|
| VAERS ID: |
926568 (history) |
| Form: |
Version 2.0 |
| Age: |
77.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2020-12-28 |
| Onset: | 2020-12-30 |
| Days after vaccination: | 2 |
| 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
SMQs:, Lack of efficacy/effect (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-04
Days after onset: 5
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: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin
Current Illness: chronic medical problems as noted below
Preexisting Conditions: dementia, peripheral vascular disease, COPD, hypertension, GERD, S/P CVA with stent of left carotid ,right common iliac and right external iliac arteries, CDK,diabetes
Allergies: clopidigrel, sulfa, vicodin
Diagnostic Lab Data:
CDC Split Type:
Write-up: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020 |
|
| VAERS ID: |
926600 (history) |
| Form: |
Version 2.0 |
| Age: |
65.0 |
| Sex: |
Male |
| Location: |
Missouri |
| Vaccinated: | 2021-01-04 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
37K20A / 1 |
RA / IM |
Administered by: Pharmacy Purchased by: ?
Symptoms: Death,
Malaise
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: Unknown
Current Illness: Diabetes, renal insufficiency
Preexisting Conditions: Diabetes, renal insufficiency
Allergies: Penicillin, ibuprofen
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient did not report any signs or symptoms of adverse reaction to vaccine. Patient suffered from several comorbidities (diabetes and renal insufficiency). Patient reported not feeling well 01/06/2021 and passed away that day. |
|
| VAERS ID: |
926797 (history) |
| Form: |
Version 2.0 |
| Age: |
93.0 |
| Sex: |
Male |
| Location: |
South Dakota |
| Vaccinated: | 2020-12-31 |
| Onset: | 2021-01-01 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Noninfectious myocarditis/pericarditis (broad)
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:
Current Illness: This is a 93 year old with significant heart issues?EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine
Preexisting Conditions: Heart disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: had a vaccination on 12/31/2020 late morning passed away early morning 01/01/2020. This is a 93 year old with significant heart issues. EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine. |
|
| VAERS ID: |
927189 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-07 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK9231 / 1 |
LA / SYR |
Administered by: Other 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: unknown
Current Illness: stroke
Preexisting Conditions: hypertension, atrial fibrillation, atherosclerosis,
Allergies: none
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient was vaccinated at 11am and was found at the facility in his room deceased at approximately 3:00pm. Nurse did not have cause of death |
|
| VAERS ID: |
927260 (history) |
| Form: |
Version 2.0 |
| Age: |
87.0 |
| Sex: |
Female |
| Location: |
Wisconsin |
| Vaccinated: | 2020-12-28 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 9 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / 1 |
AR / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Blood lactic acid increased,
Bradycardia,
Cardiac arrest,
Computerised tomogram head normal,
Death,
Heart sounds abnormal,
Pulse absent,
Respiration abnormal,
Resuscitation,
SARS-CoV-2 test negative,
Unresponsive to stimuli,
White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (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? No
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vit D3, Miralax, Spironolactone, Tramadol, Metoprolol Succinate, MOM, Ferrous Gluconate, Ondansetron, Nitroglycerin Sublingual PRN, PreserVision AREDS, Fluticasone Propionate Suspension, Lisinopril, Clopidogrel Bisulfate, Campor-Methol-Met
Current Illness: Digestive Surgery for bowel obstruction
Preexisting Conditions: HTN, AAA, Chronic Diastolic Heart Failure, Diabetes Type 2, Paroxysmal atrial fibrillation, bradycardia, Hx of STEMI, Hx of CVA, HX of uterine cancer,
Allergies: Codeine, Meperidine, Morphine, Estrogens, Penicillins, Tetanus Toxoids
Diagnostic Lab Data: Brain CT negative WBC and lactic acid increased. COVID 19 on 1/4/21 negative
CDC Split Type:
Write-up: No adverse effects noted after vaccination. Patient with cardiac history was found unresponsive at 16:45 on 1/6/21. Abnormal breathing patterns, eyes partially closed SPO2 was 41%, pulseless with no cardiac sounds upon auscultation. CPR and pulse was regained and patient was breathing. Patient sent to Hospital ER were she remained in an unstable condition had multiple cardiac arrest and severe bradycardia and in the end the hospital was unable to bring her back. |
|
| VAERS ID: |
928062 (history) |
| Form: |
Version 2.0 |
| Age: |
85.0 |
| Sex: |
Male |
| Location: |
Massachusetts |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Blood lactic acid increased,
Cardiac arrest,
Death,
Endotracheal intubation,
Hypotension,
Hypoxia,
Laboratory test,
Lethargy,
Liver function test,
Lung infiltration,
Pancytopenia,
Pulmonary congestion,
Pulmonary imaging procedure abnormal,
Troponin,
Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Agranulocytosis (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-07
Days after onset: 2
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: ACETAMINOPHEN CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA ER CITALOPRAM HBR DONEPEZIL HCL EUCERIN FINASTERIDE FLOMAX LATANOPROST OMEPRAZOLE QUETIAPINE FUMARATE QUETIAPINE FUMARATE SENNA LAX
Current Illness: Parkinson''s Disease with advanced dementia, dysphagia. Alcoholism in remission. HTN. BPH. GERD
Preexisting Conditions: Parkinson''s Disease with advanced dementia, dysphagia. Alcoholism in remission. HTN. BPH. GERD
Allergies: angioedema due to ACE and ARB meds
Diagnostic Lab Data: Pancytopenia, elevated lactate, troponin, LFTs. Left mid lung infiltrate and pulmonary vascular congestion.
CDC Split Type:
Write-up: vomiting later on 01/05/21. Lethargy and hypoxia in pm of 01/06/21. Hypotension am of 01/07/21. Hospitalized, intubated, cardiac arrest, died 01/07/21. |
|
| VAERS ID: |
928513 (history) |
| Form: |
Version 2.0 |
| Age: |
72.0 |
| Sex: |
Female |
| Location: |
Michigan |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
026L20A / 1 |
RA / IM |
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: Amiodarone Hcl, Carvedilol, Ferrous sulfate, Eliquis (cont)
Current Illness: Atrial fibrillation, Anemia, 1st degree AV block, CDK stage 4,
Preexisting Conditions: CDK stage 4, Atrial fibrillation, 1st degree AV block, Patient was under hospice care
Allergies: Aldactone, contrast dye
Diagnostic Lab Data: N/A
CDC Split Type:
Write-up: Resident passed away in her sleep |
|
| VAERS ID: |
928933 (history) |
| Form: |
Version 2.0 |
| Age: |
56.0 |
| Sex: |
Female |
| Location: |
Iowa |
| Vaccinated: | 2020-12-23 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 16 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J202A / 1 |
RA / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Death,
Resuscitation
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-08
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 had been diagnosed with COVID-19 on Dec. 11th, 2020. Symptoms were thought to have started on 12/5/2020. Received Moderna vaccine on 12/23. Unexpected death on 1/8/2021. Resuscitation attempts unsuccessful |
|
| VAERS ID: |
929359 (history) |
| Form: |
Version 2.0 |
| Age: |
76.0 |
| Sex: |
Male |
| Location: |
Florida |
| Vaccinated: | 2021-01-06 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK9231 / 2 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Breath sounds abnormal,
Death,
Oxygen saturation decreased
SMQs:, Acute central respiratory depression (narrow), Respiratory failure (narrow), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-08
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: none
Current Illness: Cerebral Atherosclerosis, malnutrition, thrombocytopenia, cva, hypothyroidism
Preexisting Conditions: Cerebral Atherosclerosis, malnutrition, thrombocytopenia, cva, hypothyroidism
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:
Write-up: 3:07 pm lung sounds diminished oxygen sats 68%, oxygen applied Oxygen sats remained low for next 36 hours ( patient on Hospice care ) expired 6:22 am 1-8-21 |
|
| VAERS ID: |
929764 (history) |
| Form: |
Version 2.0 |
| Age: |
45.0 |
| Sex: |
Male |
| Location: |
Washington |
| Vaccinated: | 2020-12-28 |
| Onset: | 2020-12-29 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-29
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: Hydrochlorthiazide (by record, not confirmed)
Current Illness:
Preexisting Conditions: Hypertension, sleep apnea, obesity. based on medical record
Allergies: no known allergies recorded in medical record
Diagnostic Lab Data:
CDC Split Type:
Write-up: The patient was found deceased at home about 24 hours after immunization. Date of Death:: 12/29/2020; estimated time of death 6:00pm |
|
