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This is VAERS ID 921641

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 921641
VAERS Form:2
Age:17.0
Sex:Female
Location:New York
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Acute respiratory failure, Hypoxia, COVID-19, SARS-CoV-2 test positive

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: acetaminophen 160 mg/5 mL (5 mL) oral solution albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization budesonide 0.5 mg/2 mL suspension for nebulization Certavite-Antioxidant 18 mg-400 mcg tablet ClearLax 17 gram/dose oral powder
Current Illness: Right lung atelectasis/infiltrate with right mediastinal shift on chest x-ray (12/25) that was treated with steroids and antibiotics
Preexisting Conditions: Chronic respiratory Failure Dependence on mechanical ventilation Seizure disorder Spastic quadriplegic cerebral palsy Encephalopathy
Allergies: NKA
Diagnostic Lab Data: 1/5/21 COVID PCR result: Positive
CDC 'Split Type':

Write-up: Administered first dose of COVID19 vaccine at 1:29pm on 1/4/21. At approximately 11:00pm resident exhibited acute respiratory decompensation with very limited air entry and hypoxemia. Patient received Benadryl, steroids, epinephrine, and Duoneb without improvement. Resident was referred to the emergency room and found to be COVID positive. No fever or rash were reported.


Changed on 5/7/2021

VAERS ID: 921641 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:New York
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Acute respiratory failure, Hypoxia, COVID-19, SARS-CoV-2 test positive

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: acetaminophen 160 mg/5 mL (5 mL) oral solution albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization budesonide 0.5 mg/2 mL suspension for nebulization Certavite-Antioxidant 18 mg-400 mcg tablet ClearLax 17 gram/dose oral powder
Current Illness: Right lung atelectasis/infiltrate with right mediastinal shift on chest x-ray (12/25) that was treated with steroids and antibiotics
Preexisting Conditions: Chronic respiratory Failure Dependence on mechanical ventilation Seizure disorder Spastic quadriplegic cerebral palsy Encephalopathy
Allergies: NKA NKA
Diagnostic Lab Data: 1/5/21 COVID PCR result: Positive
CDC 'Split Type':

Write-up: Administered first dose of COVID19 vaccine at 1:29pm on 1/4/21. At approximately 11:00pm resident exhibited acute respiratory decompensation with very limited air entry and hypoxemia. Patient received Benadryl, steroids, epinephrine, and Duoneb without improvement. Resident was referred to the emergency room and found to be COVID positive. No fever or rash were reported.


Changed on 5/14/2021

VAERS ID: 921641 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:New York
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Acute respiratory failure, Hypoxia, COVID-19, SARS-CoV-2 test positive

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: acetaminophen 160 mg/5 mL (5 mL) oral solution albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization budesonide 0.5 mg/2 mL suspension for nebulization Certavite-Antioxidant 18 mg-400 mcg tablet ClearLax 17 gram/dose oral powder
Current Illness: Right lung atelectasis/infiltrate with right mediastinal shift on chest x-ray (12/25) that was treated with steroids and antibiotics
Preexisting Conditions: Chronic respiratory Failure Dependence on mechanical ventilation Seizure disorder Spastic quadriplegic cerebral palsy Encephalopathy
Allergies: NKA NKA
Diagnostic Lab Data: 1/5/21 COVID PCR result: Positive
CDC 'Split Type':

Write-up: Administered first dose of COVID19 vaccine at 1:29pm on 1/4/21. At approximately 11:00pm resident exhibited acute respiratory decompensation with very limited air entry and hypoxemia. Patient received Benadryl, steroids, epinephrine, and Duoneb without improvement. Resident was referred to the emergency room and found to be COVID positive. No fever or rash were reported.

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