|
| VAERS ID: |
958745 (history) |
| Form: |
Version 2.0 |
| Age: |
73.0 |
| Sex: |
Male |
| Location: |
Colorado |
| Vaccinated: | 2021-01-12 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J20-2A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Asthenia,
Fall,
Pulse absent,
Pyrexia,
Skin warm,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-16
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: Divalproex Sodium Tab DR 250mg and 500mg, Lexapro 20mg, Quetiapine Fumarate 200mg tab, Senna 8.6 mg, Latanoprost drops,
Current Illness: Hx of TBI and schizophrenia with worsening behaviors over the past few months including refusing care including meals and medications and striking out with care. Resident had a fall on 1/14/2021. Resident received treatment for a UTI with Keflex for 7 days starting 12/6/2020.
Preexisting Conditions: Traumatic Brain Injury, Shizophrenia, hydrocephalus, hemiplegia following cerebrovascular disease affecting right side, aphasia, reduced mobility with use of w/c, repeated falls, dysphagia, major depression, thrombocytopenia, gluacoma, epilepsy.
Allergies: No Known Allergies
Diagnostic Lab Data: None
CDC Split Type:
Write-up: Resident was noted to have increase weakness on 1/15/2021. Resident was warm to touch with low grade fever of 99.3 F. Resident was up propelling self in w/c on 1/16/2021 he was pleasant, accepted medications and ate lunch. He was found slumped over in his w/c not responding and vital signs absent. |
|
| VAERS ID: |
958914 (history) |
| Form: |
Version 2.0 |
| Age: |
87.0 |
| Sex: |
Female |
| Location: |
Georgia |
| Vaccinated: | 2020-12-30 |
| Onset: | 2020-01-15 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1686 / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
Days after onset: 366
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Melatonin, Sertraline, Omeprazole, Resperidone, Depakote ER, vitamin E, multi vit, ASA, Lasix, gabapentin, potassium, Imodium, Zofran, Buspar, benztropine.
Current Illness:
Preexisting Conditions: Alzheimer''s, disorganized schizophrenia, HTN, CKD stage 3, Athritis, legal blindness, Dementia, Major Depression Disorder, Parkinson''s, GERD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Death on 1/15/2020 |
|
| VAERS ID: |
958935 (history) |
| Form: |
Version 2.0 |
| Age: |
92.0 |
| Sex: |
Female |
| Location: |
North Carolina |
| Vaccinated: | 2021-01-19 |
| Onset: | 2021-01-20 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / UNK |
- / SYR |
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: 2021-01-20
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, Biotin, Levothyroxine, melatonin, Namenda, Zyprexa, Trazodone, B12, B6, Vit D, Xanax
Current Illness:
Preexisting Conditions: Dementia, HTN, Hypothyroidism
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:
Write-up: Sudden Death within 24 hours of vaccine |
|
| VAERS ID: |
958971 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Male |
| Location: |
Florida |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Basal ganglia stroke,
Computerised tomogram,
Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-14
Days after onset: 0
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: Simvastatin
Current Illness:
Preexisting Conditions: Aortic Insuf Dyslipidemia h/o prostate CA
Allergies: NKDA
Diagnostic Lab Data: CT scan
CDC Split Type:
Write-up: Hemorrhagic Stroke, Right Basal Ganglion |
|
| VAERS ID: |
959001 (history) |
| Form: |
Version 2.0 |
| Age: |
55.0 |
| Sex: |
Male |
| Location: |
Illinois |
| Vaccinated: | 2021-01-15 |
| Onset: | 2021-01-16 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / UNK |
LA / IM |
Administered by: Public Purchased by: ?
Symptoms: Nausea,
Pulse absent,
Resuscitation,
Unresponsive to stimuli
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-16
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: triamcinolone (KENALOG) 0.1 % Ointment amLODIPine (NORVASC) 5 MG Tablet Take 5 mg by mouth. ondansetron (ZOFRAN-ODT) 4 MG TABLET DISPERSIBLE Take 1 Tab by mouth every 8 hours as needed for Nausea - 1st line. acetaminophe
Current Illness: Unknown
Preexisting Conditions: Asthma Developmental delay (Pediatric) Eczema HLD (hyperlipidemia) HTN (hypertension)
Allergies: Penicillin''s, Chocolate, Lactase, Fish, Nuts, Strawberry
Diagnostic Lab Data: N/A
CDC Split Type:
Write-up: Patient woke apx 0200 complaining of nausea to group home staff. Vitals were checked at that time and WNL. Patient went back to bed. When staff went to wake patient apx 0530, he was unresponsive and had no pulse. Chest compressions were started and EMS called. |
|
| VAERS ID: |
959079 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Male |
| Location: |
Colorado |
| Vaccinated: | 2021-01-06 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1686 / 1 |
LA / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Bundle branch block right,
Electrocardiogram QRS complex abnormal,
Heart rate increased,
Pain,
Respiratory rate increased,
Sinus tachycardia,
Supraventricular tachycardia,
Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Dehydration (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ascorbic Acid 500mg, Cetirizine HCL 5mg, Escitalopram Oxalate 10mg, Finasteride 5mg, Metoprolol succinate ER 25mg, Tamsulosin 0.4mg, Teriparatide 20mcg injection, Vitamin D3 Tablet, voltaren Gel 1%, Eliquis 5mg, Pantoprazole Sodium 40mg, Ac
Current Illness: Residents condition was declining over the past several months and has been treated for depression and dementia. Resident refusing care including meals, medication and ADL care.
Preexisting Conditions: Atrial Fibrillation, obstructive uropathy, chronic kidney disease, asthma, bradycardia, major depression, dysphagia, Parkinson''s disease, dependence on supplemental oxygen, osteoporosis, hyperlipidemia,
Allergies: No Known Allergies
Diagnostic Lab Data: 1/9/2021- 12 lead EKG performed which states sinus tachycardia with supraventricular complexes and low voltage QRS as well as right bundle 1/9/2021- CXR ordered but discontinued at request of POA
CDC Split Type:
Write-up: On 1/9/2021 observed with elevated respirations of 38-42 per minute, BP manually 72/50. pulse is jumping rapidly between 110-16 bpm. oxygen sat 76% RA, resident refusing oxygen at first attempt, allowed oxygen to be placed, is now 84% on 4L. resident shaking head yes that he is hurting, and yes that he would take medication for pain. Dr. notified, branch block. Received order for morphine 2mg per hr as needed for elevated respirations and pain. Dr. also gave orders to D/C Tamsulosin and finasteride. Resident continue with decreased O2 sats and elevated respirations. Absence of vital signs on 1/10/21 at 826PM. |
|
| VAERS ID: |
959147 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Female |
| Location: |
Ohio |
| Vaccinated: | 2020-12-28 |
| Onset: | 2021-01-02 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
E10140 / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Jaundice
SMQs:, Cholestasis and jaundice of hepatic origin (narrow), Acute pancreatitis (broad), Biliary system related investigations, signs and symptoms (narrow), Biliary tract disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
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:
Current Illness: Alzheimer''s disease, Type 2 with chronic kidney disease,
Preexisting Conditions: copd, Depression,psychosis,atherosclerotic heart disease
Allergies: penicillin
Diagnostic Lab Data: none as resident was comfort care only
CDC Split Type:
Write-up: Unknown as to any correlation with vaccine as this was a hospice patient that was already experiencing decline. Patient became Jaundice for approximately one week prior to expiring. |
|
| VAERS ID: |
959167 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Male |
| Location: |
Alabama |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-16 |
| Days after vaccination: | 2 |
| 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: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-16
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:
Preexisting Conditions: Seizures were reported on vaccine form
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient received COVID 19 vaccine 01/14/2021. Patient died in his sleep 01/16/2021. |
|
| VAERS ID: |
959179 (history) |
| Form: |
Version 2.0 |
| Age: |
79.0 |
| Sex: |
Male |
| Location: |
Colorado |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-17 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL8982 / 1 |
RA / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Acute kidney injury,
Alanine aminotransferase increased,
Aspartate aminotransferase increased,
Blood albumin decreased,
Blood bilirubin normal,
Blood calcium decreased,
Blood chloride decreased,
Blood creatinine increased,
Blood culture negative,
Blood glucose increased,
Blood lactic acid,
Blood magnesium normal,
Blood phosphorus increased,
Blood potassium normal,
Blood sodium normal,
Blood urea increased,
Cardiac arrest,
Culture urine negative,
Death,
Diastolic dysfunction,
Echocardiogram abnormal,
Ejection fraction decreased,
Haematocrit decreased,
Haemoglobin decreased,
Hyperkalaemia,
Left ventricular dysfunction,
Left ventricular hypertrophy,
Platelet count normal,
Pulseless electrical activity,
SARS-CoV-2 test negative,
Troponin increased,
Ventricular fibrillation,
Ventricular hypokinesia,
White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-18
Days after onset: 1
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: losartan 100 mg QD, metformin 1000 mg BID, simvastatin 40 mg QD, tamsulosin 0.4 mg QD
Current Illness:
Preexisting Conditions: Type 2 DM, Diabetic neuropathy/nephropathy, CKD Stage 3, Hyperlipidemia, Hypertension
Allergies: None
Diagnostic Lab Data: COVID-19 negative (1/18/2021); Blood X 2 ngtd (1/17/2021); urine ngtd (1/17/2021); ECHO (1/18/2021) - Left Ventricle: The left ventricle is normal in size. There is mild asymmetric left ventricular hypertrophy. Left ventricular function is mildly reduced. Considering 2D visualization and technical calculations the left ventricular ejection fraction estimate is 40-45%. The inferolateral wall is hypokinetic. There is no evidence of a thrombus in the left ventricle. There is echocardiographic evidence of diastolic dysfunction; CMP (1/18/2021) Na 144, K 4.6, Cl 96, gluc 290, BUN 73, Scr 7.68, Ca 7.2, Mg 1.8, Phos 7.3, AST 436, ALT 271, Alb 2.7, T bili 0.4, lactate $g 12.0; CBC (1/18/2021) WBC 24.6, Hgb 12.4, Hct 38.4, Plt 383
CDC Split Type:
Write-up: Patient received COVID-19 vaccination on 1/14/2021. On 1/17/2021, patient was transferred to Hospital s/p multiple cardiac arrests. Patient was hyperkalemic and in acute renal failure at time of transfer. Hyperkalemia was treated, but the patient suffered PEA vs VFib. At the time of transfer, patient was on vasopressin, norepinephrine, and epinephrine. The patient had an EF of 40-45% and elevated troponins. Patient was made DNR and placed on comfort care. Patient passed away on 1/18/2021. Ultimately we suspect that the patients condition was a direct result of his underlying disease states, but wanted to make sure reporting was made available. |
|
| VAERS ID: |
959272 (history) |
| Form: |
Version 2.0 |
| Age: |
85.0 |
| Sex: |
Male |
| Location: |
Kansas |
| Vaccinated: | 2021-01-12 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J20-2A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death
SMQs:
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? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: uncertain illness, however, patient was on Hospice.
Preexisting Conditions: uncertain illness, however, patient was on Hospice. We are not his primary care providers, just provided the vaccine.
Allergies: none
Diagnostic Lab Data: n/a
CDC Split Type:
Write-up: Patient died 4 days after immunization. Probably unrelated to immunization, as patient has been in poor health and was receiving hospice services. I have no details related to his illness or symptoms. Daughter is the HIPAA/emergency contact and will have all the information needed. |
|
