|
| VAERS ID: |
988369 (history) |
| Form: |
Version 2.0 |
| Age: |
82.0 |
| Sex: |
Male |
| Location: |
Illinois |
| Vaccinated: | 2021-01-19 |
| Onset: | 2021-01-21 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-30 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
026L20A / 1 |
LA / - |
Administered by: Unknown Purchased by: ?
Symptoms: Death,
Pneumonia aspiration
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-22
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: Carvedilol Citalopram Phenytion Olanzapine
Current Illness:
Preexisting Conditions: diabetes gastroparesis MitraClip
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:
Write-up: aspiration pneumonia/death |
|
| VAERS ID: |
991450 (history) |
| Form: |
Version 2.0 |
| Age: |
|
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 0000-00-00 |
| Onset: | 0000-00-00 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-30 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Muscle spasms,
Muscle tightness,
Myalgia,
Neck pain
SMQs:, Rhabdomyolysis/myopathy (broad), Dystonia (broad), Eosinophilic pneumonia (broad), Arthritis (broad), Tendinopathies and ligament disorders (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: Lisinopril, furosemide, omeprazole, amlodipine, meclizine, loratadine
Current Illness:
Preexisting Conditions: Coronary artery disease (CAD); Hypertension (HTN); Renal Disease (e.g. CKD, HD, ESRF)
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: The patient developed left sided neck and trapezoid tightness and pain after receiving the moderna covid vaccine in her left shoulder. The injection site is non tender and does not show any erythema or tenderness. The tenderness is over the left trapezius and left lateral neck area. It also feel tight like a muscle spasm. |
|
| VAERS ID: |
989006 (history) |
| Form: |
Version 2.0 |
| Age: |
58.0 |
| Sex: |
Female |
| Location: |
Virginia |
| Vaccinated: | 2021-01-30 |
| Onset: | 2021-01-30 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-31 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL9263 / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Airway secretion clearance therapy,
Breath sounds abnormal,
Cardiac arrest,
Cardioversion,
Death,
Dyspnoea,
Endotracheal intubation,
Mobility decreased,
Pulseless electrical activity,
Unresponsive to stimuli,
Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (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), Parkinson-like events (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)
Life Threatening? Yes
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? No
Previous Vaccinations:
Other Medications: Per reviewed on medical records: metformin, gabapentin, glipizide
Current Illness: unknown
Preexisting Conditions: diabetes obesity hypoventilation syndrome
Allergies: penicillin latex
Diagnostic Lab Data:
CDC Split Type:
Write-up: After being observed for approximately 20 minutes and patient walked to her car without assistance I was called to assess the patient in the parking lot for troubles breathing. EMS was called as I made my way outside. Upon my arrival patient was leaning out of the car and stating that she could not breath. She was able to tell me that she was allergic to penicillin. Oxygen was immediately placed on the patient with minimal relief. Lung sounds were coarse throughout. She then began to vomit about every 20-30 seconds. Epipen was administered in the right leg with no relief. Patient continued to complain of troubles breathing and vomiting. A second epipen was administered in the patients right arm again with no relief. A few minutes later patient was given racemic epinephrine through the oxygen mask. There appeared to be mild improvement in her breathing as she appeared more comfortable, but still complaining of shortness of breath and vomiting. When EMS arrived patient was unable to transport herself to the stretcher. When EMS and clinical staff transferred patient to the stretcher she became unresponsive. She appeared to still be breathing. She did not respond to verbal stimuli. Per ED report large amount of fluid was suctioned from the patients lungs following intubation in the ambulance. When patient arrived to the ED she was extubated and re-intubated without difficulty and further fluid was suctioned. At that time patient was found to be in PEA, shock was delivered. Shortly thereafter no cardiac activity was found and patient pronounced dead. |
|
| 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 |
|
