Adverse Event Reporting

VAERS ID 1682432
Gender Male
Age 85
StateCode PA
Pharmaceutical Company PFIZER\BIONTECH
Lot Number EL9262
Number of vaccinations 1
Vaccinated 2021-01-29
Onset 2021-08-28
Condition Hospitalized Died
Symptoms
  • Confusional state
  • Pyrexia
  • Chills
  • Condition aggravated
  • Wheezing
  • Chest X-ray abnormal
  • C-reactive protein increased
  • SARS-CoV-2 test positive
  • Tachypnoea
  • Influenza A virus test negative
  • Liver function test normal
  • Influenza B virus test
  • Respiratory syncytial virus test negative
  • Influenza virus test negative
  • Productive cough
  • Procalcitonin increased
  • Thrombocytopenia
  • Mycoplasma test negative
  • Respiratory viral panel
  • Platelet transfusion
  • Troponin increased
  • Serum ferritin normal
  • COVID-19 pneumonia
  • Death
  • Lung opacity
  • Viral test negative
  • Sputum discoloured
  • General physical health deterioration
  • Blood lactate dehydrogenase increased
  • Rhonchi
  • Adenovirus test
  • Bordetella test negative
  • Chlamydia test negative
  • Enterovirus test negative
  • Human metapneumovirus test
  • Human rhinovirus test
  • Coronavirus test negative

Current Illness

Preexisting Conditions

Nervous Common migraine without aura Nicotine dependence Transient ischemic attack, posterior circulation, acute Right arm weakness Cervicalgia Left lumbar radiculopathy Left leg paresthesias Acute back pain less than 4 weeks duration Chronic back pain greater than 3 months duration Respiratory COPD, moderate Pulmonary nodule Pneumonia due to COVID-19 virus Allergic rhinitis Asthma without status asthmaticus Circulatory Benign essential hypertension Bradycardia Myocardial infarction Peripheral vascular disease Ascending aortic aneurysm Arteriosclerosis of artery of extremity Sinus pause Mobitz type II atrioventricular block Dilated aortic root Moderate concentric left ventricular hypertrophy Digestive Gastroesophageal reflux disease without esophagitis Diverticulitis of intestine Intestinal obstruction Malignant neoplasm of large intestine Colon distention Acute upper gastrointestinal hemorrhage Vitamin D deficiency Small bowel obstruction Calculus of gallbladder without cholecystitis without obstruction SBO (small bowel obstruction) Colon cancer Genitourinary Benign localized hyperplasia of prostate Calculus of kidney Acute renal failure (ARF) Musculoskeletal Degenerative joint disease of shoulder region Malignant neoplasm of skin Osteoarthritis Fracture of humerus following insertion of orthopedic implant, joint prosthesis, or bone plate, left arm Closed nondisplaced fracture of acromial end of left clavicle, initial encounter Partial tear of rotator cuff Closed fracture of neck of radius Closed supracondylar fracture of humerus Effusion of joint of hand Localized, primary osteoarthritis Onychomycosis Radial styloid tenosynovitis Interphalangeal osteoarthritis DDD (degenerative disc disease), lumbar Endocrine/Metabolic Gout Hypercholesterolemia Impaired fasting glucose Mixed hyperlipidemia Neoplasm of uncertain behavior of adrenal gland Hematologic Thrombocytopenia MDS (myelodysplastic syndrome), low grade Other Obesity (BMI 30.0-34.9) Incisional hernia Lumbosacral spinal stenosis Malignant neoplasm of rectum and anus Melanoma in situ Fall Acute alcohol intoxication History of cholecystectomy History of right shoulder replacement Tobacco user Ambulatory dysfunction Degenerative cervical spinal stenosis S/P lumbar spinal fusion Anxiety state

Other Medications

TYLENOL 325 mg tablet VENTOLIN HFA 90 mcg/actuation inhaler ZYLOPRIM 300 mg tablet aspirin 81 mg tablet LIPITOR 40 mg tablet (Expired) SYMBICORT 160-4.5 mcg/actuation inhaler VITAMIN D2 1,250 mcg (50,000 unit) capsule PEPCID 40 mg ta

Previous Vaccinations

Allergies

DigoxinDizziness / Lightheaded DoxazosinOther (document details in comments) GabapentinDizziness / Lightheaded

Laboratory Data

08/31/21 1456 Respiratory virus detection panel Collected: 08/31/21 1356 | 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 DetectedCritical 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 Procedure Component Value Ref Range Date/Time X-ray chest 1 view, portable - STAT Resulted: 09/01/21 1529 Order Status: Completed Updated: 09/01/21 1529 Narrative: XR CHEST 1 VW PORT IMPRESSION: Stable-to-slightly worsened mild-to-mild/moderate multifocal bilateral COVID-19 pneumonia.
END OF IMPRESSION: INDICATION: Pneumonia, unresolved Pneumonia, unresolved.
TECHNIQUE: Upright AP portable chest.
COMPARISON: 8/31/2021 FINDINGS: Multifocal bilateral airspace disease consistent with COVID-19 pneumonia -minimally more conspicuous compared to 8/31/2021.
No pleural effusion, pulmonary edema or pneumothorax; heart, mediastinum, bones and left subclavian approach CCD are grossly stable.
This report was created using Voice Recognition software.
Thank you for allowing us to participate in the care of your patient.
X-ray chest 1 view, Portable Resulted: 08/31/21 1419 Order Status: Completed Updated: 08/31/21 1420 Narrative: XR CHEST 1 VW PORT IMPRESSION: Multifocal opacities within the lungs concerning for pneumonia.
END OF IMPRESSION: INDICATION: wheezing, productive cough, rhonchi.
TECHNIQUE: AP portable chest.
COMPARISON: 4/26/2021 FINDINGS: Multifocal airspace opacities are identified notably in the right perihilar region and left lung base concerning for pneumonia.
No pleural effusion or pneumothorax.
Heart size appears top normal.
Stable dual-lead pacemaker.
No pneumothorax is identified.
No acute bony abnormalities.
Left shoulder arthroplasty is identified.

Write-up

ED to Hosp-Admission Discharged 8/31/2021 - 9/2/2021 (2 days) - DECEASED 09/02/2021 Presenting Problem/History of Present Illness/Reason for Admission Thrombocytopenia [D69.
6] History of myelodysplastic syndrome [Z86.
2] Pneumonia due to COVID-19 virus [U07.
1, J12.
82] Hospital Course Patient is an 86 yo gentleman with past medical history of MDS, on IV chemotherapy with Vidaza.
Most recent chemo was given 8/9/2021 through 8/17/2021.
He also has past medical history of GERD, HTN, BPH, asthma, thrombocytopenia, COPD, HLD, CAD, PVD, AAA, TIA, Mobitz type II AV block, LVH.
He presented to ED from infusion center on 08/31/2021.
He was there for a platelet transfusion.
He was found to have a temperature and shaking chills.
For approximately 3 days prior to admission he had been having increasing cough productive of yellow sputum.
Pt lives at nursing facility where he was possible exposed to COVID.
In the ED he was found positive for COVID 19 pneumonia.
Initially on admission pt had fever and no hypoxia.
He was not initially started on dexamethasone.
Overnight he developed fevers which steadily climbed during the day.
Blood work in the morning showed a normal ferritin, elevated crp/LDH/trop and procalcitonin, normal LFT's Mid afternoon pt became tachypnic and per nursing pt was more confused.
He was oriented to person, place and time when I examined him.
His temp increased and did not respond to tylenol.
Antibiotics were initiated due to concerns of possible bacterial pneumonia.
Repeat lab work was ordered.
I was contacted again around 6 pm that pt's temp was 106.
The call provider was contacted to see the pt at bedside.
She was already aware of the situation.
ICU was called and made aware of the pt.
They indicated that pt's condition was dire and family was updated on the pt's current status.
PT's sister who is POA was contacted and pt was made DNR/DNI.
Pt continued to decline overnight.
Pt's sister, who is also his POA was contacted that and updated that he was actively dying.
Due to COVID she declined to come into the hospital.
Patient expired at 0758 09/02/2021