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

This is VAERS ID 942290

Case Details

VAERS ID: 942290 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Crepitations, Death, Decreased appetite, Dizziness, Dyspnoea, Fall, Hospice care, Hyperhidrosis, Lethargy, Leukaemia, Nausea, Pyrexia, SARS-CoV-2 test negative, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Haematological malignant tumours (narrow), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Influenza Virus Vaccines - Unknown date/type or brand
Other Medications: Tylenol, tylenol with codeine, Artificial Tears, ASA, Cal-Mag-Zinc, Claritin, Sertraline, Melatonin, MOM, Latuda, Estradiol, Gabapentin, Alendronate, Atorvastatin, Multi-Vit
Current Illness:
Preexisting Conditions: Glaucoma, Low back pain, restless leg syndrome, Osteoporosis, Compression Fx-Lumbar
Allergies: Dilaudid; Morphine Sulfate; Sulfonamides; Influenza Virus Vaccines
Diagnostic Lab Data: Resident has allergy to Influenza Virus Vaccines, pharmacists were informed of this prior to resident receiving the vaccine and both pharmacists stated that was not a risk factor.
CDC Split Type:

Write-up: Resident received 1st dose on 1/4/2021. On 1/6/2021 resident having SOB, increased weakness with O2 sats at 91% RA. On 8th resident sustained a fall, O2 sats 88-92, dizzy, weakness. Rapid COVID test performed with negative results. Evening of 8th resident was lethargic and diaphoretic with fever of 99.9. Resident transferred to ER, on 5lt of oxygen. Resident returned from the ER on 1/9/2021 with new diagnosis of Leukemia and orders for hospice. Continued with fever, crackles and N/V and loss of appetite from the 9th and 10th of January. Resident expired at 820am on 1/11/2021.

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