|
| VAERS ID: |
933578 (history) |
| Form: |
Version 2.0 |
| Age: |
43.0 |
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 2021-01-08 |
| Onset: | 0000-00-00 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
LA / IM |
Administered by: Public 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: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021 |
|
| VAERS ID: |
933739 (history) |
| Form: |
Version 2.0 |
| Age: |
54.0 |
| Sex: |
Female |
| Location: |
Ohio |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1685 / 1 |
RA / IM |
Administered by: Other Purchased by: ?
Symptoms: Brain death,
Bronchial secretion retention,
Cardio-respiratory arrest,
Death,
Dyspnoea,
Electroencephalogram abnormal,
Intensive care,
Mechanical ventilation,
Resuscitation,
SARS-CoV-2 test negative,
Withdrawal of life support
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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), Cardiomyopathy (broad), Respiratory failure (broad), COVID-19 (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-10
Days after onset: 1
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: Aspirin, Diazepam, Doxepin HCL, Duloxetine, Juven POW, Lamotri Levothyroxin, Loratadine, Melatonin, Mucus Relief, Olanzapine, Prazosin HCL, Pregabalin,
Current Illness: Recent g-tube placement, Several hospitalizations over the pas few months due to low Oxygen Levels.
Preexisting Conditions: Major depression, borderline personality disorder, Cerebral Palsy, History of dissected left carotid artery
Allergies: Penicillin
Diagnostic Lab Data: COVID-19 test administered - 1/9/2021 - Negative 2 EEGs were performed on 1/9/2021 and both indicated she had not brain activity
CDC Split Type:
Write-up: Staff member checked on her at 3am and patient stated that she felt like she couldn''t breathe. 911 was called and taken to the hospital. While in the ambulance, patient coded. Patient was given CPR and "brought back". Once at the hospital, patient was placed on a ventilator and efforts were made to contact the guardian for end of life decisions. Two EEGs were given to determine that patient had no brain activity. Guardian, made the decision to end all life saving measures. Patient was taken off the ventilator on 1/9/2021 and passed away at 1:30am on 1/10/2021. The initial indication from the ICU doctor was the patient had a mucus plug that she couldn''t clear. |
|
| VAERS ID: |
933846 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Female |
| Location: |
West Virginia |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-02 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
077L20A / 1 |
RA / IM |
Administered by: Public Purchased by: ?
Symptoms: Back pain,
Cardiac disorder,
Death,
Dizziness,
Pain in extremity
SMQs:, Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-04
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: MACULAR DEGENERATION 10 YEARS OR MORE
Preexisting Conditions: NONE
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:
Write-up: 1-2-2021 10:30 PM Complained Right arm/back hurt - took Tylenol 1-3-2021 Complained Right arm hurt, dizzy 1-4-2021 Felt better - did laundry, daughter found her deceased at 3:30 pm. Dr. at hospital said it was "cardiac event" according to death certificate. |
|
| VAERS ID: |
934050 (history) |
| Form: |
Version 2.0 |
| Age: |
68.0 |
| Sex: |
Male |
| Location: |
Kansas |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J202A / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Fall,
Posture abnormal,
Resuscitation,
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), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
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 a resident in Group Home Current Medications Treatments/PRN Medications: Start Date: 04/02/14: Benztropine 2mg tab BID (8-8) 02/27/15: Midodrine (Proamatine) 5mg tab TID (8-12-8) 12/30/15: Cetirizine 10mg tab daily @8am 1
Current Illness: No Acute Illnesses
Preexisting Conditions: Diagnosis: - Impulse Control Disorder - Epilepsy - Tardive Dyskinesia - Ulcerative Proctitis and Colitis - Mental Retardation (mod) - Hammer toes (bilat.) - Dermatitis (scalp/torso) - Seborrheic keratosis of left armpit - Major Depression - Infantile Meningitis - History of Squamous Cell Carcinoma (L arm)
Allergies: Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:
Write-up: Staff reported that patient was found Friday morning (Jan 8) sitting at a table with his head tilted forward and unresponsive to verbal or physical stimuli. Staff lowered patient to floor and started CPR. EMS was called and continued CPR at scene, however they were not able to revive patient. Patient was pronounced dead at the scene. Staff written statements following the death of patient show that he had a fall about 1 hr. prior. It is unknown if this fall contributed to patient''s death. An autopsy has been requested. |
|
| VAERS ID: |
934059 (history) |
| Form: |
Version 2.0 |
| Age: |
99.0 |
| Sex: |
Female |
| Location: |
Iowa |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Acute myocardial infarction,
Death
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-10
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: tramadol, calcium, Tylenol, lisinopril, Mucinex, MVI, namenda
Current Illness: Had Covid 19 infection in November recovered, had spinal stenosis with leg weakness chronic
Preexisting Conditions:
Allergies: anastrozole
Diagnostic Lab Data:
CDC Split Type:
Write-up: Acute anterior MI with death |
|
| VAERS ID: |
934263 (history) |
| Form: |
Version 2.0 |
| Age: |
92.0 |
| Sex: |
Male |
| Location: |
New Mexico |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-01 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
- / UN |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Malaise,
SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-02
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Again, I cannot confirm the results of any test, i.e., COVID or other, because the patient is independent and sought care independent of the center.
CDC Split Type:
Write-up: The resident resides in an independent living facility/apartment. The reporter at the center was informed by his daughter he was not feeling well on 1/1/2021 (specific symptoms could not be ascertained). He reportedly went to be COVID tested on 1/1/2020 and observed to be deceased in his apartment on 1/2/2020. I do not have confirmation of his COVID results, although the reporter indicates his daughter reports his test was positive. |
|
| VAERS ID: |
934373 (history) |
| Form: |
Version 2.0 |
| Age: |
82.0 |
| Sex: |
Female |
| Location: |
West Virginia |
| Vaccinated: | 2021-01-09 |
| Onset: | 2021-01-10 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1284 / 1 |
LA / IM |
Administered by: Public Purchased by: ?
Symptoms: Death,
Pulse absent,
Resuscitation
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-10
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: Husband only knew that she took several medications.
Current Illness: Newly diagnosed heart murmur the week prior by PCP. Was referred to her cardiologist.
Preexisting Conditions: She did have open heart surgery in 2013. She last saw her cardiologist 4 months ago, and she did a phone consult with him a week or so ago.
Allergies: PCN & Sulfa drugs
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient went to bed around 11pm on Saturday PM and sometime between then and 1:30am on Sunday morning got up and went into the living room without waking up her husband (which is normal). At 1:30am, the husband got up to use the restroom and she was out of bed then, but the husband did not know if she was having any problems at this time. When he got up at 7:45am, she was in the recliner and did not move or anything, which is normal for her. At 8:45am, the husband went back into the living room and tried to wake his wife and that is when he noticed there was no pulse and he called 9-1-1 at this time. EMS got on scene and did CPR for 30 mins and she was pronounced dead at 9:21am. |
|
| VAERS ID: |
934507 (history) |
| Form: |
Version 2.0 |
| Age: |
89.0 |
| Sex: |
Female |
| Location: |
Massachusetts |
| Vaccinated: | 2021-01-03 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
LA / 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: 2021-01-05
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: Coumadin 2mg po Sat-Mon-Tues-Thurs Coumadin 1mg po Fri Sun APAP 650 mg po PRN pain or temp above 101 Amiodarone 200mg po daily Ativan 0.5mg po PRN anxiety Claritin 10mg po daily Gabapentin 100mg po BID PRN phantom pain Miralax 17Gm po with
Current Illness: No other illness prior to vaccination or within the month prior
Preexisting Conditions: Covid 19 Recovered spring 2020 Chronic stage 5 kidney disease with dialysis 3 times weekly Chronic diastolic congestive heart failure Chronic A-fib Diabetes Mellitus with other circulatory complications Hypertension Right and Left Below the knee amputations
Allergies: KNDA KNFA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident died suddenly and expectantly on 01/05/2021 |
|
| VAERS ID: |
934539 (history) |
| Form: |
Version 2.0 |
| Age: |
68.0 |
| Sex: |
Female |
| Location: |
Kentucky |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
D12L20A / 1 |
RA / IM |
Administered by: Public Purchased by: ?
Symptoms: Autopsy,
Blood test,
Culture tissue specimen,
Death,
Toxicologic test,
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: 2021-01-09
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, Oxybutynin, Fosamax, Prednisone, Meloxicam, Eliquis, Bumetanide, Triamcinolone cream, Klor-Con, Lisinopril, Promethazine,
Current Illness: Cellulitis of left lower limb (12/2020)
Preexisting Conditions: Hypertension
Allergies: No known allergies
Diagnostic Lab Data: Postmortem examination was performed at the State Medical Examiner Office on January 10, 2021 (MEC21-0019). Tissue samples were obtained for histology and red top/tiger top/purple top tubes of blood were obtained for potential further studies. Samples of blood and vitreous humor were also obtained and submitted to AXIS Laboratories for toxicologic analysis.
CDC Split Type:
Write-up: Patient received COVID-19 (Moderna) vaccine from the Health Department on afternoon of January 8, 2021 and went to sleep approximately 2300 that night. Was found unresponsive in bed the following morning and pronounced dead at 1336 on January 9, 2021 |
|
| VAERS ID: |
934745 (history) |
| Form: |
Version 2.0 |
| Age: |
79.0 |
| Sex: |
Female |
| Location: |
Iowa |
| Vaccinated: | 2021-01-09 |
| Onset: | 2021-01-10 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1284 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Heart rate increased,
Musculoskeletal stiffness,
Oxygen saturation decreased,
Peripheral coldness,
Presyncope,
Pulse absent,
Respiratory rate increased,
Seizure like phenomena,
Skin discolouration,
Skin warm,
Thrombosis,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dystonia (broad), Parkinson-like events (broad), Thrombophlebitis (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)
Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 2021-01-12
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: Exelon 13.3 mg daily, APAP 500 mg three times a day, Namenda 10 mg two times a day, Senna 8.6 mg two tablets daily, Mirilax 27 grams two times a day, 2 cal 4oz three times a day, Amlodipine 5 mg daily
Current Illness: NA
Preexisting Conditions: Alzheimers, dementia, hypertension,
Allergies: NKA
Diagnostic Lab Data: Family requested comfort cares. No tests provided.
CDC Split Type:
Write-up: Resident had seizure like activity followed by a vagel response with large bowel movement. Resident then began to show signs of blood clot to left lower extremity. No pedal pulse, area on leg warm to touch. Left lower leg now cold to touch, stiff, purple and white in color. No other signs of modeling, body warm to touch, no fever noted. Respirations and pulse increased with low oxygen levels. Resident not responding to stimuli. |
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