|
| VAERS ID: |
962716 (history) |
| Form: |
Version 2.0 |
| Age: |
62.0 |
| Sex: |
Female |
| Location: |
North Dakota |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-19 |
| Days after vaccination: | 20 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
RA / IM |
Administered by: Pharmacy Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-19
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: TRAMADOL, CHOLESTYRAMINE, DICOLFENAC SODIUM TOPICAL GEL, GABAPENTIN, TRAZODONE, LEVETIRACETAM, HYDROXYZINE HCL, FUROSEMIDE, DIVALPROEX SODIUM, ELIQUIS, LEVOTHYROXINE
Current Illness:
Preexisting Conditions:
Allergies: CEPHALEXIN, CODEINE, PENICILLIN, TETRACYCLINE
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient deceased |
|
| VAERS ID: |
962764 (history) |
| Form: |
Version 2.0 |
| Age: |
73.0 |
| Sex: |
Male |
| Location: |
Alaska |
| Vaccinated: | 2020-12-17 |
| Onset: | 2020-12-21 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / 1 |
- / IM |
Administered by: Private Purchased by: ?
Symptoms: Cardiac failure chronic,
Condition aggravated,
Death,
Ischaemic cardiomyopathy,
Pneumonia aspiration
SMQs:, Cardiac failure (narrow), Cardiomyopathy (narrow), Other ischaemic heart disease (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-23
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen suppository 650mg, polyvinyl alcohol solution 1.4%, atropine 1% ophthalmic solution, fentanyl patch 72hr 50mcg/hr, lorazepam concentrate 2mg/ml, morphine sulfate solution 20mg/ml.
Current Illness: Scrotal edema, aspiration pneumonia
Preexisting Conditions: Ischemic cardiomyopathy, congestive heart failure, hypertensive heart disease, type 2 diabetes with diabetic neuropathy, spinal stenosis with neurogenic claudication, chronic kidney disease, atrial fibrillation, COPD, venous insufficiency.
Allergies: lisinopril, seroquel, penicillins, beer
Diagnostic Lab Data: None.
CDC Split Type:
Write-up: Patient did not have any adverse reaction to the COVID vaccine, but we were asked by our health dept to submit a VAERS report since the patient died between his first and second dose. Received Pfizer Dose #1 12/17/2020. No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Date of death 12/23/2020 from aspiration pneumonia complicated by end-stage heart failure and ischemic cardiomyopathy. Death was anticipated and not sudden. |
|
| VAERS ID: |
962784 (history) |
| Form: |
Version 2.0 |
| Age: |
88.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2021-01-09 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK9231 / 1 |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: COVID-19,
Death,
Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
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: PNEUMONIA
Preexisting Conditions:
Allergies: LATEX, NATURAL RUBBER
Diagnostic Lab Data:
CDC Split Type:
Write-up: patient expired 1/15/2021; had been treated as outpatient for pneumonia, likely COVID-19 but no positive test result in December 2020. PMH diabetes |
|
| VAERS ID: |
962827 (history) |
| Form: |
Version 2.0 |
| Age: |
93.0 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Asthenia,
Death,
Decreased appetite,
Fatigue,
General physical health deterioration,
Hypoglycaemia,
Lactic acidosis
SMQs:, Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Guillain-Barre syndrome (broad), Hypoglycaemia (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-14
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: chronic combined CHF, diabetes mellitus, HTN, hyperlipidemia, CKD stage 3
Allergies: ATORVASTATIN; CODEINE; DOXY
Diagnostic Lab Data:
CDC Split Type:
Write-up: Admitted 1/14/21: Patient is an elderly 93-year-old female with multiple medical problems including chronic combined CHF, P 80, diabetes mellitus, HTN, hyperlipidemia, CKD stage 3, has been complaining of generalized weakness, fatigue, decreased appetite for the past few days. She had an outpatient COVID-19 vaccine earlier today. Within 2 hr of admitting the patient to the hospital, condition clinically deteriorated. Patient elected to be DNR/DNI while in the ED. Patient was pronounced dead at 10:30 p.m. earlier today. Preliminary cause of death: Hypoglycemia induced lactic acidosis. |
|
| VAERS ID: |
962940 (history) |
| Form: |
Version 2.0 |
| Age: |
83.0 |
| Sex: |
Male |
| Location: |
Wisconsin |
| Vaccinated: | 2021-01-20 |
| Onset: | 2021-01-20 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 2 |
UN / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Cold sweat,
Crepitations,
Death,
Dyspnoea,
Pallor,
Productive cough
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-20
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: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin
Current Illness: Unknown
Preexisting Conditions: Dementia, Diabetes, Chronic A Fib, Dyslipidemia, Depression, Osteoarthritis
Allergies: Galantamine
Diagnostic Lab Data: None
CDC Split Type:
Write-up: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt''s room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127. |
|
| VAERS ID: |
962966 (history) |
| Form: |
Version 2.0 |
| Age: |
80.0 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-16 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL3249 / 1 |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Death,
Laboratory test,
Nausea,
Pharyngeal swelling,
Syncope,
Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (narrow), Arrhythmia related investigations, signs and symptoms (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
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:
Other Medications:
Current Illness:
Preexisting Conditions: atrial fibrillation, hypertension, and hyperlipidemia
Allergies: Codeine
Diagnostic Lab Data:
CDC Split Type:
Write-up: On Saturday, 1/16/2021, Patient went to the grocery store. Upon her return, she indicated she was experiencing N/V and some throat swelling. Patient subsequently collapsed and expired before she could be brought to an emergency room. During investigation by Coroners Office, it has been reported that Patient may have gotten some takeout food while she was out. Labs are pending and the Coroners investigation is ongoing. Spouse believes that her death was caused by the vaccine. |
|
| VAERS ID: |
962995 (history) |
| Form: |
Version 2.0 |
| Age: |
61.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-15 |
| Onset: | 2021-01-19 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
030L20A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-19
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: Unknown
Preexisting Conditions: Unknown
Allergies: No known allergies.
Diagnostic Lab Data: N/A
CDC Split Type:
Write-up: No immediate reaction. Patient-reported deceased four days later on Jan. 19, 2021. As of this date cause of death is unknown to our clinic. |
|
| VAERS ID: |
963016 (history) |
| Form: |
Version 2.0 |
| Age: |
65.0 |
| Sex: |
Female |
| Location: |
Pennsylvania |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
013L20A / 1 |
LA / IM |
Administered by: Public Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
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: denied ill symtpoms at time of vaccination
Preexisting Conditions: denied
Allergies: unknown. Denied allergies on vaccine form
Diagnostic Lab Data: unknown
CDC Split Type:
Write-up: unknown. Event occurred after leaving vaccination site |
|
| VAERS ID: |
963057 (history) |
| Form: |
Version 2.0 |
| Age: |
96.0 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2021-01-09 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1283 / 1 |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Abdominal pain,
Asthenia,
Atrial fibrillation,
Azotaemia,
Bilevel positive airway pressure,
Death,
Fatigue,
General physical health deterioration,
Hypertensive urgency,
Hypoxia,
Intensive care,
Sepsis,
Urine output decreased
SMQs:, Acute renal failure (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-17
Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hypertension, hypothyroidism, emphysema, CKD 3, and history of breast cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: presented to ED 1/9/21 with abdominal pain, progressive worsening weakness and fatigue and new onset A fib with RVR likely due to hypertensive urgency . Patient progressed clinically with severe hypoxia and transferred to ICU and started on BiPAP; progressive decline with decreased urinary output with uremia likely secondary to sepsis. Concern with patient worsening clinical decline, palliative care had been consulted on end of life care. Patient expired 1/17/21 |
|
| VAERS ID: |
963235 (history) |
| Form: |
Version 2.0 |
| Age: |
94.0 |
| Sex: |
Female |
| Location: |
Texas |
| Vaccinated: | 2021-01-04 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / 1 |
LA / IM |
Administered by: Work Purchased by: ?
Symptoms: COVID-19,
Death,
Exposure to SARS-CoV-2,
SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-18
Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Klonipin, Myrbetriq, Zoloft, Carafate, Isosorbide, Allopurinol, Colace, Calcium Carbonate, Synthroid, Famotidine, Metoprolol, Losartan, Tylenol
Current Illness:
Preexisting Conditions: HTN, Depression, Atherosclerotic heart disease, GERD, Hypothyroidism, Chronic renal failure stage 3, CHF
Allergies: Lisinopril
Diagnostic Lab Data: COVID test
CDC Split Type:
Write-up: Patient diagnosed with COVID on January 9, 2021 after being exposed to family member that was under quarantine in the same household. Admitted to the hospital and was discharged on January 14, 2021 with home hospice. Patient passed away on January 18, 2021 |
|
