|
| VAERS ID: |
956962 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 2021-01-06 |
| Onset: | 2021-01-19 |
| Days after vaccination: | 13 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-19 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER |
COVID 19 KNOWN< / 1 |
UN / UN |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Death,
Hyperhidrosis,
Hypotension,
Hypoxia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (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), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-19
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: Unavail
Current Illness: CVA seizure disorder all chronic HTN CAD had COVID 19 in April 2020
Preexisting Conditions: as above PAtient had accute respiratory distress followed prolptly by cardiac arrest
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:
Write-up: COVID 19 vaccine, unknown which company Chronically ill in a skilled nursing facility found diaphoretic, hypotensive, hypoxia to 85% arrived to Emergency dept in cardiac arrest Died within 65 minutes of nursing finding patient in distress Wife felt it may have been related to vaccine date of vaccination 1/6/20 hx covid 19 PNA in April 2020 |
|
| VAERS ID: |
956994 (history) |
| Form: |
Version 2.0 |
| Age: |
73.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-15 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-19 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
- / IM |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Dyspnoea,
Rash
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), Cardiomyopathy (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-19
Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cholecalciferol, duloxetine, fenofibrate, gabapentin, hydrocortisone suppository, melatonin, metformin, metoprolol succinate, mineral oil, nitroglycerin, omeprazole, pravastatin, quetiapine, selenium sulfide shampoo, quetiapine, sumatriptan
Current Illness:
Preexisting Conditions: Hypertension, Type II diabetes, hyperlipidemia, GERD
Allergies: Aspirin, penicillin, vicodin, acetaminophen, niacin
Diagnostic Lab Data:
CDC Split Type:
Write-up: The patient had severe shortness of breath resulting in cardiac arrest on the 5th day after the vaccine. Shortness of breath started 12 hours after injection. On the 5th day, the patient was discovered to also have a rash throughout his body, but it is unknown when this rash started. |
|
| VAERS ID: |
957116 (history) |
| Form: |
Version 2.0 |
| Age: |
75.0 |
| Sex: |
Male |
| Location: |
Hawaii |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-18 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-19 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / IM |
Administered by: Military 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: 2021-01-18
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: Atovastatin, Ferrous sulfate, Finasteride, Flomax, Humulin N, Pantoprazole, ProAir, Reglan, Spiriva, Turmeric
Current Illness: Diabetes, Chronic renal failure on hemodialysis, Atrial fibrillation, Quadriplegia, Thrombocytopenia, Gastroparesis, Vitamin D deficiency, BPH, Neurogenic bladder, distant history of small intestine carcinoid tumor, right cerebral artery aneurysm, Barrett''s esophagus, MGUS, Hypertension, obstructive sleep apnea, Pulmonary hypertension, Junctional tachycardia.
Preexisting Conditions: see above. Sudden death without warning likely due to medical problems above but spouse feels it was somehow related to the vaccine 4 days before and it is a new vaccine.
Allergies: Cipro caused nausea, Coreg caused bradycardia, Hydrocodone, calcium acetate
Diagnostic Lab Data: none
CDC Split Type:
Write-up: Sudden death without warning symptoms 4 days after vaccine. Many medical problems which most likely explain the outcome but spouse feels it is related and it is a new vaccine. Monitor for pattern? |
|
| VAERS ID: |
957163 (history) |
| Form: |
Version 2.0 |
| Age: |
54.0 |
| Sex: |
Male |
| Location: |
New Jersey |
| Vaccinated: | 2021-01-11 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-19 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1284 / 1 |
LA / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Cardio-respiratory arrest,
Death,
Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), 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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-12
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:
CDC Split Type:
Write-up: Resident received 1st on 1/11/21 at 12:10am (1/12/21) resident was found unresponsive. Code Blue, 911 called at 12:11am. FD and EMS arrived, resident pronounced at 12:51am. |
|
| VAERS ID: |
957799 (history) |
| Form: |
Version 2.0 |
| Age: |
81.0 |
| Sex: |
Male |
| Location: |
Virginia |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
- / IM |
Administered by: Private Purchased by: ?
Symptoms: Asthenia,
Cardiac arrest,
Confusional state,
Death,
Electrocardiogram,
Full blood count normal,
Metabolic function test,
Troponin normal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), 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? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: sotaloL (BETAPACE) 80 mg Tablet omeprazole (PRILOSEC) 20 mg Capsule, Delayed Release(E.C.) sevelamer carbonate (RENVELA) 800 mg Tablet polyethylene glycol 3350 (MIRALAX PO) acetaminophen (TYLENOL EXTRA STRENGTH PO) fluticasone propionate (F
Current Illness:
Preexisting Conditions: HTN AAA with endovascular stent ESRD COPD
Allergies: Lipitor
Diagnostic Lab Data: CBC - unremarkable CMP - stable known renal disease otherwise unremarkable Troponin normal EKG - non acute
CDC Split Type:
Write-up: Presented to Urgent Care for weakness and confusion, transferred to ED, patient had a cardiac arrest and was unable to be resuscitated |
|
| VAERS ID: |
958069 (history) |
| Form: |
Version 2.0 |
| Age: |
94.0 |
| Sex: |
Female |
| Location: |
Florida |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-19 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
RA / IM |
Administered by: Private Purchased by: ?
Symptoms: Cough,
Dyspnoea,
Feeling abnormal
SMQs:, Anaphylactic reaction (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-20
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: Cartia XT 120mg daily, Zaditor 0.025% 1 drop into eye twice a day, Folic Acid 1mg daily, Metoprolol Succinate ER 100mg twice a day, Lasix 40mg daily, Erythromycin 2% to area twice a day, Hydroxychloroquine Sulfate 200mg 2 tabs daily, Ferrou
Current Illness: None
Preexisting Conditions: Rheumatoid arthritis, osteoarthritis, lumbar spinal stenosis, diabetes, bradycardia with pacemaker
Allergies: Codeine
Diagnostic Lab Data:
CDC Split Type:
Write-up: Started with cough, mild shortness of breath and feeling terrible in evening of 1/19. |
|
| VAERS ID: |
958072 (history) |
| Form: |
Version 2.0 |
| Age: |
57.0 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2021-01-16 |
| Onset: | 2021-01-18 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK4176 / 2 |
LA / IM |
Administered by: Work Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-19
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Death 3 days after receiving 2nd dose of COVID vaccine, unknown if related to vaccine administration. |
|
| VAERS ID: |
958228 (history) |
| Form: |
Version 2.0 |
| Age: |
83.0 |
| Sex: |
Male |
| Location: |
Illinois |
| Vaccinated: | 2021-01-12 |
| Onset: | 2021-01-18 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
0329K20A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Alanine aminotransferase normal,
Anion gap,
Aspartate aminotransferase normal,
Blood albumin decreased,
Blood alkaline phosphatase increased,
Blood bilirubin normal,
Blood calcium normal,
Blood chloride increased,
Blood creatinine increased,
Blood glucose increased,
Blood potassium increased,
Blood sodium increased,
Blood urea increased,
Carbon dioxide decreased,
Death,
Diet refusal,
Hypernatraemia,
Metabolic function test,
Protein total normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-18
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: 1) AMLODIPINE BESYLATE TAB 5MG PO QPM ACTIVE 2) ASPIRIN (OTC) TAB,CHEWABLE 81MG PO QDAILY ACTIVE 3) CARVEDILOL TAB 12.5MG PO BID ACTIVE 4) CHOLECALCIFEROL (VIT D3) 25MCG=100
Current Illness: none other than chronic conditions as listed under item 12.
Preexisting Conditions: acute on chronic kidney failure, Alzheimer''s dementia, diabetes mellitus type II, hypothyroidism, bipolar disorder, hypertension, hyperlipidemia
Allergies: Niacin - rash
Diagnostic Lab Data: Collection time: Jan 17, 2021@06:00 Test Name Result Units Range --------- ------ ----- ----- GLUCOSE 166H mg/dL 70 - 99 UREA NITROGEN 138H mg/dL 7 - 18 CREATININE 6.93H mg/dL .7 - 1.3 SODIUM 165H* mmol/L 136 - 145 POTASSIUM 5.2H mmol/L 3.5 - 5.1 CHLORIDE 130H mmol/L 98 - 107 CO2 21 mmol/L 21 - 32 CALCIUM, TOTAL 9.2 mg/dL 8.5 - 10.1 PROTEIN, TOTL 7.8 g/dL 6.4 - 8.2 ALBUMIN 3.2L g/dL 3.4 - 5.0 AST 16 U/L 15 - 37 ALT 22 U/L 16 - 63 BILI,TOTAL 0.3 mg/dL 0.2 - 1.0 ALKAL PHOS 168H U/L 46 - 116 EGFR canc ANION GAP 20.0 mmol/L 10 - 20
CDC Split Type:
Write-up: Patient has end stage renal disease and rapidly worsening dementia, family could no longer care for him at home, and he was admitted for 14-day quarantine prior to admission to inpatient hospice. Received vaccine on 1/12 without apparent adverse reactions. Patient started refusing oral intake on 1/16, and CMP on 1/17 showed hypernatremia 165 (new issue). His BUN 138 CREAT 6.93 K 5.2 were his baseline. He was found to be deceased on 1/18 at 11:18 pm. |
|
| VAERS ID: |
958322 (history) |
| Form: |
Version 2.0 |
| Age: |
62.0 |
| Sex: |
Male |
| Location: |
Florida |
| Vaccinated: | 2021-01-19 |
| Onset: | 2021-01-19 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL8982 / 1 |
RA / SYR |
Administered by: Other Purchased by: ?
Symptoms: Tremor,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (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: 2021-01-19
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: ASPIRIN ASPIRIN EC 325 MG TABLET TAKE 1 TABLET BY MOUTH DAILY ATORVASTATIN 40 MG TABLET LIPITOR 40 MG TABLET TAKE 1 TABLET BY MOUTH IN THE EVENING AT 5PM OLANZAPINE 10 MG TABLET ZYPREXA 10 MG TABLET TAKE ONE-HALF (1/2) TABLET BY MOUTH TWICE
Current Illness: Hyperlipidemia, Head Trauma, Hx of Seizures, Unspecified Psychosis, Depression, Mood Disorder, Substance Abuse
Preexisting Conditions: Hyperlipidemia, Psychosis, Depression
Allergies: None
Diagnostic Lab Data: Was sent to ER
CDC Split Type:
Write-up: Shaking and then became unresponsive |
|
| VAERS ID: |
958565 (history) |
| Form: |
Version 2.0 |
| Age: |
71.0 |
| Sex: |
Male |
| Location: |
Florida |
| Vaccinated: | 2021-01-11 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011L20A / 1 |
RA / IM |
Administered by: Public Purchased by: ?
Symptoms: Arrhythmia,
Chest discomfort,
Death
SMQs:, Anaphylactic reaction (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-12
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol nebulizer, Saline nebulizer, Metoprolol, Vespi, Albuterol Inhaler, antibiotic 2-3 times per week
Current Illness: lung infection treated with antibiotics a couple of weeks ago
Preexisting Conditions: Hypertension, COPD
Allergies: None Known
Diagnostic Lab Data: Unknown
CDC Split Type:
Write-up: Clients wife reported on 1/18/2021, that her husband died unexpectedly the day after receiving the COVID 19 vaccine. I called and spoke with her. She stated that the client had started experienced some tightness in his chest the evening of 1/11/2021. She stated that it was normal for him to have the tightness in his chest if he got stressed. She stated that she found him on the garage floor on 1/12/2021 at 2120. He was taken by ambulance to the hospital. She stated that the hospital told her that his COPD had caused him to go into arrythmia. |
|
