|
| VAERS ID: |
989015 (history) |
| Form: |
Version 2.0 |
| Age: |
69.0 |
| Sex: |
Male |
| Location: |
Connecticut |
| Vaccinated: | 2021-01-26 |
| Onset: | 2021-01-27 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-31 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL9261 / 2 |
- / IM |
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: 2021-01-27
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: End Stage Renal Disease, NON ST Elevation (NSTEM) Myocardial Infarction,, Type II Diabetes Mellitus, Cardiac Arrest cause unspecified, Paroxysmal atrial fibrillation, acute embolism and thrombosis of unspecified deep veins of right lower extremity, Alzheimer''s disease, Chronis systolic heart failure,
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:
Write-up: Myocardial Infarction |
|
| VAERS ID: |
990034 (history) |
| Form: |
Version 2.0 |
| Age: |
79.0 |
| Sex: |
Male |
| Location: |
Texas |
| Vaccinated: | 2021-01-17 |
| Onset: | 2021-01-31 |
| Days after vaccination: | 14 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-31 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Condition aggravated,
Death,
Rheumatoid arthritis
SMQs:, Arthritis (narrow), Immune-mediated/autoimmune disorders (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-31
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: Rheumatoid arthritis, diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: I helped facilitate scheduling for his COVID vaccine and received notification from his wife that he passed away unexpectedly this morning. She reported he had been experiencing a rheumatoid arthritis flare and was on steroids. His diabetes was not well controlled as a result. He did not have any reactions in the days immediately after the vaccine. |
|
| VAERS ID: |
990780 (history) |
| Form: |
Version 2.0 |
| Age: |
75.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2021-01-25 |
| Onset: | 2021-01-28 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
027L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-28
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: N/A
Current Illness: Marko Cell Carcinoma Matasisized
Preexisting Conditions: was in hospice since 8/11/20 had cancer
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:
Write-up: patient passed |
|
| VAERS ID: |
990956 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Male |
| Location: |
Illinois |
| Vaccinated: | 2021-01-12 |
| Onset: | 2021-01-12 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1283 / 1 |
AR / IM |
Administered by: Senior Living 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Systemic: Other- Patient passed away |
|
| VAERS ID: |
991060 (history) |
| Form: |
Version 2.0 |
| Age: |
88.0 |
| Sex: |
Male |
| Location: |
Pennsylvania |
| Vaccinated: | 2021-01-27 |
| Onset: | 2021-01-28 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 2 |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Anaemia,
Cardiac failure congestive,
Condition aggravated,
Death,
Packed red blood cell transfusion,
Pyrexia,
Unresponsive to stimuli
SMQs:, Cardiac failure (narrow), Haematopoietic erythropenia (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Myelodysplastic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-31
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril 10mg daily, Lasix 40 mg daily, Simvastatin 40 mg daily, Senna 8.6/50mg twice daily, Namenda XR 28mg daily, Protonix 40mg daily, ASA 81 mg daily, Potassium Chloride ER 10 meq daily, Amiodarone 100mg daily, metoprolol 25 mg daily.
Current Illness: Dementia, heart failure, paroxysmal atrial fib.. BHP, HTN, thorasic aortic aneurysm, polyosteoarthritis, history of falls, anemia
Preexisting Conditions: as above Resident was transferred to hospital on 1/28/21. Returned to nursing facility on 1/30 and passed away on 1/31/21.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Fever 101.1, unresponsive episode. Transferred to Hospital on 1/28. Diagnosis there was anemia and CHF, aware that he had vaccine day prior. Transfused with 2 units pRBC''s. Transferred back to Nursing Home on 1/30 and passed away 0140 1/31/2021 |
|
| VAERS ID: |
991080 (history) |
| Form: |
Version 2.0 |
| Age: |
69.0 |
| Sex: |
Male |
| Location: |
Massachusetts |
| Vaccinated: | 2020-12-28 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 9 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-06
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: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient sudden death reported by family. No further details available at this time. |
|
| VAERS ID: |
991117 (history) |
| Form: |
Version 2.0 |
| Age: |
90.0 |
| Sex: |
Female |
| Location: |
California |
| Vaccinated: | 2021-01-28 |
| Onset: | 2021-01-28 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EN5318 / 2 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Dyspnoea,
Oxygen saturation decreased
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Systemic: Other- pt had history of copd and DNR on file. approx 3 1/2hr after vaccine pt had sob and lowo2 sat, emergency services called, pt passed on their arrival.staff felt due to pt existing condition |
|
| VAERS ID: |
991216 (history) |
| Form: |
Version 2.0 |
| Age: |
70.0 |
| Sex: |
Male |
| Location: |
Kansas |
| Vaccinated: | 2021-01-26 |
| Onset: | 2021-01-28 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J202A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death,
Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-28
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: History of Heart Condition
Allergies: NKDA
Diagnostic Lab Data: Unknown
CDC Split Type: 921134 WebIZ #
Write-up: Vaccine given on 01-25-2021. Wife reported on 01-29-2021 that patient had a ran a fever on 01-26-2021, Was better on 01-27-2021. She found him dead when she came home work on the evening of 01-28-2021. |
|
| VAERS ID: |
991622 (history) |
| Form: |
Version 2.0 |
| Age: |
90.0 |
| Sex: |
Female |
| Location: |
Massachusetts |
| Vaccinated: | 2021-01-28 |
| Onset: | 2021-01-29 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 2 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-29
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: 81 mg Aspirin Prevident 5000 Pepcid 20 mg Propafenone 150 mg Biscodyl Suppository Milk of Magnesia Acetaminophen 325 mg Miralax Powder Ferrous Sulfate 325 mg
Current Illness: Cerebral Infarction due to embolism Crohn''s Disease Gastric Reflux Hyperlipidemia HTN SENILE DEGENERATION OF BRAIN, NOT ELSEWHERE CLASSIFIED PRIMARY GENERALIZED (OSTEO)ARTHRITIS
Preexisting Conditions: See Item 11
Allergies: Adhesive Tape (intolerance) Procaine (intolerance)
Diagnostic Lab Data: None.
CDC Split Type:
Write-up: Death |
|
| VAERS ID: |
991677 (history) |
| Form: |
Version 2.0 |
| Age: |
63.0 |
| Sex: |
Female |
| Location: |
Illinois |
| Vaccinated: | 2021-01-21 |
| Onset: | 2021-01-30 |
| Days after vaccination: | 9 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 1 |
RA / IM |
Administered by: Public Purchased by: ?
Symptoms: Death,
Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-31
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: diagnosed with Covid on 12/03/2020
Preexisting Conditions: hypertension, hyperlipidemia, diabetes, GERD
Allergies: Sulfa, Flexeril, trimethoprim
Diagnostic Lab Data:
CDC Split Type:
Write-up: got up in the night and stated that she couldn''t breath, ambulance was called, pt expired in route to hospital. *relayed to me by Facility staff RN. |
|
