 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Adenovirus test, Asymptomatic COVID-19, Bordetella test negative, COVID-19, COVID-19 pneumonia, Chlamydia test negative, Chronic kidney disease, Condition aggravated, Coronavirus test negative, Dental caries, Enterovirus test negative, Essential hypertension, Exposure to SARS-CoV-2, Haematopoietic neoplasm, Human metapneumovirus test, Human rhinovirus test, Influenza A virus test negative, Influenza B virus test, Malignant lymphoid neoplasm, Mycoplasma test negative, Pulmonary embolism, Respiratory syncytial virus test negative, Respiratory viral panel, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Embolic and thrombotic events, venous (narrow), Hypertension (narrow), Chronic kidney disease (narrow), Malignant lymphomas (narrow), Haematological malignant tumours (narrow), Haematological tumours of unspecified malignancy (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Outpatient Medications acetaminophen (TYLENOL) 325 mg tablet apixaban (ELIQUIS) 5 mg tablet aspirin 81 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 25 mcg (1,000 unit) capsule (Expired) cyanocobalamin 1,000 mcg oral tablet furo
Current Illness:
Preexisting Conditions: Non-Hospital Preop cardiovascular exam Actinic keratosis Dyslipidemia Prediabetes B-cell lymphoma (CMS/HCC) Adenomatous polyp of colon Arthritis At risk for falls Benign liver cyst Degeneration of intervertebral disc of lumbar region Diverticulosis Eczema Gynecomastia, male History of non-Hodgkin''s lymphoma History of lymphadenopathy History of hearing problem Lymphadenopathy Pancreas, cyst, true Malignant tumor of prostate (CMS/HCC) Hypokalemia Hypomagnesemia On antineoplastic chemotherapy Neoplasm of uncertain behavior of skin Chronic gout of left ankle Elevated brain natriuretic peptide (BNP) level Dyspnea on exertion Nonischemic cardiomyopathy (CMS/HCC) Abnormal nuclear cardiac imaging test Basal cell carcinoma of skin Hydronephrosis Incomplete emptying of bladder Malignant lymphoma of lymph nodes (CMS/HCC) Malignant melanoma (CMS/HCC) Squamous cell carcinoma Neoplasm of uncertain behavior of kidney Peripheral vascular disease (CMS/HCC) Squamous cell carcinoma in situ of skin Urethral stricture Parent refuses immunizations Vitamin D insufficiency Incidental pulmonary nodule, greater than or equal to 8mm Mild intermittent asthma Peripheral sensory neuropathy due to type 2 diabetes mellitus (CMS/HCC) Hearing loss of right ear due to cerumen impaction Mass of right side of neck Postnasal drip Non-traumatic rhabdomyolysis Rhabdomyolysis AKI (acute kidney injury) (CMS/HCC) SIRS (systemic inflammatory response syndrome) (CMS/HCC) Dental abscess
Allergies: LisinoprilCoughing Imdur [Isosorbide Mononitrate] LosartanDizziness / Lightheaded
Diagnostic Lab Data: Pneumonia due to COVID-19 virus 10/3/2021 - Present New Results - Lab Updated Procedure 10/02/21 1604 COVID-19 (SARS CoV-2,RNA Molecular Amplification) Collected: 10/02/21 1500 | Final result | Specimen: Swab from Nasopharynx COVID-19 SARS-CoV-2 Overall Result Detected Critical 10/02/21 1604 COVID-19 PCR - Communal Living / SNF Placement (Asymptomatic) Collected: 10/02/21 1500 | Final result | Specimen: Swab from Nasopharynx 09/13/21 1402 Respiratory virus detection panel Collected: 09/13/21 1217 | Final result | Specimen: Swab from Nasopharynx Adenovirus Not Detected Mycoplasma pneumoniae Not Detected Chlamydophila pneumoniae Not Detected Parainfluenza Not Detected COVID-19 SARS-CoV-2 Overall Result Detected Critical Enterovirus/Rhinovirus Not Detected Coronavirus Not Detected Respiratory Syncytial Virus Not Detected Influenza A Not Detected Bordetella pertussis Not Detected Influenza B Not Detected Bordetella parapertussis Not Detected Metapneumovirus Not Detected
CDC Split Type:

Write-up: Admission Current 10/3/2021 - present (1 day) medical facility Last attending ? Treatment team Pneumonia due to COVID-19 virus Principal problem Hospital Problem List Benign hypertension with CKD (chronic kidney disease) stage III (CMS/HCC) Chronic kidney disease, stage 3 (CMS/HCC) Malignant neoplasm of lymphoid, hematopoietic, and related tissue (CMS/HCC) Caries involving multiple surfaces of tooth Acute pulmonary embolism without acute cor pulmonale (CMS/HCC) Pneumonia due to COVID-19 virus


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