|
| VAERS ID: |
924126 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Female |
| Location: |
Michigan |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-01 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-06 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-01
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: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium
Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.
Preexisting Conditions: CHF, Heart Failure, hypertension, Atrial-fibrillation, Crohns disease.
Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin
Diagnostic Lab Data: N/A
CDC Split Type:
Write-up: resident expired 1/1/2021 |
|
| VAERS ID: |
924186 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Female |
| Location: |
Michigan |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-03 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-06 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-03
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: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident expired 1/3/21 |
|
| VAERS ID: |
924456 (history) |
| Form: |
Version 2.0 |
| Age: |
85.0 |
| Sex: |
Female |
| Location: |
California |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-06 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK9231 / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Pupil fixed,
Regurgitation,
Respiratory arrest,
SARS-CoV-2 test positive,
Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-05
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: Lexapro, famotidine, Namenda, Seroquel, simvastatin, Trazodone; Tamsulosin; Docusate sodium; Polyethylene glycol; Celebrex; Acetaminophen
Current Illness: COVID-19 detected after vaccination; asymptomatic
Preexisting Conditions: Hyperlipidemia; Alzheimer''s disease; Atherosclerotic heart disease of native coronary artery w/o angina pectoris; Osteoarthritis; Major depressive disorder, single episode, unspecified; unspecified severe protein-calorie malnutrition
Allergies: No known allergies
Diagnostic Lab Data: OVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19
CDC Split Type:
Write-up: Patient did not display any obvious signs or symptoms; the vaccination was administered at approximately 10:00 AM and the patient continued throughout her day without any complaints or signs of adverse reaction. Patient was helped to bed by the nursing assistant estimated at around 9:00 PM. The facility received notification from the lab around 11:00 PM that the patient''s COVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19. When the nursing staff went to the room to check on the resident and prepare her to move to a COVID-19 care area the patient was found unresponsive, no movement, no chest rises, noted regurgitated small amount of food to mouth left side, lying on left side. Pupils non reactive. |
|
| VAERS ID: |
924464 (history) |
| Form: |
Version 2.0 |
| Age: |
61.0 |
| Sex: |
Female |
| Location: |
Iowa |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-06 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Condition aggravated,
Haemoptysis,
Lung neoplasm malignant
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Non-haematological malignant tumours (narrow), Infective pneumonia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-06
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: COPD, lung cancer
Preexisting Conditions: COPD, lung cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: coughing up blood, significant hemoptysis -- $g cardiac arrest. started day after vaccine but likely related to ongoing progression of lung cancer |
|
| VAERS ID: |
924664 (history) |
| Form: |
Version 2.0 |
| Age: |
92.0 |
| Sex: |
Female |
| Location: |
Hawaii |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-06 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
O11L20A / 1 |
LA / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Computerised tomogram abnormal,
Death,
Intracranial aneurysm,
Pulmonary oedema,
Unresponsive to stimuli,
X-ray abnormal
SMQs:, Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-06
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: Metoprolol succ ER 50mg 1 tab PO daily Omeprazole DR 20mg 1 cap PO daily Amlodipine besylate 5mg 1 tab PO daily Aspirin 81mg 1 tab PO daily Carbamazepine ER 100mg 1 tab PO TID Docusate 100mg 1 cap PO daily Multivitamin 1 tab PO daily Olmesa
Current Illness: none
Preexisting Conditions: history of stroke, hyperlipidemia, dementia, GERD, and macular degeneration
Allergies: Hydrochlorothiazide
Diagnostic Lab Data: CT scan, X ray 1/5/2021
CDC Split Type:
Write-up: At approximately, 1855, I was alerted by caregiver, resident was not responding. Per caregiver, she was doing her rounds and found resident in bed, unresponsive, mouth open, observed gurgling noises and tongue hanging out of mouth. This primary caregiver observed resident at baseline and ambulating after dinner at approximately, 1800 less than an hour prior to incident. This PCG called 911 for EMS and gave report of incident. Resident was taken to Medical Center Emergency Department. At ER, CT scan and X-ray was performed. Per report from ER RN, CT scan and x-ray revealed an intracranial aneurysm and fluid in the lungs. Per RN, resident was still unresponsive and was admitted to Medical Center for observation and comfort measures. This primary caregiver reported to RN, resident recently received the first dose of COVID-19 vaccine on 1/2/21. Primary caregiver received a call from Castle RN at 0700, resident expired at 0615. |
|
| VAERS ID: |
925154 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Female |
| Location: |
Florida |
| Vaccinated: | 2021-01-03 |
| Onset: | 2021-01-04 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / - |
Administered by: Public Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-04
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: Avorstatin Aspirin Oxycodone
Current Illness: NONE
Preexisting Conditions: COPD
Allergies: None
Diagnostic Lab Data: Hospital
CDC Split Type:
Write-up: Deceased |
|
| VAERS ID: |
925264 (history) |
| Form: |
Version 2.0 |
| Age: |
77.0 |
| Sex: |
Male |
| Location: |
Oklahoma |
| Vaccinated: | 2020-12-31 |
| Onset: | 0000-00-00 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
LA / IM |
Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-07
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norco 5/325 1 tablet every 6 hours as needed. Warfarin 4mg , 2 tablets orally Monday and Friday Torsemide 100mg, 1/2 tablet orally once a day Sabcubitril-Valsartan 24/26mg 1/4 tablet orally twice a day Gabapentin 300mg, tablet once daily Ca
Current Illness: CHF HTN DM 2 CKD Obesity DDD
Preexisting Conditions: CHF HTN DM 2 CKD Obesity DDD
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:
Write-up: PT was found deceased in his home on 1/5/2021 |
|
| VAERS ID: |
925556 (history) |
| Form: |
Version 2.0 |
| Age: |
81.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 7 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-06
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: Acute on chronic heart failure, sepsis
Preexisting Conditions: CAD, CKD, DM type 2, CHF, Hx TIA, Atrial fibrillation
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Expired 1/05/2021 |
|
| VAERS ID: |
926269 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Male |
| Location: |
Maryland |
| Vaccinated: | 2021-01-04 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Cardioversion,
Death,
Pulse absent,
Respiratory arrest,
Resuscitation,
Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-05
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: Acetaminophen Tablet 325 MG, Enulose Solution 10 GM/15ML (Lactulose Encephalopathy), HYDROcodone-Acetaminophen Tablet 5-325 MG, Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide, Potassium Chloride ER Tablet Extended Release 20 ME
Current Illness: Fracture of right superior and inferior pubic rami, fracture of the right sacral alla, and fracture of the L3 vertebral body. UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
Preexisting Conditions: Abdominal aortic aneurysm CHRONIC OBSTRUCTIVE PULMONARY DISEASE tobacco abuse, EtOH abuse Ambulatory dysfunction, debility, high risk for falls, deconditioning, ambulatory dysfunction/debility/deconditioning/high fall risk/generalized weakness MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED PERSONAL HISTORY OF MALARIA
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pt last seen at 1200 by nurse for ID band check. No visible signs of distress noted. Pt states "I just want to be left alone". 1230 nurse was called to pt room. Pt was noted unresponsive, no pulse and respiration noted. CPR started immediately, at 1239 first shock given. 1245 EMT took over, at 1319 EMT called time of death |
|
| VAERS ID: |
926462 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2020-12-28 |
| Onset: | 2021-01-04 |
| Days after vaccination: | 7 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1042 / 1 |
UN / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Absence of immediate treatment response,
Death,
Hypoxia
SMQs:, Asthma/bronchospasm (broad), Lack of efficacy/effect (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-05
Days after onset: 1
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: Lorazepam, pantoprazole, miralax, senna plus, carbodopa-levodopa, metoprolol, mirtazipine, quetiapine
Current Illness: dementia, Upper gastrointestinal bleed
Preexisting Conditions: Advanced dementia, Parkinson''s'' disease ,chronic kidney disease, sciatica, hyperlipidemia
Allergies: no known food or medication allergies
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient developed hypoxia on 1/4/2021 and did not respond to maximal treatment and passed way on 1/5/2021 |
|
