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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1780455

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Case Details

VAERS ID: 1780455 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-23
Onset:2021-10-09
   Days after vaccination:200
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Deep vein thrombosis, Pulmonary embolism, Respiratory failure, Ultrasound Doppler abnormal
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), 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), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vitamin D3, Genicin, Flomax
Current Illness:
Preexisting Conditions: Chest pain, hyperlipidemia, syncope and collapse.
Allergies: NKMA
Diagnostic Lab Data: CT PE study and LLE Doppler.
CDC Split Type:

Write-up: Patient admitted to hospital with respiratory failure due to hypoxia, bilateral PE and LLE DVT.


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