|
| VAERS ID: |
949523 (history) |
| Form: |
Version 2.0 |
| Age: |
61.0 |
| Sex: |
Female |
| Location: |
California |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
General physical condition abnormal,
Resuscitation,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
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: Ascorbic Acid Tablet 500 MG GT QD Multi-Vite Liquid (Multiple Vitamins-Minerals) 15 ml GT QD Famotidine Tablet 20 MG GT BID Memantine HCl Tablet 10 MG GT BID Polyethylene Glycol 3350 Kit 7gm GT QD Senna Tablet 8.6 MG (Sennosides) 2 tablets
Current Illness: None
Preexisting Conditions: History of Stroke, Diabetes Mellitus Type 2, Dementia, Dysphagia, Depression, Pressure Injuries Sacral and Left Heel
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:
Write-up: Around 00:50am on 01/15/21, C.N.A. reported that the resident looked different and not responding. Initiated Code Blue and started CPR. 911 arrived and pronounced resident dead at 1:01 am. |
|
| VAERS ID: |
949630 (history) |
| Form: |
Version 2.0 |
| Age: |
98.0 |
| Sex: |
Female |
| Location: |
Hawaii |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-03 |
| 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: Other Purchased by: ?
Symptoms: Blood pressure decreased,
Death,
Hypophagia,
Hypotension,
Hypoxia,
Oxygen therapy,
Tachypnoea
SMQs:, Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-08
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: Senna-S, cranberry pills
Current Illness: Redness to left foot about 1 week prior to vaccination that resolved a few days prior
Preexisting Conditions: Advanced Dementia, Seizure disorder, CAD, prior stroke, HTN
Allergies: Simvastatin
Diagnostic Lab Data: None as she was under hospice care
CDC Split Type:
Write-up: This patient has been under hospice care for over 2 years at the nursing home. She has had a steady decline with gradual weight loss. She was totally dependent in her care needs. She received the vaccine on 1/2/2021 as part of the facility vaccination campaign. No adverse events noted initially. On 1/3/2021 at 6:06 pm, she was noted on vital sign checks (done every 4 hours for first 72 hours after vaccination) with BP 64/52 but otherwise asymptomatic. Subsequent BP improved. On 1/4/2021 at 4:45 am, pt found with respiratory rate of 30 with otherwise normal vital signs. Tachypnea persisted, so she received liquid morphine 2.5 mg without improvement. Supplemental oxygen was applied. Tachypnea persisted. She had poor oral intake after that point had persistent tachypnea and worsening hypoxemia despite clear lungs on exam. She remained under hospice care and comfort measures were continued. No blood testing or imaging tests were done. She required increasing amounts of oxygen, became hypotensive, and died peacefully on 1/8/2021 at 7:45 pm. |
|
| VAERS ID: |
949657 (history) |
| Form: |
Version 2.0 |
| Age: |
89.0 |
| Sex: |
Male |
| Location: |
D.C. |
| 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 |
EK9231 / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death,
Posture abnormal,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
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: Xarelto ,topical lidocaine patch
Current Illness:
Preexisting Conditions: Atrial fibrillation, Congestive heart failure, Anterior ischemic optic neuropathy of right eye
Allergies: none
Diagnostic Lab Data:
CDC Split Type:
Write-up: Veteran was found by family slumped over and unresponsive at the breakfast table on 1/13/21, had expired |
|
| VAERS ID: |
949965 (history) |
| Form: |
Version 2.0 |
| Age: |
101.0 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2021-01-11 |
| Onset: | 2021-01-13 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1685 / UNK |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Blood culture negative,
Bradycardia,
Chest X-ray normal,
Culture urine negative,
Death,
Hypotension,
Hypothermia,
Laboratory test normal,
Respiratory viral panel,
Unresponsive to stimuli,
Viral test,
Viral test negative
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)
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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No cause of death found on labs/cxr including cultures (blood and urine) that are now growth to date and viral respiratory pcr that was negative.
CDC Split Type:
Write-up: Patient 101 years old, nursing home resident, received vaccine 1/11, on 1/13 found on floor without obvious trauma, unresponsive. Brought to ED and was bradycardic, hypotensive, hypothermic and refractory to aggressive medical management. No obvious cause of death found on exam or labs, cxr. Unknown if event could be related to vaccine or not. Medical Examiner accepted case although initially unknown that patient had recently received vaccine. ME updated with that information today as soon as discovered. |
|
| VAERS ID: |
950057 (history) |
| Form: |
Version 2.0 |
| Age: |
49.0 |
| Sex: |
Female |
| Location: |
Alabama |
| Vaccinated: | 2021-01-15 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
UN / IM |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (broad)
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:
Preexisting Conditions: Hydrocephalus with ventricular shunting Prior history of leukemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient suffered a cardiac arrest and was unable to give details about her symptoms. Per husband, patient did not complain of any symptoms after vaccine administration. She began seizing without warning which was complicated by cardiac arrest of uncertain etiology |
|
| VAERS ID: |
950073 (history) |
| Form: |
Version 2.0 |
| Age: |
63.0 |
| Sex: |
Male |
| Location: |
Wisconsin |
| Vaccinated: | 2021-01-15 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Body temperature increased,
Death,
Headache,
Lethargy,
Mycobacterium tuberculosis complex test negative,
Neck pain,
Respiration abnormal,
Tremor,
Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Arthritis (broad), Respiratory failure (broad), 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: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC Split Type:
Write-up: On 1/15/2021 at 1800, resident noted to be lethargic and shaking, stating "I don''t care." repeatedly. C/O head and neck pain. T100.6. Given Tylenol with no relief of pain. Order received for Aleve and administered.. Assisted to bed as usual in evening. Monitored during night shift and noted to be resting comfortably/sleeping.. Noted agonal breathing at 4:10 AM 1/16/2021 , T 99.4, Absence of vital signs at 4:15AM 1/16/21 and death pronounced at 4:40AM 1/16/21. |
|
| VAERS ID: |
950108 (history) |
| Form: |
Version 2.0 |
| Age: |
53.0 |
| Sex: |
Female |
| Location: |
Kentucky |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-12 |
| Days after vaccination: | 7 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 1 |
LA / IM |
Administered by: Public Purchased by: ?
Symptoms: Catheterisation cardiac abnormal,
Death,
Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Pt. stated she was not ill at the time of vaccination.
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:
Write-up: "Moderna COVID-19 Vaccine EUA" It has been reported to me that pt. had gone into hospital for a heart catheterization on 1/12/2021. It was found during this procedure that pt. had suffered a MI. She was release to home the following day and passed away at her residence on 1/15/2021. |
|
| VAERS ID: |
950441 (history) |
| Form: |
Version 2.0 |
| Age: |
66.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-15 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1283 / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Adjusted calcium,
Alanine aminotransferase increased,
Albumin globulin ratio,
Anion gap,
Aspartate aminotransferase increased,
Band neutrophil percentage decreased,
Basophil count normal,
Basophil percentage,
Blood albumin normal,
Blood alkaline phosphatase increased,
Blood bilirubin normal,
Blood calcium normal,
Blood chloride decreased,
Blood creatinine normal,
Blood glucose normal,
Blood magnesium increased,
Blood potassium decreased,
Blood sodium decreased,
Blood urea nitrogen/creatinine ratio,
Blood urea normal,
Carbon dioxide normal,
Cardiac arrest,
Death,
Differential white blood cell count abnormal,
Echocardiogram abnormal,
Eosinophil count normal,
Eosinophil percentage,
Full blood count abnormal,
Globulin,
Glomerular filtration rate,
Haematocrit normal,
Haemoglobin normal,
Immature granulocyte percentage increased,
Lymphocyte count normal,
Lymphocyte percentage increased,
Mean cell haemoglobin concentration decreased,
Mean cell haemoglobin normal,
Mean cell volume increased,
Mean platelet volume increased,
Mechanical ventilation,
Metabolic function test abnormal,
Monocyte count normal,
Monocyte percentage,
Neutrophil count normal,
Neutrophil percentage decreased,
Neutrophil toxic granulation present,
Platelet count normal,
Protein total normal,
Pupil fixed,
Red blood cell count normal,
Red blood cell nucleated morphology present,
Red cell distribution width normal,
Resuscitation,
Unresponsive to stimuli,
Ventricular fibrillation,
White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Agranulocytosis (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Hypokalaemia (narrow), Noninfectious myocarditis/pericarditis (broad)
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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorothiazide Toprol XL spironolactone prasugrel furosemide Vit D3 albuterol inhaler sildenafil aspirin 81mg Crestor nitroglycerin SL singulair testosterone gel levothyroxine
Current Illness: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris
Preexisting Conditions: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris lower extremity edema
Allergies: Walnuts
Diagnostic Lab Data: 1/15/2021 CBC WITH AUTO DIFF - Abnormal Result Value WBC 8.8 RBC 5.1 Hgb 15.7 Hematocrit 49.5 MCV 97.1 (*) MCH 30.8 MCHC 31.7 (*) Red Cell Distribution Width 14.3 Platelets 173 Mean Platelet Volume 11.4 COMPREHENSIVE METABOLIC PANEL - Abnormal Glucose 167 (*) Blood Urea Nitrogen 14 Creat, Serum 1.2 Sodium 134 (*) Potassium 3.1 (*) Chloride 93 (*) CO2 25 Anion Gap 16 (*) Calcium 9.9 Total Bilirubin 1.0 Alkaline Phosphatase 126 AST 62 ALT (SGPT) 41 Total Protein 6.7 Albumin 3.6 Globulin, Total 3.1 A/G Ratio 1.16 BUN/Creatinine Ratio 11.67 Corrected Calcium 10.2 eGFR $g60.00 Narrative: Specimen slightly hemolyzed, K, AST & ALK may be affected. MAGNESIUM - Abnormal Magnesium 2.4 (*) Narrative: Specimen slightly hemolyzed, Mg may be affected. DIFFERENTIAL, MANUAL - Abnormal Total Counted 100 Nucleated Red Blood Cell 1.0 Neutrophils Relative 45 Band Neutrophils Relative 0 Lymphocytes Relative 46 Monocytes Relative 5 Eosinophils Relative 1 Basophils Relative 1 Immature Granulocytes Relative 2 Neutrophils Absolute 4.0 Lymphocytes Absolute 4.0 (*) Monocytes Absolute 0.4 Eosinophils Absolute 0.1 Basophils Absolute 0.1 Toxic Granulation Present Platelet Estimate Normal
CDC Split Type:
Write-up: Pt had witnessed arrest by wife. Pt wife started CPR and called EMS. CPR started at 15:12. Continued by EMS. Pt arrived to medical center asystole with CRP in progress and ventilated via igel device. He was in refractory ventricular fibrillation and continued CPR for a total of 1 hour. At that point, we checked a bedside ultrasound which showed his heart at a standstill. He was unresponsive to verbal and tactile stimulus and had fixed unreactive pupils. He was pronounced at 16:13. |
|
| VAERS ID: |
950893 (history) |
| Form: |
Version 2.0 |
| Age: |
90.0 |
| Sex: |
Female |
| Location: |
Pennsylvania |
| Vaccinated: | 2021-01-03 |
| Onset: | 2021-01-07 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-07
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: Ask the nursing home,
Current Illness: Diabetes dementia, cll, trigeminal neuralgia
Preexisting Conditions: Diabetes dementia cll trigeminal neuralgia
Allergies: Shellfish, other
Diagnostic Lab Data: None
CDC Split Type:
Write-up: Death |
|
| VAERS ID: |
967747 (history) |
| Form: |
Version 2.0 |
| Age: |
73.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-13 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
013L20A / 1 |
LA / IM |
Administered by: Other 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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pt passed away evening of 1/13 - unknown reason currently Narrative: |
|
