|
| VAERS ID: |
929997 (history) |
| Form: |
Version 2.0 |
| Age: |
86.0 |
| Sex: |
Male |
| Location: |
Wisconsin |
| Vaccinated: | 2021-01-04 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011L20A / 1 |
AR / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Dysphagia,
Feeding disorder,
Lethargy,
Mobility decreased,
Speech disorder
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg daily, Dexamethasone 4 mg daily (for itching related to renal failure), Isosorbide dinitrate 30 mg daily, Levothyroxine 0.075 mg daily, Bisoprolol 5 mg BID, Furosemide 80 mg BID, saline nasal spray, Tylenol 1000 mg PO TID
Current Illness: none acute
Preexisting Conditions: He was on hospice for about the last 1 month for CHF (EF 20-25%) and renal failure (creat 3-4). He was on hospice but was up and around and able to eat and take pills. The day after he had his injection, he was very lethargic and only mumbled. Was not able to take meds or eat. He was on hospice, so did not want work-up or treatment. He passed away on 1/7 am. We don''t know if it was a coincidence that he died or if the vaccine caused him to deteriorate more quickly.
Allergies: Losartan, lisinopril, metoprolol
Diagnostic Lab Data: He did not have testing at that point because he was on Hospice.
CDC Split Type:
Write-up: Patient received vaccine on 1/4/2021. He was in Hospice for CHF and renal failure, but was able to get up in his wheelchair and eat and take medications and talk. On 1/5/2021 am, he was noted to be very lethargic an could only mumble, could not swallow. No localizing neurologic findings. He was too lethargic to get up in chair. |
|
| VAERS ID: |
930154 (history) |
| Form: |
Version 2.0 |
| Age: |
60.0 |
| Sex: |
Male |
| Location: |
Ohio |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K2020A / 1 |
LA / IM |
Administered by: Public Purchased by: ?
Symptoms: Death
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: unknown
Current Illness: unkown
Preexisting Conditions: unknown
Allergies: Sulfa
Diagnostic Lab Data:
CDC Split Type: VFC # 21109
Write-up: Notified today that he passed away. No other details known at this time. |
|
| VAERS ID: |
930431 (history) |
| Form: |
Version 2.0 |
| Age: |
|
| Sex: |
Female |
| Location: |
Connecticut |
| Vaccinated: | 2021-01-06 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
AR / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Cardiac disorder,
Death
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: Enteric Coded Aspirin, Atenolol, Centrum Silver, Citrical, Levothyroxin, Lisinipril, Phillips Colon Health Caps, Vitamin D
Current Illness: none
Preexisting Conditions: Aortic Stenosis, Status post Tavr procedure, Hypothyroidism, Hypertension, Thoracogenic Scoliosis, Polymyalgia Rheumatica, Heart Valve Replacement, Hyperparathyroidism
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:
Write-up: Cardiac event, 2 days after vaccination, patient expired. |
|
| VAERS ID: |
930466 (history) |
| Form: |
Version 2.0 |
| Age: |
82.0 |
| Sex: |
Female |
| Location: |
Louisiana |
| 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 |
UN / IM |
Administered by: Private Purchased by: ?
Symptoms: Chest pain,
Dyspnoea,
Myocardial infarction,
Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (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:
Current Illness:
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:
Write-up: Fever, shortness of breath and chest pain that resulted in a heart attack a few hours after vaccination |
|
| VAERS ID: |
930487 (history) |
| Form: |
Version 2.0 |
| Age: |
86.0 |
| Sex: |
Male |
| Location: |
North Carolina |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / UNK |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)
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: calcium-D tablet, cholecalciferol, fish oil, melatonin, tylenol,
Current Illness: na
Preexisting Conditions: bph, apraxia, , dysphagia, muscle weakness, alzheimers disease
Allergies: cephalexin
Diagnostic Lab Data: na
CDC Split Type:
Write-up: Medical docter state patient has a acute cardiac attack |
|
| VAERS ID: |
930876 (history) |
| Form: |
Version 2.0 |
| Age: |
88.0 |
| Sex: |
Male |
| Location: |
Texas |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
027L20A / 1 |
RA / IM |
Administered by: Pharmacy Purchased by: ?
Symptoms: Death,
X-ray with contrast
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: Prostate Cancer
Allergies:
Diagnostic Lab Data: Had IV dye imaging procedure after he received the COVID-19 vaccine (the same day in the afternoon) and passed away overnight.
CDC Split Type:
Write-up: Death |
|
| VAERS ID: |
958443 (history) |
| Form: |
Version 2.0 |
| Age: |
1.08 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2020-12-24 |
| Onset: | 2020-12-26 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Other Purchased by: ?
Symptoms: Completed suicide,
Death,
Gun shot wound
SMQs:, Suicide/self-injury (narrow), Accidents and injuries (narrow), Hostility/aggression (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-26
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: death by suicide Narrative: death by suicide; 12/26/20, self inflicted gun shot wound; found deceased by family member |
|
| VAERS ID: |
930910 (history) |
| Form: |
Version 2.0 |
| Age: |
52.0 |
| Sex: |
Female |
| Location: |
Hawaii |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-09 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
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: Patient was refusing to take all medications for over a year
Current Illness: None
Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation
Allergies: Metformin, morphine, statins, latex
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm. |
|
| VAERS ID: |
930912 (history) |
| Form: |
Version 2.0 |
| Age: |
73.0 |
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-09 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
UN / UN |
Administered by: Unknown Purchased by: ?
Symptoms: Death,
Diarrhoea
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-01-08
Days after onset: 7305
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: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:
Write-up: Diarrhea followed by death 24 hrs after vaccination |
|
| VAERS ID: |
951518 (history) |
| Form: |
Version 1.0 |
| Age: |
77.0 |
| Sex: |
Male |
| Location: |
Wyoming |
| Vaccinated: | 2020-12-28 |
| Onset: | 2021-01-04 |
| Days after vaccination: | 7 |
| Submitted: |
2021-01-05 |
| Days after onset: | 1 |
| Entered: |
2021-01-09 |
| Days after submission: | 4 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 2 |
LA / - |
Administered by: Other Purchased by: Other
Symptoms: Death,
SARS-CoV-2 test negative,
Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)
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? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Specimen: NASOPHARYNX. Specimen Collection Date: Dec 29, 2020@09:45 Test name Result units Ref. range Site Code COVID-19 (M2000) Not Detected
CDC Split Type:
Write-up: Narrative: Patient with severe aphasia and only able to say "hey, hey, hey" or "uh huh" or shake his head no as a way to communicate. Patient previously able to ambulate with significant limp and hyperextension of right knee, but mostly wheelchair bound over last several years as he had had a slow and steady decline in overall health and mobility. Patient developed aggressive behavior of shouting "hey" and grabbing of groin in 2016. This was worked up with CT scans, labs, referral to urology, neurology, and referrals to psychiatry. The exact etiology of this action was never able to be affirmed, but thought to be more psychiatrically related. It improved significantly with addition of antipsychotics, worsened when antipsychotics were reduced, and improved again with addition of injectable antipsychotic on 12-10-2020.Patient suffered from falls on occasion given his significantly impaired physical mobility. His last documented fall was 8-31-2019. Patient began utilizing wheelchair most of time following that fall. No significant injuries noted in documentation of the falls. In the last 3 months, patient would often refuse medications. He would sometimes indicate that they would cause dizziness, and other times he would simply refuse. We attempted to hide medications in his food/fluid (with wife''s blessing) and when he detected this he would occasionally refuse to eat. Patient previously on DOAC. After pharmacy review in 12/2020 it was recommended to discontinue this as no clear indication to continue use. He was high fall risk and would often refuse this medication as well since 10/2020. Noted to be in NSR on EKGs and decision made to discontinue the DOAC. Patient had no evidence of adverse effects noted after vaccination on December 28th. Patient seen by provider on the morning of his death (1/4/2021) with no noticeable significant change in health condition. Temperature 36.8Con January 4th at 19:45. During routine bedtime cares, patient suddenly collapsed and death was pronounced January 4, 2021 at 20:05. Autopsy was requested from next of kin and no autopsy was granted. Symptoms: & DEATH Treatment: |
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