|
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. |
|
VAERS ID: |
991849 (history) |
Form: |
Version 2.0 |
Age: |
88.0 |
Sex: |
Male |
Location: |
Minnesota |
Vaccinated: | 2021-01-25 |
Onset: | 2021-01-27 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-01 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
041620A / 2 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Asthenia,
Dyspnoea,
Hypoxia,
Respiratory tract congestion,
Tachycardia SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-28
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: clonazepam, Flomax, Flunisolide Soln., Melatonin, Omeprazole, Miralax, Sertraline, Milk of Mag, Tylenol Current Illness: Preexisting Conditions: Epilepsy, HTN, BPH, ASHD, GERD, Alzheimer''s Disease, Depression, OCD Allergies: NKA Diagnostic Lab Data: nonne CDC Split Type:
Write-up: Congestion, Hypoxia, SOB, Tachycardia, Weakness. Started on O2 @ 3L, HOB elevated, Tylenol supp |
|
VAERS ID: |
991859 (history) |
Form: |
Version 2.0 |
Age: |
89.0 |
Sex: |
Male |
Location: |
Illinois |
Vaccinated: | 2021-01-29 |
Onset: | 2021-01-29 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-01 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012M20A / 1 |
RA / IM |
Administered by: Public Purchased by: ? Symptoms: Asthenia,
Death,
Decreased appetite,
Food refusal,
Memory impairment,
Mobility decreased,
Somnolence,
Urine output decreased,
Visual impairment SMQs:, Acute renal failure (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Depression (excl suicide and self injury) (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-01
Days after onset: 3
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: hospice patient for 1 year Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: Per granddaughter''s report, pt became very weak within hours of receiving the first dose of the Moderna COVID-19 vaccine and could not get out of bed the next morning without assistance, reported difficulty seeing, and did not recognize some family members. By Sunday, 1/31, pt was unable to be awakened, would not eat, and had low urinary output. Granddaughter reports that the morning of 2/1 he was awake and ate a small amount and seemed to be improving although still weak and unable to get out of bed. Granddaughter reported he died 2/1 around 10am in the morning. |
|
VAERS ID: |
991927 (history) |
Form: |
Version 2.0 |
Age: |
86.0 |
Sex: |
Male |
Location: |
North Dakota |
Vaccinated: | 2021-01-05 |
Onset: | 2021-01-12 |
Days after vaccination: | 7 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-01 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
RA / IM |
Administered by: Private Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-12
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: Diphenhydramine HCl, atorvastatin, furosemide, gabapentin, Healthy Eyes (vitamin A, C, & E with lutein minerals), Imodium, Isosorbide mononitrate, Jantoven, Potassium Cl, Metoprolol succinate, Nitroglycerin. Current Illness: Preexisting Conditions: Constipation, acute exacerbation of chronic congestive heart failure , osteoarthritis, mitral and aortic incompetence, abnormal renal function, hernia of abdominal cavity, polyp of colon, coronary arteriosclerosis, atrial fibrillation, aortic valve stenosis, aortic valve disorder, cerebrovascular disease, long term current use of anticoagulant, sick sinus syndrome, edema, gout, angina co-occurrent and due to coronary arteripolyneuropathy, essential hypertension, mixed hyperlipidemia, chronic kidney disease stage 3, chronic systolic heart failure, angina, prosthetic cardiac paravalvular leak, prosthetic heart valve in situ, aortic stenosis-non-rheumatic, macrocytic anemia, diarrhea-occasionally, heart disease, cerebrovascular accident, old MI, Squamous cells carcinoma of skin of face, long QT syndrome- 6/18/2020 PPM placed. Allergies: No known defined allergies. Diagnostic Lab Data: CDC Split Type:
Write-up: Patient was found deceased at Nursing Home in his room 01/12/2021 at 5:25 AM. |
|
VAERS ID: |
991997 (history) |
Form: |
Version 2.0 |
Age: |
71.0 |
Sex: |
Female |
Location: |
Minnesota |
Vaccinated: | 2021-01-28 |
Onset: | 2021-01-30 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-01 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
029L20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Blood glucose increased,
Blood potassium increased,
Cardiogenic shock,
Cold sweat,
Death,
Endotracheal intubation,
Nausea,
Sepsis,
Troponin increased,
Vomiting,
White blood cell count increased SMQs:, Cardiac failure (narrow), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-30
Days after onset: 0
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: Tylenol, Levemir, Humalog, Trazodone, Prozac, Metoprolol, Eliquis, Plavix, Atorvastatin, Pantoprazole, Dialyvite, Renagel Current Illness: COVID + diagnosis (12/17/2020) ASYMPTOMATIC Multiple oral extractions completed by dentist on 1/26/2020 ESRD (on 3x week dialysis-last date of dialysis 1/29/2020) Preexisting Conditions: ESRD, Diabetic, Heart Disease, Vascular Disease, HTN, Allergies: Bactrim/Sulfa, Cyclobenzaprine, Fentanyl, Gabapentin, Lisinopril, Metoprolol, Primidone Diagnostic Lab Data: Multiple test completed during course of ER and hospital stay WBC 16.8, K+ 6.1, Serial Troponins 363, 444, 578 CDC Split Type:
Write-up: Resident c/o nausea evening of 1/29 (nausea common for her post dialysis), had a large emesis at approx 2220, 0030 (unusual for resident to vomit)- received Zofran per order. Skin cool and damp, Blood sugar 147 (checked due to h/o diabetes and poor intake). At approx 230am Blood pressured checked and noted to be 52/29. Resident transferred to ER, intubated and transferred to higher level of care where she passed away on 1/30 at 736pm. Resident''s medical notes indicated likely shock, cardiogenic in nature, sepsis (source unknown) along with a multitude of other co-morbidities that resident has. |
|
VAERS ID: |
992063 (history) |
Form: |
Version 2.0 |
Age: |
80.0 |
Sex: |
Male |
Location: |
Wisconsin |
Vaccinated: | 2021-01-19 |
Onset: | 2021-01-29 |
Days after vaccination: | 10 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-01 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
UNKNOWN / 1 |
- / - |
Administered by: Unknown Purchased by: ? Symptoms: Death,
Dyspnoea,
Hypoxia,
Respiratory depression,
SARS-CoV-2 test positive,
Skin discolouration SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-30
Days after onset: 1
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: Tums, folic acid, hydroxychloroquine (pre-existing prescription to pandemic), pain pump, symbicort inhaler, multi-vitamin, albuterol inhaler, duloxetine, nystatin powder, senna-docusate, tofacitinib citrate, probiotic, polyethylene glycol, Current Illness: Preexisting Conditions: Vascular dementia, swelling of left lower extremity (chronic), subclinical hypothyroidism, STEMI (2014), rheumatoid arthritis, postinflammatory pulmonary fibrosis, posterior tibial tendon dysfunction, paroxsymal atrial fibrillation, osteoporosis, OSA on CPAP, microscopic colitis, interstitial lung disease, hypertension, hx of squamous cell carcinoma of skin, hx of basal cell carcinoma, hearing loss, gout, GERD, dyspnea on exertion, dyslipidemia, diverticulitis, HX of CVA, COPD, chronic heart failure w. preserved ejection fraction, chronic back pain, carotid artery stenosis, CAD, BPH, Barrett''s esophagus, asthma, anxiety, allergic rhinitis, actinic keratosis. Allergies: Amoxicillin (N&V), "poison ivy/treatments" Diagnostic Lab Data: Positive COVID-19 per PCR, 1/29/2021 CDC Split Type:
Write-up: Patient received first dose of the COVID-19 Moderna vaccine on 1/19/2021 at an outside facility (no lot #, route, or site available to me in electronic charting). Pt began having hypoxia, SOB, and a dusky appearance of extremities on 1/29/2021 and was brought by EMS to our hospital. PT is a DNR and family had been looking into a hospice sign up due to dementia and general decline in the weeks prior to hospitalization. Pt tested positive on admission for COVID-19 via PCR test on 1/29/2021. Pt continued to have respiratory decline, was put on comfort care per wishes of family/advanced directives, and he passed away the evening of 1/30. |
|