| VAERS ID: |
1199455 (history) |
| Form: |
Version 2.0 |
| Age: |
17.0 |
| Sex: |
Female |
| Location: |
Wisconsin |
| Vaccinated: | 2021-04-02 |
| Onset: | 2021-04-10 |
| Days after vaccination: | 8 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-04-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Chest pain,
Death,
Dyspnoea
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-10
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: fluoxetine, fesoterodine, ortho-tricyclen, oxybutynin
Current Illness: NA
Preexisting Conditions: spina bifida, spinal meningocele, VP shunt, scoliosis, neurogenic bladder, constipation
Allergies: bananas, cephalexin, kiwi, mango, pineapple, latex
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient reported difficulty breathing and chest pain; suffered cardiac arrest and death |
