|
| VAERS ID: |
971736 (history) |
| Form: |
Version 2.0 |
| Age: |
88.0 |
| Sex: |
Male |
| Location: |
Iowa |
| Vaccinated: | 2021-01-21 |
| Onset: | 2021-01-21 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Neurological symptom,
Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-21
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: acetaminophen, aspirin, atorvastatin, bicalutamide, Plavix, lisinopril, metoprolol, multivitamin, oxycodone, Seroquel, sertraline, vanicream
Current Illness: DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING (S72.142D), MALIGNANT NEOPLASM OF PROSTATE(C61), UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE(F03.90), ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS(I25.10), DISPLACED FRACTURE OF BASE OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING(S72.041D), ESSENTIAL (PRIMARY) HYPERTENSION(I10), ANEMIA, UNSPECIFIED(D64.9), HYPOKALEMIA(E87.6), ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE(I21.3), MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED(F33.9), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), ALZHEIMER''S DISEASE WITH LATE ONSET(G30.1), OTHER ABNORMALITIES OF GAIT AND MOBILITY(R26.89), DISORIENTATION, UNSPECIFIED(R41.0), MUSCLE WEAKNESS (GENERALIZED)(M62.81), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12)
Preexisting Conditions: see #11
Allergies: terbinafine, ACE inhibitors, tetanus toxoids
Diagnostic Lab Data:
CDC Split Type:
Write-up: Vomit 30 minutes after administration. approx. 9 hours later, resident has Stroke-like symptoms. He was previously on Hospice before admitting to our facility and planned to be readmitted to hospice upon discharge. |
|
| VAERS ID: |
971813 (history) |
| Form: |
Version 2.0 |
| Age: |
85.0 |
| Sex: |
Female |
| Location: |
Alabama |
| Vaccinated: | 2021-01-20 |
| Onset: | 2021-01-20 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / 1 |
LA / IM |
Administered by: Public Purchased by: ?
Symptoms: Death,
Posture abnormal
SMQs:, Dystonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-21
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: not known
Current Illness: A fib, type 2 diabetes, HTN, seizure disorder, CHF
Preexisting Conditions: A fib, type 2 diabetes, HTN, seizure disorder, CHF, Z alpha hydroxylase deficiency
Allergies: Iodine
Diagnostic Lab Data:
CDC Split Type:
Write-up: patient received vaccine on 1/20/2121, later that night husband found her slumped in chair, called EMS and patient was taken to Hospital where she died on 1/21/2021 |
|
| VAERS ID: |
971969 (history) |
| Form: |
Version 2.0 |
| Age: |
72.0 |
| Sex: |
Female |
| Location: |
Louisiana |
| Vaccinated: | 2021-01-15 |
| Onset: | 2021-01-21 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1283 / 1 |
- / IM |
Administered by: Private Purchased by: ?
Symptoms: Seizure
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-21
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: HTN, BCC, HLD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:
Write-up: brought by EMS to ED; seizures at home in bed; 6 Epi and 1 bicarb; no hx of seizure |
|
| VAERS ID: |
972092 (history) |
| Form: |
Version 2.0 |
| Age: |
88.0 |
| Sex: |
Female |
| Location: |
California |
| Vaccinated: | 2021-01-19 |
| Onset: | 2021-01-19 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL8982 / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death
SMQs:
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: Diabetes Prescription
Current Illness: Diabetes Mellitus
Preexisting Conditions: Diabetes Mellitus
Allergies: None reported
Diagnostic Lab Data:
CDC Split Type:
Write-up: Reportedly, this employee''s mother died the night of the vaccine. The details are not known at this time. |
|
| VAERS ID: |
972113 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Female |
| Location: |
Tennessee |
| Vaccinated: | 2021-01-12 |
| Onset: | 2021-01-13 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Epistaxis,
Lethargy,
Mouth haemorrhage,
Pneumonia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-14
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: Pantoprzole, Miralax, Potassium, buspirone, Aspirin 81mg, Atenolol, Depakote, Glucosamine-chondroitin, mirabegron ER, Zyprexa, Atorvastatin, Ocuviteeye&MVM
Current Illness: Resident was Dx with pneumonia the day after vaccine.
Preexisting Conditions: ENCEPHALOPATHY, UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED,UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE, UNSTEADINESS ON FEET, UNSPECIFIED HEARING LOSS, UNSPECIFIED EAR, DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS, CONSTIPATION, UNSPECIFIED, LONG TERM (CURRENT) USE OF ASPIRIN,MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED , GENERALIZED ANXIETY DISORDER, AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE,HYPERLIPIDEMIA, UNSPECIFIED, LOCALIZED EDEMA, ESSENTIAL (PRIMARY) HYPERTENSIONGASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS, UNSPECIFIED URINARY INCONTINENCE,
Allergies: NKA
Diagnostic Lab Data: No test performed. Resident''s family did not wish for any tx to be provided. Comfort measures only
CDC Split Type:
Write-up: Resident became lethargic and reports of blood coming from resident''s nose and mouth on the morning of 1/13/21. Resident went out to ER for eval, and came back to facility with dx of pneumonia and recommendations for resident to be placed on hospice. Resident deceased on 1/14/21. Unknown if vaccine related, but with timeline of events I was advised to report this per medical director of facility, as well as Pharmacy who administered the vaccine. |
|
| VAERS ID: |
972148 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Female |
| Location: |
Michigan |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Computerised tomogram head,
Fall,
X-ray of pelvis and hip
SMQs:, Accidents and injuries (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-13
Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ATIVAN 0.5MG EVERY 6 HOURS SYNTHROID 75MCG DAILY METOPROLOL TARTRATE 50MG TWICE DAILY MED PASS 2.0 THREE TIMES DAILY COLACE 200MG DAILY DICYCLOMINE 10MG TWICE DAILY NORCO 5-325MG FOUR TIMES DAILY NEURONTIN 100MG TWICE DAILY NEURONTIN 3
Current Illness: RESIDENT SUSTAINED A FALL ON 1/5/2021.
Preexisting Conditions: HYPOTHYROIDISM HYPERTENSION GERD ANXIETY DEPRESSION OSTEOARTHRITIS TRAUMATIC SUBDURAL HEMORRHAGE DEMENTIA HYPERLIPIDEMIA ALZHEIMERS SPINAL STENOSIS ATHEROSCLEROTIC HEART DISEASE PULMONARY FIBROSIS ABDOMINAL HERNIA BLADDER DISORDER
Allergies: NKDA
Diagnostic Lab Data: X-RAY OF PELVIS/HIP CT SCAN OF BRAIN
CDC Split Type:
Write-up: VACCINATION WAS RECEVIED THE MORNING OF 1/5/2021- IN THE EVENING OF THAT DAY RESIDENT SUSTAINED A FALL AND WAS TRASNPORTED TO FACILITY FOR TREATMENT. IT IS NOT UNUSUAL THAT RESIDENT WAS SELF TRANSFERRING AND HAS A HISTORY OF FALLS. |
|
| VAERS ID: |
972167 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Male |
| Location: |
Alabama |
| Vaccinated: | 2021-01-22 |
| Onset: | 2021-01-22 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
032L20A / 1 |
LA / IM |
Administered by: Public 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: 0000-00-00
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None listed
Current Illness: none listed
Preexisting Conditions: none listed
Allergies: None listed
Diagnostic Lab Data: None known
CDC Split Type:
Write-up: Wife reported that 3 hours after receiving vaccine, pt had MI. |
|
| VAERS ID: |
972370 (history) |
| Form: |
Version 2.0 |
| Age: |
60.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2021-01-20 |
| Onset: | 2021-01-21 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / - |
Administered by: Pharmacy Purchased by: ?
Symptoms: Death,
Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-21
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 received covid vaccine and had a heart attack the next day and died |
|
| VAERS ID: |
972392 (history) |
| Form: |
Version 2.0 |
| Age: |
78.0 |
| Sex: |
Female |
| Location: |
Illinois |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-02 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
AR / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: COVID-19,
Death,
General physical health deterioration,
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: 2021-01-25
Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Left femur fx 12-7-20 UTI 12-7-20
Preexisting Conditions: Diabetes Type 1 Rheumatoid Arthritis GERD HTN
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient sent to hospital 1/2 and 1/5. Returned both times to nursing home covid unit without a hospital admission. Resident had been diagnosed with COVID later in the day on 12/30, when routine testing PCR results returned to facility, after resident had already had her first covid vaccination on 12/30/20 in the morning. Resident continued decline, was again sent to hospital on 1/24/21, and expired in hospital 1/25/21. |
|
| VAERS ID: |
972394 (history) |
| Form: |
Version 2.0 |
| Age: |
65.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-19 |
| Onset: | 2021-01-20 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-25 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
UN / SYR |
Administered by: Pharmacy Purchased by: ?
Symptoms: Death
SMQs:
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:
Current Illness: Unknown
Preexisting Conditions: No chronic health conditions
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:
Write-up: Died about 24 hours later |
|
