|
| VAERS ID: |
947841 (history) |
| Form: |
Version 2.0 |
| Age: |
83.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
027L20A / 1 |
RA / 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: 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: unknown.
CDC Split Type:
Write-up: Patient had no immediate effects from the vaccine, but died approximately 8 hours after receiving first dose of vaccine. |
|
| VAERS ID: |
947843 (history) |
| Form: |
Version 2.0 |
| Age: |
81.0 |
| Sex: |
Female |
| Location: |
Wisconsin |
| Vaccinated: | 2020-12-29 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 10 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
General physical health deterioration
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-10
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: Metoprolol, Ferrex, Hydroxychloroquine, Calcitriol, Fluticason,Loperamide, Levothyroxine, Famotdine, Amlodipine, ES Tylenol, Prednisone, Slow-Magnesium
Current Illness: Sepsis, Chronic Kidney Disease, A-Fib, Nonrheumatic aortic val valve stenosis, Crohn''s Disease
Preexisting Conditions: See above
Allergies: Penicillins, Estrogens, Estrogens, Conjugated, Codeine, Epen, Epinepherine, Raloxifene HCl, Warafrin, Hydrochlorothiazide, Lasix, Triamterene, Cephalexin, Sulfas, Azathioprine, Clarithromycin, Zolpidem Tartrate, Alendronate Sodium
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident began having a general decline in condition on 1/8/21 and continued to decline until her passing on 1/10/21. |
|
| VAERS ID: |
947891 (history) |
| Form: |
Version 2.0 |
| Age: |
93.0 |
| Sex: |
Male |
| Location: |
Wisconsin |
| Vaccinated: | 2020-12-29 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 10 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
RA / 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: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus, Benzapril, Metoprolol, Fluticasone, Aspirin, Tylenol, Miralax, Multiple Vitamin, Glipizide, Gabapentin, Vitamin D
Current Illness: Diabetes, Dementia, Hypercholesterolemia, Malignant Neoplasm of Pancreas, Hypertensive Chronic Kidney Disease, Athlerosclerotic Heart Disease
Preexisting Conditions: As above
Allergies: None
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident experienced an overall decline in condition on 1/8/21 and continued to decline until he passed away on 1/13/21. |
|
| VAERS ID: |
948150 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Male |
| Location: |
Ohio |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1685 / 1 |
LL / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Asthenia,
Blood pressure decreased,
Breath sounds abnormal,
Death,
Dyskinesia,
Fatigue,
Hyperhidrosis,
Incontinence,
Loss of consciousness,
Muscular weakness,
Oxygen saturation decreased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dyskinesia (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-12
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: MANTOUX; ACIDOPHILUS; ALPHA LIPOIC ACID; ASPIRIN EC; BUMETANIDE; C-GEL; ESCITALOPRAM; PROSCAR; KRILL OIL; LEVOTHYROXINE; MAGOX; K-DUR; FLOMAX; VITAMIN B-12; VITAMIN D3; LIORESAL; CALCIUM CITRATE; COCONUT OIL; CURCUMIN; PROAMATINE; PRESERVIS
Current Illness: pneumonia,
Preexisting Conditions: A-FIB; HYPERCHOLESTEROLEMIA; CKD 3; BPH; DEPRESSION; CERVICAL DISC DISORDER; SPINAL STENOSIS; BLADDER; COPD
Allergies: ibuprofen,sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:
Write-up: increase weakness and fatigue, weakness in extremities, incontinent, jerky arm movements, within first 24 hours, continue to decline sent to hospital returned weaker, within 24 hrs hours BP dropped, low pulse oximeter reading, diaphoretic, lung sounds diminished, loss consciousness and passed away. 01-12-2021 |
|
| VAERS ID: |
948164 (history) |
| Form: |
Version 2.0 |
| Age: |
77.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2021-01-06 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
02SL20A / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Abdominal pain,
Chest X-ray,
Chest pain,
Computerised tomogram,
Computerised tomogram abdomen,
Confusional state,
Decreased appetite,
Full blood count,
Headache,
Hepatic enzyme increased,
Metabolic function test
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
Days after onset: 7
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: Multivitamin, Zinc, Doxycycline, Ultram, Xanax, Pepcid, Nitroglycerin, Tylenol, Simethicone, Metoprolol Succinate ER, Loperamide, Levothyroxine,
Current Illness: UTI and Sinus infection
Preexisting Conditions: Encephalopathy, Type 2 diabetes, Morbid obesity, hypothyroidism, CKD, HTN, iron deficiency anemia, Atrial fibrillation, IBS,
Allergies:
Diagnostic Lab Data: CT- 1/14/21, chest x-ray 1/14/21 & 1/15/21, abdomen CT 1/14/21; CBC, CMP, Liver panel 1/14/21
CDC Split Type:
Write-up: Abdominal pain, Headaches, chest pain, loss of appetite, confusion, elevated liver enzymes 1/8-1/15/21 |
|
| VAERS ID: |
948181 (history) |
| Form: |
Version 2.0 |
| Age: |
89.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 0000-00-00 |
| Onset: | 0000-00-00 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Chest pain,
Death,
Heart rate irregular
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ANORA, Albuterol, Flovent, Bumex, Carvediol; omeprazole
Current Illness:
Preexisting Conditions: COPD, CHF, renal; ASCVD; MI hx
Allergies: 0
Diagnostic Lab Data:
CDC Split Type:
Write-up: Death Chest pain; irreg heart rhythm; evening of vaccine; death on toilet on 1/13/21 |
|
| VAERS ID: |
948228 (history) |
| Form: |
Version 2.0 |
| Age: |
78.0 |
| Sex: |
Male |
| Location: |
Florida |
| Vaccinated: | 2021-01-12 |
| Onset: | 2021-01-13 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL 1284 / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient reportedly expired the day following receipt of the vaccine. |
|
| VAERS ID: |
948418 (history) |
| Form: |
Version 2.0 |
| Age: |
37.0 |
| Sex: |
Female |
| Location: |
Colorado |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-12 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / UNK |
LA / IM |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK9231 / UNK |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-12
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: Received 1st Covid vaccine 12/18/2020; 2nd 1/7/2021. This patient is now deceased 1/12/2021.
Preexisting Conditions: Per patient health history: hearing loss, asthma, bronchiolitis, chronic cough, anemia, depression
Allergies: No known
Diagnostic Lab Data: Autopsy pending;
CDC Split Type:
Write-up: Expired on 1/12/2021; unknown cause of death |
|
| VAERS ID: |
948428 (history) |
| Form: |
Version 2.0 |
| Age: |
82.0 |
| Sex: |
Female |
| Location: |
Louisiana |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
041L20A / 1 |
LA / SYR |
Administered by: Pharmacy Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
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: unknown
Diagnostic Lab Data:
CDC Split Type:
Write-up: We got a call from a home health nurse Brandu Talamo, stating that the patient passed away. |
|
| VAERS ID: |
949474 (history) |
| Form: |
Version 2.0 |
| Age: |
79.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Respiratory arrest,
Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Respiratory failure (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? No
Previous Vaccinations:
Other Medications: Melatonin 3mg PO QHS Amlopidine Besylate 5mg PO QD Atorvastin Calcium 20mg PO QHS Carbidopa-Levodopa 25-100mg PO TID Multiple Vitamin 1 PO QD Senna 8.6mg PO BID Calcium-Vitamin D 600mg PO BID Metformin HCl 500mg PO BID Rivastigmine patch 9
Current Illness: None but he has History of COVID-19 previously when initially admitted to the facility.
Preexisting Conditions: Parkinson''s Disease, Diabetes Mellitus Type 2, Hyperlipidemia, Dementia, ASHD, Psychosis, Hypertension, Dysphagia, Acute Sinusitis
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:
Write-up: Resident had lunch on 01/14/21 and after lunch around 2:00pm, he vomited and stopped breathing. We coded the resident and 911 paramedics came. They pronounced him dead at 2:18pm. |
|
