|
| VAERS ID: |
952799 (history) |
| Form: |
Version 2.0 |
| Age: |
79.0 |
| Sex: |
Male |
| Location: |
Pennsylvania |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-17 |
| Days after vaccination: | 12 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK9231 / 1 |
RA / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Apnoeic attack,
Death,
Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Respiratory failure (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-17
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: On 1/17/2021 at 4:35 am resident found apneic and pulseless, at 4:40am death confirmed |
|
| VAERS ID: |
952881 (history) |
| Form: |
Version 2.0 |
| Age: |
89.0 |
| Sex: |
Male |
| Location: |
Missouri |
| Vaccinated: | 2021-01-10 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20-2A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Alanine aminotransferase normal,
Blood albumin decreased,
Blood chloride decreased,
Blood potassium normal,
Blood sodium decreased,
Blood urea normal,
Brain natriuretic peptide increased,
Carbon dioxide increased,
Death,
Dyspnoea,
Glomerular filtration rate,
Haematocrit decreased,
Haemoglobin decreased,
Lymphocyte count decreased,
Mean cell haemoglobin concentration decreased,
Mean cell haemoglobin decreased,
Neutrophil count normal,
Oedema,
Red blood cell count decreased,
Red cell distribution width increased
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasix, Timolol Maleate, Benefiber, Pravastatin, Multivitamin, Carbidopa ER 50-Levodopa 200 daily; Carbidopa ER 50-Levodopa 200 2 tabs daily, I-vite, Lactobacillus; Metoprolol Succinate; Tamsulosin, Finasteride, Oxubytynin
Current Illness: Edema, Hypokalemia, Hypertensive heart with heart failure
Preexisting Conditions: Parkinson''s Disease; COPD; Heart failure unspecified; Old myocardial infarction, Overactive bladder, Hyperlipidemia, Adult Failure to thrive, Urinary retention, Constipation unspecified, Unspecified urinary incontinence, Benign prostatic hyperplasia, other seasonal allergies rhinitis, unspecified glaucoma, mild cognitive impairment, Pressure ulcer of right heel, history of falling, dependence in wheelchair, COVID-19 on 11/23/2020
Allergies: No known allergies
Diagnostic Lab Data: RBC 3.72; HGB 9.8; HCT 32.7; MCH 26.3; MCHC 30; RDW 15.2; Neut # 7.18; Lymph # 0.97; NA 135; K 5.0; CL 97; CO2 34; BUN 11; CRT 0.76; ALB 1.9; ALT/SGPT 6; GFR $g60; BNP 415
CDC Split Type:
Write-up: Resident was seen by MD on 1/11/2021 due to increasing in edema and shortness of breath. Lasix 40 mg STAT given. New orders to get a STAT CBC, CMP, and BNP. Resident has been dependent on Oxygen since his diagnosis of COVID-19 on 11/23/2020. Labs were abnormal. Continued on the lasix 40 mgs. Resident remained short of breath with exertion and on oxygen. He was assisted to the toilet on 1/15/2021 in the morning where he subsequently passed away. |
|
| VAERS ID: |
953129 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Female |
| Location: |
Kentucky |
| Vaccinated: | 2021-01-09 |
| Onset: | 2021-01-18 |
| Days after vaccination: | 9 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K208 / 1 |
AR / IM |
Administered by: Private Purchased by: ?
Symptoms: Arthralgia,
Back pain,
Cardiac arrest,
Death,
Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-18
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known
Preexisting Conditions: hypertension; colon cancer (recovered); smoker
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:
Write-up: Patient presented to our Emergency Department via EMS in full code status; asystole. Patient expired. Per nursing, husband stated patient awoke this AM and reported pain in back between shoulders and in bilateral shoulders. Patient then went unresponsive and husband called EMS. |
|
| VAERS ID: |
953183 (history) |
| Form: |
Version 2.0 |
| Age: |
83.0 |
| Sex: |
Male |
| Location: |
Pennsylvania |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK9231 / 1 |
RA / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Oxygen saturation decreased,
Pyrexia,
Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-14
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: 1/11/21 at 8:57 Resident with fever and at 11 am saturation down to 83 O2 to 10 liters. Resident continued to decline until CTB on 1/14/2021 at 1325 |
|
| VAERS ID: |
953348 (history) |
| Form: |
Version 2.0 |
| Age: |
81.0 |
| Sex: |
Male |
| Location: |
Arkansas |
| Vaccinated: | 2020-12-22 |
| Onset: | 2020-12-24 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-14
Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Ibuprofen, Oxybutinin, Morphine Sulfate
Current Illness:
Preexisting Conditions: Chronic pain, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient was living in a nursing home with positive cases when administered. His age and chronic condition was such that he did not have time after the vaccination to avoid exposure or develop immunity. |
|
| VAERS ID: |
953590 (history) |
| Form: |
Version 2.0 |
| Age: |
82.0 |
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
LA / OT |
Administered by: Other Purchased by: ?
Symptoms: Culture negative,
Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-11
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Arthritis; Chronic kidney disease; COPD; Dementia; Diabetes mellitus; Failure to thrive; Hyperlipidemia; Metabolic encephalopathy; Weakness
Allergies:
Diagnostic Lab Data: Test Date: 20210109; Test Name: Nasal Swab; Test Result: Negative
CDC Split Type: USPFIZER INC2021025371
Write-up: resident expired; This is a spontaneous report from a contactable healthcare professional. An 82-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE; Lot number: EL0140), intramuscular in the left arm on 05Jan2021 15:00 at a single dose for COVID-19 immunization. Medical history included metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia. Known allergies was none. The patient took unspecified concomitant medication. On 11Jan2021, the resident expired. The patient underwent lab tests and procedures which included nasal swab: negative on 09Jan2021. There was no treatment given for the event. The patient died on 11Jan2021. An autopsy was not performed.; Sender''s Comments: Lacking information on the cause of patient''s demise, the Company cannot completely exclude a causal relationship between COVID 19 vaccine, BNT162B2, and patient''s death of unknown cause, as a cautionary measure and for reporting purposes. The patient''s pre-existing medical condition of metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia may have provided the contribution to the event in this 82-year-old male patient. The impacts of this report on the benefit/risk profile of the product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: resident expired |
|
| VAERS ID: |
953754 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Female |
| Location: |
New Jersey |
| Vaccinated: | 2021-01-06 |
| Onset: | 2021-01-13 |
| Days after vaccination: | 7 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK4176 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-13
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not provided by facility
Current Illness:
Preexisting Conditions: COVID-19 4/24/2020, hyperlipidemia, type 2 diabetes, generalized idiopathic epilepsy, chronic gingivitis, paranoid schizophrenia, extrapyramidal movements (G25.9), BMI 29, major depressive disorder, hypertensive heart disease, GERD
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:
Write-up: patient suddenly developed pneumonia 7 days after vaccination and died the evening of developing pneumonia |
|
| VAERS ID: |
953785 (history) |
| Form: |
Version 2.0 |
| Age: |
73.0 |
| Sex: |
Female |
| Location: |
Florida |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-16 |
| Days after vaccination: | 9 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
LA / IM |
Administered by: Pharmacy Purchased by: ?
Symptoms: Autopsy,
Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-16
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Hypersensitivity/ anaphylaxis to standard flu vaccine (egg containing) ~ 20 years ago. Of note, did tolerate FluBlok this past
Other Medications: No scheduled medications Tylenol and Zyrtec as needed
Current Illness: None
Preexisting Conditions: None Known
Allergies: Egg (anaphylaxis) Chicken
Diagnostic Lab Data: Autopsy pending
CDC Split Type:
Write-up: Death |
|
| VAERS ID: |
953858 (history) |
| Form: |
Version 2.0 |
| Age: |
76.0 |
| Sex: |
Female |
| Location: |
Tennessee |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-13 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / UNK |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
General physical health deterioration
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-13
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Seroquel, ibandronate, atenolol, Lexapro, simvastatin, acetaminophen, estradiol, famotidine, calcium citrate, antacid, donepezil, ferrous sulfate, Probiotic Pearls Complete, memantine, Antifungal cream, potassium chloride, Creon, bisacodyl
Current Illness: COVID-19, ARDS, enterocolitis, Sepsis, UTI, Acute renal failure
Preexisting Conditions: Chronic kidney disease, dementia with lewy bodies, COPD, GERD, anxiety, anemia, osteoarthritis, unspecified heart failure, paroxysmal atrial fibrillation
Allergies: nka
Diagnostic Lab Data: general decline starting 1/10/2021 - patient deceased 1/13/2021
CDC Split Type:
Write-up: patient started to decline 1/10/2021, patient seen at facility by medical professional - patient deceased 1/13/2021 |
|
| VAERS ID: |
953865 (history) |
| Form: |
Version 2.0 |
| Age: |
99.0 |
| Sex: |
Male |
| Location: |
Rhode Island |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-17 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL3246 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Breath sounds abnormal,
Death,
Hypoxia,
Pulmonary congestion,
SARS-CoV-2 test negative
SMQs:, Cardiac failure (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Infective pneumonia (broad), COVID-19 (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-17
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: FINASTERIDE 5MG QD, FAMOTIDINE 20 MG DAILY, FOLIC ACID 400 MCG QD, SENNA 8.6 DAILY
Current Illness: NONE
Preexisting Conditions: HYPOTHYROIDISM, DEMENTIA, SCHIZOPHRENIA, HTN, DYSPAGIA, INTELLECTUAL DISABILITIES, CKD MACULAR DEGENERATION
Allergies: NKA
Diagnostic Lab Data: RAPID COVID-19 TEST ON 1/17 NEGATIVE NO OTHER TESTS
CDC Split Type:
Write-up: REPORTING ONLY AS RESIDENT EXPIRED ON 1/17/2021 3 DAYS AFTER. S/S HYPOXIA/CONGESTED LUNG SOUNDS |
|
