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From the 11/19/2021 release of VAERS data:

Found 4,746 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died

Government Disclaimer on use of this data



Case Details

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VAERS ID: 909095 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Colorado  
Vaccinated:2020-12-23
Onset:2020-12-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2020-12-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Foaming at mouth, Pain in extremity, Pallor, Pulse absent, Respiratory arrest, Somnolence, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-25
   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: Tamsulosin 0.4mg, Lactobacillus tablet, Nephro-vite tablet 0.8mg, Allopurinol 100mg, ferrous gluconate 324mg, melatonin 6mg, lisinopril 2.5mg, colace 100mg, metamucil powder, aspirin 81mg, amidoarone 200mg, hydrooxyzine 25mg, cholestyramine
Current Illness: End stage renal disease with dependence on renal dialysis, COPD, cirrhosis of the liver, hypokalemia, gout, heart failure, hyperlipidemia, atrial fibrillation.
Preexisting Conditions: Refused dialysis frequently resulting in episodes of hypokalemia and hospitalization, resident dependent on supplemental oxygen. The resident refused to go to dialysis on 12/23/2020 and said he was feeling fine.
Allergies: alprazolam, Lorazepam
Diagnostic Lab Data: None
CDC Split Type:

Write-up: on 12/24/2020 the resident was sleepy and stayed in bed most of the shift. He stated he was doing okay but requested pain medication for his legs at 250PM. At 255AM on 12/25/2020 the resident was observed in bed lying still, pale, eyes half open and foam coming from mouth and unresponsive. He was not breathing and with no pulse


VAERS ID: 910363 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: California  
Vaccinated:2020-12-23
Onset:2020-12-26
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA LOT 039K20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypophagia, Hypotension, Somnolence
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   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: risperidone daily doxazosin
Current Illness: dementia declining oral intake
Preexisting Conditions: history of aspiration pneumonia BPH
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia.


VAERS ID: 913733 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2020-12-29
Onset:2020-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My grandmother died a few hours after receiving the moderna covid vaccine booster 1. While I don?t expect that the events are related, the treating hospital did not acknowledge this and I wanted to be sure a report was made.


VAERS ID: 914621 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Iowa  
Vaccinated:2020-12-22
Onset:2020-12-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J02A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dementia, Fatigue
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-27
   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: None
Preexisting Conditions: Resident in long term care facility for 9+ years Coronary Artery Disease Dementia Hypothyroidism Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident in our long term care facility who received first dose of Moderna COVID-19 Vaccine on 12/22/2020, only documented side effect was mild fatigue after receiving. She passed away on 12/27/2020 of natural causes per report. Has previously been in & out of hospice care, resided in nursing home for 9+ years, elderly with dementia. Due to proximity of vaccination we felt we should report the death, even though it is not believed to be related.


VAERS ID: 915880 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Montana  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   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: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died within 12 hours of receiving the vaccine.


VAERS ID: 917117 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, 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: 2021-01-01
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Quietapine, Mertazipine, Hydrocodone, Fentanyl
Current Illness: Yes
Preexisting Conditions: Yes
Allergies: None
Diagnostic Lab Data: COVID-19 positive test approximately one week after vaccination. There is no evidence to support that the vaccine caused his death in any way.
CDC Split Type:

Write-up: After vaccination, patient tested positive for COVID-19. Patient was very ill and had numerous chronic health issues prior to vaccination. Facility had a number of patients who had already tested positive for COVID-19. Vaccination continued in an effort to prevent this patient from contracting the virus or to mitigate his risk. This was unsuccessful and patient died.


VAERS ID: 917790 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-29
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, Exposure to SARS-CoV-2, 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: 2021-01-03
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Torsemide, Trazadone, Amitizide, Morphine Sulfate, Fentanyl, Carbidoba-Levodopa, Prednisone, Potassium Chloride, Escalitapram, Incruse Ellipta, Mirtazipane, Clonazepam, Levothyroxine
Current Illness: Patient was a resident of a long term care facility and had numerous chronic conditions prior to vaccination.
Preexisting Conditions: Thyroid disease, chronic elderly conditions.
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: At the time of vaccination, there was an outbreak of residents who had already tested positive for COVID 19 at the nursing home where patient was a resident. About a week later, patient tested positive for COVID 19. She had a number of chronic, underlying health conditions. The vaccine did not have enough time to prevent COVID 19. There is no evidence that the vaccination caused patient''s death. It simply didn''t have time to save her life.


VAERS ID: 917793 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-29
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, 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: 2021-01-02
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol-Tartrate, Latanoprost, Glipizide, Pravastatin, Metformin, Benaprezil, Potassium-Chloride, Levothyroxine
Current Illness: Diabetes, Thyroid disease
Preexisting Conditions: Diabetes, Thyroid Disease
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Prior to the administration of the COVID 19 vaccine, the nursing home had an outbreak of COVID-19. Patient was vaccinated and about a week later she tested positive for COVID-19. She had underlying thyroid and diabetes disease. She died as a result of COVID-19 and her underlying health conditions and not as a result of the vaccine.


VAERS ID: 918065 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: California  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: - Invega Trenza 546mg Q3months - Lithium 300mg BID - Oxybutynin 5mg QID - lipitor 20mg QHS - cogentin 2mg BID - Norvasc 5mg QD - Dyazide Capsule 37.5-25 MG (Triamterene-HCTZ) QD
Current Illness: - covid-19
Preexisting Conditions: - SCHIZOPHRENIA, UNSPECIFIED - ANEMIA, UNSPECIFIED - OVERWEIGHT - OVERACTIVE BLADDER - ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS - HYPOTHYROIDISM DUE TO MEDICAMENTS AND OTHER EXOGENOUS SUBSTANCES - NICOTINE DEPENDENCE, UNSPECIFIED, UNCOMPLICATED - CHRONIC VIRAL HEPATITIS C - UNSPECIFIED AGE-RELATED CATARACT - ESSENTIAL (PRIMARY) HYPERTENSION - CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED - UNSPECIFIED CONVULSIONS - INHALANT ABUSE, UNCOMPLICATED - OTHER SEIZURES
Allergies: - Clozaril - Tegretol
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: 1/1/2020: Residents was found unresponsive. Pronounced deceased at 6:02pm


VAERS ID: 918487 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Michigan  
Vaccinated:2020-01-02
Onset:2021-01-04
   Days after vaccination:368
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L2OA / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Two days post vaccine patient went into cardiac arrest and passed away.


VAERS ID: 918518 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2020-12-31
Onset:2020-12-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Cardio-respiratory arrest, Death, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   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: To be determined
Current Illness: To be determined
Preexisting Conditions: To be determined
Allergies: To be determined
Diagnostic Lab Data: Autopsy being performed
CDC Split Type:

Write-up: syncopal episode - arrested - CPR - death


VAERS ID: 919537 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-03
Onset:2021-01-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   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: Robitussin Cough+Chest Cong DM Liquid 5-100 MG/5ML (Dextromethorphan-guaiFENesin) Tylenol Extra Strength Tablet (Acetaminophen) amLODIPine Besylate Tablet 5 MG Morphine Solu Tab 2.5MG Capsaicin Cream 0.025 % Leflunomide Tablet 10 MG Levothy
Current Illness: Resident had suspected vasovagal episode with drop in O2 saturation.
Preexisting Conditions: ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE RHEUMATOID ARTHRITIS, UNSPECIFIED ANEMIA, UNSPECIFIED HYPOTHYROIDISM, UNSPECIFIED CACHEXIA ESSENTIAL (PRIMARY) HYPERTENSION DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE AGE-RELATED PHYSICAL DEBILITY OTHER CHRONIC PAIN DILATED CARDIOMYOPATHY ERYTHEMATOUS CONDITION, UNSPECIFIED UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE PRIMARY GENERALIZED (OSTEO)ARTHRITIS OTHER SPONDYLOSIS WITH RADICULOPATHY, LUMBAR REGION HYPERKALEMIA OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE CERVICALGIA OTHER BIOMECHANICAL LESIONS OF LUMBAR REGION ??? BILATERAL PRIMARY OSTEOARTHRITIS OF KNEE LOCALIZED EDEMA HYPO-OSMOLALITY AND HYPONATREMIA OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE HISTORY OF FALLING WEAKNESS
Allergies: Celebrex and Tramadol
Diagnostic Lab Data: N/A.
CDC Split Type:

Write-up: Resident exhibited no adverse events during 30 minute monitoring following vaccine administration. Resident found without pulse at 1900.


VAERS ID: 920326 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Indiana  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Erythema, Hospice care, Localised oedema, Skin warm
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Cetirizine, Lactaid
Current Illness: G30.1 Alzheimer''s disease with late onset (Primary) M19.90 Unspecified osteoarthritis, unspecified site J44.9 Chronic obstructive pulmonary disease, unspecified I95.1 Orthostatic hypotension J45.909 Unspecified asthma, uncomplicated R13.12 Dysphagia, oropharyngeal phase M15.0 Primary generalized (osteo)arthritis M85.80 Other specified disorders of bone density and structure, unspecified site Note: Osteopenia J30.9 Allergic rhinitis, unspecified F41.1 Generalized anxiety disorder M24.511 Contracture, right shoulder M24.512 Contracture, left shoulder M24.521 Contracture, right elbow R29.3 Abnormal posture M17.4 Other bilateral secondary osteoarthritis of knee M25.561 Pain in right knee R26.89 Other abnormalities of gait and mobility Z74.1 Need for assistance with personal care Z91.81 History of falling M62.81 Muscle weakness (generalized) R29.6 Repeated falls R27.8 Other lack of coordination R63.3 Feeding difficulties E73.8 Other lactose intolerance R53.1 Weakness I95.89 Other hypotension
Preexisting Conditions: G30.1 Alzheimer''s disease with late onset (Primary) M19.90 Unspecified osteoarthritis, unspecified site J44.9 Chronic obstructive pulmonary disease, unspecified I95.1 Orthostatic hypotension J45.909 Unspecified asthma, uncomplicated R13.12 Dysphagia, oropharyngeal phase M15.0 Primary generalized (osteo)arthritis M85.80 Other specified disorders of bone density and structure, unspecified site Note: Osteopenia J30.9 Allergic rhinitis, unspecified F41.1 Generalized anxiety disorder M24.511 Contracture, right shoulder M24.512 Contracture, left shoulder M24.521 Contracture, right elbow R29.3 Abnormal posture M17.4 Other bilateral secondary osteoarthritis of knee M25.561 Pain in right knee R26.89 Other abnormalities of gait and mobility Z74.1 Need for assistance with personal care Z91.81 History of falling M62.81 Muscle weakness (generalized) R29.6 Repeated falls R27.8 Other lack of coordination R63.3 Feeding difficulties E73.8 Other lactose intolerance R53.1 Weakness I95.89 Other hypotension
Allergies: Lactose
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Redness and warmth with edema to right side of neck and under chin. Resident was on Hospice services and expired on 1.1.21


VAERS ID: 920368 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Indiana  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Body temperature increased, Chest X-ray abnormal, Decreased appetite, Dyspnoea, Erythema, Full blood count, Hospice care, Influenza virus test negative, Lung infiltration, Metabolic function test, Respiratory rate increased, Vital functions abnormal, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Acetaminophen, Atenolol, Colace, Lisinopril, Mirtazapine, Omeprazole, Simvastatin, Vitamin D3
Current Illness: F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Preexisting Conditions: U07.1 2019-nCoV acute respiratory disease (Primary) F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Allergies: quinine sulfate
Diagnostic Lab Data: Influenza Swab: 12/30/20-Negative Results CBC: 12/30/20 showed WBC of 14.1 (H) CMP: 12/30/20 showed BUN: 113 (H); Creatinine 2.7 (H) CXR: 12/30/20 showed: Conclusion: A mild left lower lung infiltrate
CDC Split Type:

Write-up: 12/30/2020 07:02 AM Resident noted to have some redness in face and respiration were fast. Resident vital signs were abnormal except blood pressure. Temp at the time was 102.0 F taken temporal. Resident respirations were 22 labored at times. Pulse is 105 and pulse ox 94% on room air. Resident is made comfortable in bed. Notified triage of change in condition also made triage aware of resident receiving Covid vaccination yesterday morning. Resident appetite and fluid consumption has been poor for few days. 12/30/2020 07:32 AM Received order from agency to administer Acetaminophen 650mg suppos rectally due to resident not wanting to swallow anything including fluids, medications and food. This writer administered medication as NP ordered. Will monitor for effectiveness and adverse effects if any. 12/30/2020 08:41 AM Received new orders to obtain Flu swab, obtain CBC and BMP, and Chest Xray all to be obtained today. Notified family of resident having temperature and vital signs excluding b/p that was abnormal. Family was thankful for call and inierated to nurse that family does not want resident sent to hospital. Did educate family on benefits of Hospice services, but family persistant on continued daily care provided by nursing staff. Requests visits if decline continues. Family assured if resident continues to decline, facility will accomandate resident family to be able to be at bedside when time comes to do so. NP ordered IVF and IV Levaquin on 12/31/20. Family chose at that time to sign for Hospice services and not have resident provided with IVF or IV Antibiotics


VAERS ID: 920815 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-30
Onset:2021-01-04
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: Per employee health records HTN, DM, Breast CA 2016 with radiation, obesity, gastric sleeve 10 years ago, arthritis, plantar fasciitis, ankle tendonitis, DeQuarvains, carpal tunnel, anxiety
Allergies: Lisinpril, Codeine, Latex , environmental (hay fever)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found deceased in her home, unknown cause, 6 days after vaccine.


VAERS ID: 921547 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-01-02
Onset:2021-01-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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 Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Pain. elevated Temp. Phone Active 05/08/2020 05/08/2020 AmLODIPine Besylate Tablet 10 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYP
Current Illness: CEREBRAL INFARCTION, UNSPECIFIED(I63.9), LONG TERM (CURRENT) USE OF ASPIRIN(Z79.82), VITAMIN DEFICIENCY, UNSPECIFIED(E56.9), ACUTE KIDNEY FAILURE, UNSPECIFIED(N17.9), HYPERKALEMIA(E87.5), ACUTE RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA(J96.00), PURE HYPERCHOLESTEROLEMIA, UNSPECIFIED(E78.00), PAIN IN RIGHT FOOT(M79.671), ESSENTIAL (PRIMARY) HYPERTENSION(I10), ACIDOSIS(E87.2), ABNORMAL LEVELS OF OTHER SERUM ENZYMES(R74.8), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), DISORDER OF THYROID, UNSPECIFIED(E07.9), GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS(K21.9), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES(M62.59), COGNITIVE COMMUNICATION DEFICIT(R41.841), UNSPECIFIED LACK OF COORDINATION(R27.9), OTHER DYSPHAGIA (R13.19), OTHER CHRONIC PAIN(G89.29), HYPOTHYROIDISM, UNSPECIFIED(E03.9), DRY EYE SYNDROME OF UNSPECIFIED LACRIMAL GLAND (H04.129), METABOLIC ENCEPHALOPATHY(G93.41), UNSPECIFIED CONVULSIONS(R56.9), POLYNEUROPATHY, UNSPECIFIED(G62.9), TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA(E10.319), NASAL CONGESTION(R09.81), BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC(J40), HYPOKALEMIA(E87.6), ELEVATED WHITE BLOOD CELL COUNT, UNSPECIFIED(D72. 829), OTHER MALAISE(R53.81), CELLULITIS OF RIGHT LOWER LIMB(L03.115), CELLULITIS OF LEFT LOWER LIMB(L03.116), EDEMA, UNSPECIFIED (R60.9), IRON DEFICIENCY ANEMIA, UNSPECIFIED(D50.9), CUTANEOUS ABSCESS, UNSPECIFIED(L02.91), COVID-19(U07.1)
Preexisting Conditions: UNCONTROLLED DIABETES MELLITUS ON INSULIN
Allergies: NKDA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DEATH ON 1/4/2021, RESIDENT RECIEVED VACCINE ON 1/2/20


VAERS ID: 921572 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Death, Fall, Hip fracture, Oxygen saturation decreased, Pain, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl
Current Illness: Heart Failure
Preexisting Conditions: Chronic Kidney Disease, Atherosclerotic Heart Disease
Allergies: Lisinopril, Losartan
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident had body aches, a low O2 sat and had chills starting on 12/30/20. He had stated that they had slightly improved. On 1/1/21 he sustained a fall with a diagnosis of a displaced hip fracture. On 1/2/21 during the NOC shift his O2 sat dropped again. He later went unresponsive and passed away.


VAERS ID: 922977 (history)  
Form: Version 1.0  
Age: 71.0  
Sex: Male  
Location: New York  
Vaccinated:2020-12-21
Onset:2020-12-27
   Days after vaccination:6
Submitted: 2020-12-28
   Days after onset:1
Entered: 2021-01-05
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Pyrexia, Respiratory depression, SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever, RespDepression & COVID positive REMDESIVIR (EUA) 200 mg x1 then 100 mg daily


VAERS ID: 923993 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2020-12-30
Onset:2021-01-02
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   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: No
Preexisting Conditions: History of stage II (T3N0) appendiceal carcinoma - s/p resection Dec 2014. CAD s/p stenting Diabetes Mellitus Hyperlipidemia Hypertension Glaucoma
Allergies: Hay fever
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was vaccinated Dec 30, 2020. Prime dose of Moderna vaccine. Observed for full 15 minutes post-injection. No complaints when asked during observation. Released. Subsequently, vaccine clinic staff learned from the patient''s supervisor that on Jan 4, 2021 that the patient had expired on Jan 2, 2021. By report from the supervisor, the patient was found dead at his home. The patient''s primary care provider was unaware of his death when contacted by this reporter today (Jan 6, 2021). Electronic Medical Record without any information since the vaccination.


VAERS ID: 924126 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Michigan  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium
Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.
Preexisting Conditions: CHF, Heart Failure, hypertension, Atrial-fibrillation, Crohns disease.
Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: resident expired 1/1/2021


VAERS ID: 924186 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Michigan  
Vaccinated:2020-12-30
Onset:2021-01-03
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   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: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired 1/3/21


VAERS ID: 924664 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-01-02
Onset:2021-01-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O11L20A / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram abnormal, Death, Intracranial aneurysm, Pulmonary oedema, Unresponsive to stimuli, X-ray abnormal
SMQs:, Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Metoprolol succ ER 50mg 1 tab PO daily Omeprazole DR 20mg 1 cap PO daily Amlodipine besylate 5mg 1 tab PO daily Aspirin 81mg 1 tab PO daily Carbamazepine ER 100mg 1 tab PO TID Docusate 100mg 1 cap PO daily Multivitamin 1 tab PO daily Olmesa
Current Illness: none
Preexisting Conditions: history of stroke, hyperlipidemia, dementia, GERD, and macular degeneration
Allergies: Hydrochlorothiazide
Diagnostic Lab Data: CT scan, X ray 1/5/2021
CDC Split Type:

Write-up: At approximately, 1855, I was alerted by caregiver, resident was not responding. Per caregiver, she was doing her rounds and found resident in bed, unresponsive, mouth open, observed gurgling noises and tongue hanging out of mouth. This primary caregiver observed resident at baseline and ambulating after dinner at approximately, 1800 less than an hour prior to incident. This PCG called 911 for EMS and gave report of incident. Resident was taken to Medical Center Emergency Department. At ER, CT scan and X-ray was performed. Per report from ER RN, CT scan and x-ray revealed an intracranial aneurysm and fluid in the lungs. Per RN, resident was still unresponsive and was admitted to Medical Center for observation and comfort measures. This primary caregiver reported to RN, resident recently received the first dose of COVID-19 vaccine on 1/2/21. Primary caregiver received a call from Castle RN at 0700, resident expired at 0615.


VAERS ID: 925154 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-03
Onset:2021-01-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: Avorstatin Aspirin Oxycodone
Current Illness: NONE
Preexisting Conditions: COPD
Allergies: None
Diagnostic Lab Data: Hospital
CDC Split Type:

Write-up: Deceased


VAERS ID: 925264 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2020-12-31
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norco 5/325 1 tablet every 6 hours as needed. Warfarin 4mg , 2 tablets orally Monday and Friday Torsemide 100mg, 1/2 tablet orally once a day Sabcubitril-Valsartan 24/26mg 1/4 tablet orally twice a day Gabapentin 300mg, tablet once daily Ca
Current Illness: CHF HTN DM 2 CKD Obesity DDD
Preexisting Conditions: CHF HTN DM 2 CKD Obesity DDD
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: PT was found deceased in his home on 1/5/2021


VAERS ID: 926600 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-04
Onset:2021-01-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 37K20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

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: Diabetes, renal insufficiency
Preexisting Conditions: Diabetes, renal insufficiency
Allergies: Penicillin, ibuprofen
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient did not report any signs or symptoms of adverse reaction to vaccine. Patient suffered from several comorbidities (diabetes and renal insufficiency). Patient reported not feeling well 01/06/2021 and passed away that day.


VAERS ID: 926797 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2020-12-31
Onset:2021-01-01
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / IM

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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: This is a 93 year old with significant heart issues?EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine
Preexisting Conditions: Heart disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: had a vaccination on 12/31/2020 late morning passed away early morning 01/01/2020. This is a 93 year old with significant heart issues. EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine.


VAERS ID: 927260 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2020-12-28
Onset:2021-01-06
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood lactic acid increased, Bradycardia, Cardiac arrest, Computerised tomogram head normal, Death, Heart sounds abnormal, Pulse absent, Respiration abnormal, Resuscitation, SARS-CoV-2 test negative, Unresponsive to stimuli, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Lactic acidosis (narrow), 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), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (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? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vit D3, Miralax, Spironolactone, Tramadol, Metoprolol Succinate, MOM, Ferrous Gluconate, Ondansetron, Nitroglycerin Sublingual PRN, PreserVision AREDS, Fluticasone Propionate Suspension, Lisinopril, Clopidogrel Bisulfate, Campor-Methol-Met
Current Illness: Digestive Surgery for bowel obstruction
Preexisting Conditions: HTN, AAA, Chronic Diastolic Heart Failure, Diabetes Type 2, Paroxysmal atrial fibrillation, bradycardia, Hx of STEMI, Hx of CVA, HX of uterine cancer,
Allergies: Codeine, Meperidine, Morphine, Estrogens, Penicillins, Tetanus Toxoids
Diagnostic Lab Data: Brain CT negative WBC and lactic acid increased. COVID 19 on 1/4/21 negative
CDC Split Type:

Write-up: No adverse effects noted after vaccination. Patient with cardiac history was found unresponsive at 16:45 on 1/6/21. Abnormal breathing patterns, eyes partially closed SPO2 was 41%, pulseless with no cardiac sounds upon auscultation. CPR and pulse was regained and patient was breathing. Patient sent to Hospital ER were she remained in an unstable condition had multiple cardiac arrest and severe bradycardia and in the end the hospital was unable to bring her back.


VAERS ID: 928513 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-05
Onset:2021-01-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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: Amiodarone Hcl, Carvedilol, Ferrous sulfate, Eliquis (cont)
Current Illness: Atrial fibrillation, Anemia, 1st degree AV block, CDK stage 4,
Preexisting Conditions: CDK stage 4, Atrial fibrillation, 1st degree AV block, Patient was under hospice care
Allergies: Aldactone, contrast dye
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident passed away in her sleep


VAERS ID: 928933 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Iowa  
Vaccinated:2020-12-23
Onset:2021-01-08
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Resuscitation
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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 had been diagnosed with COVID-19 on Dec. 11th, 2020. Symptoms were thought to have started on 12/5/2020. Received Moderna vaccine on 12/23. Unexpected death on 1/8/2021. Resuscitation attempts unsuccessful


VAERS ID: 929764 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Washington  
Vaccinated:2020-12-28
Onset:2020-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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: Hydrochlorthiazide (by record, not confirmed)
Current Illness:
Preexisting Conditions: Hypertension, sleep apnea, obesity. based on medical record
Allergies: no known allergies recorded in medical record
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient was found deceased at home about 24 hours after immunization. Date of Death:: 12/29/2020; estimated time of death 6:00pm


VAERS ID: 929997 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-04
Onset:2021-01-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dysphagia, Feeding disorder, Lethargy, Mobility decreased, Speech disorder
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   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: Amlodipine 5 mg daily, Dexamethasone 4 mg daily (for itching related to renal failure), Isosorbide dinitrate 30 mg daily, Levothyroxine 0.075 mg daily, Bisoprolol 5 mg BID, Furosemide 80 mg BID, saline nasal spray, Tylenol 1000 mg PO TID
Current Illness: none acute
Preexisting Conditions: He was on hospice for about the last 1 month for CHF (EF 20-25%) and renal failure (creat 3-4). He was on hospice but was up and around and able to eat and take pills. The day after he had his injection, he was very lethargic and only mumbled. Was not able to take meds or eat. He was on hospice, so did not want work-up or treatment. He passed away on 1/7 am. We don''t know if it was a coincidence that he died or if the vaccine caused him to deteriorate more quickly.
Allergies: Losartan, lisinopril, metoprolol
Diagnostic Lab Data: He did not have testing at that point because he was on Hospice.
CDC Split Type:

Write-up: Patient received vaccine on 1/4/2021. He was in Hospice for CHF and renal failure, but was able to get up in his wheelchair and eat and take medications and talk. On 1/5/2021 am, he was noted to be very lethargic an could only mumble, could not swallow. No localizing neurologic findings. He was too lethargic to get up in chair.


VAERS ID: 930154 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K2020A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: unkown
Preexisting Conditions: unknown
Allergies: Sulfa
Diagnostic Lab Data:
CDC Split Type: VFC # 21109

Write-up: Notified today that he passed away. No other details known at this time.


VAERS ID: 930487 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / -

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: 2021-01-08
   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: calcium-D tablet, cholecalciferol, fish oil, melatonin, tylenol,
Current Illness: na
Preexisting Conditions: bph, apraxia, , dysphagia, muscle weakness, alzheimers disease
Allergies: cephalexin
Diagnostic Lab Data: na
CDC Split Type:

Write-up: Medical docter state patient has a acute cardiac attack


VAERS ID: 930876 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, X-ray with contrast
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: Prostate Cancer
Allergies:
Diagnostic Lab Data: Had IV dye imaging procedure after he received the COVID-19 vaccine (the same day in the afternoon) and passed away overnight.
CDC Split Type:

Write-up: Death


VAERS ID: 930910 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: Patient was refusing to take all medications for over a year
Current Illness: None
Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation
Allergies: Metformin, morphine, statins, latex
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm.


VAERS ID: 951518 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2020-12-28
Onset:2021-01-04
   Days after vaccination:7
Submitted: 2021-01-05
   Days after onset:1
Entered: 2021-01-09
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Death, SARS-CoV-2 test negative, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: Specimen: NASOPHARYNX. Specimen Collection Date: Dec 29, 2020@09:45 Test name Result units Ref. range Site Code COVID-19 (M2000) Not Detected
CDC Split Type:

Write-up: Narrative: Patient with severe aphasia and only able to say "hey, hey, hey" or "uh huh" or shake his head no as a way to communicate. Patient previously able to ambulate with significant limp and hyperextension of right knee, but mostly wheelchair bound over last several years as he had had a slow and steady decline in overall health and mobility. Patient developed aggressive behavior of shouting "hey" and grabbing of groin in 2016. This was worked up with CT scans, labs, referral to urology, neurology, and referrals to psychiatry. The exact etiology of this action was never able to be affirmed, but thought to be more psychiatrically related. It improved significantly with addition of antipsychotics, worsened when antipsychotics were reduced, and improved again with addition of injectable antipsychotic on 12-10-2020.Patient suffered from falls on occasion given his significantly impaired physical mobility. His last documented fall was 8-31-2019. Patient began utilizing wheelchair most of time following that fall. No significant injuries noted in documentation of the falls. In the last 3 months, patient would often refuse medications. He would sometimes indicate that they would cause dizziness, and other times he would simply refuse. We attempted to hide medications in his food/fluid (with wife''s blessing) and when he detected this he would occasionally refuse to eat. Patient previously on DOAC. After pharmacy review in 12/2020 it was recommended to discontinue this as no clear indication to continue use. He was high fall risk and would often refuse this medication as well since 10/2020. Noted to be in NSR on EKGs and decision made to discontinue the DOAC. Patient had no evidence of adverse effects noted after vaccination on December 28th. Patient seen by provider on the morning of his death (1/4/2021) with no noticeable significant change in health condition. Temperature 36.8Con January 4th at 19:45. During routine bedtime cares, patient suddenly collapsed and death was pronounced January 4, 2021 at 20:05. Autopsy was requested from next of kin and no autopsy was granted. Symptoms: & DEATH Treatment:


VAERS ID: 956903 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-22
Onset:2020-12-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asymptomatic COVID-19, 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: 2020-12-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: mi Narrative: patient with asymptomatic covid 19, covid positive 12/10/2020.


VAERS ID: 956966 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-25
Onset:2020-12-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Body temperature increased, Complication associated with device, Cough, Dyspnoea, Hypoxia, Secretion discharge
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: hypoxia, secretions,cough, dyspnea Narrative: ALS patient on hospice with ongoing history of aspiration pna, receiving tube feeds. Developed incr in secretions, hypoxeia, temp and with recently noted clogged feeding tube.


VAERS ID: 933578 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-08
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       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: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021


VAERS ID: 933846 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-01-02
Onset:2021-01-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 077L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Back pain, Cardiac disorder, Death, Dizziness, Pain in extremity
SMQs:, Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: NONE
Current Illness: MACULAR DEGENERATION 10 YEARS OR MORE
Preexisting Conditions: NONE
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1-2-2021 10:30 PM Complained Right arm/back hurt - took Tylenol 1-3-2021 Complained Right arm hurt, dizzy 1-4-2021 Felt better - did laundry, daughter found her deceased at 3:30 pm. Dr. at hospital said it was "cardiac event" according to death certificate.


VAERS ID: 934050 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Fall, Posture abnormal, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: Patient was a resident in Group Home Current Medications Treatments/PRN Medications: Start Date: 04/02/14: Benztropine 2mg tab BID (8-8) 02/27/15: Midodrine (Proamatine) 5mg tab TID (8-12-8) 12/30/15: Cetirizine 10mg tab daily @8am 1
Current Illness: No Acute Illnesses
Preexisting Conditions: Diagnosis: - Impulse Control Disorder - Epilepsy - Tardive Dyskinesia - Ulcerative Proctitis and Colitis - Mental Retardation (mod) - Hammer toes (bilat.) - Dermatitis (scalp/torso) - Seborrheic keratosis of left armpit - Major Depression - Infantile Meningitis - History of Squamous Cell Carcinoma (L arm)
Allergies: Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Staff reported that patient was found Friday morning (Jan 8) sitting at a table with his head tilted forward and unresponsive to verbal or physical stimuli. Staff lowered patient to floor and started CPR. EMS was called and continued CPR at scene, however they were not able to revive patient. Patient was pronounced dead at the scene. Staff written statements following the death of patient show that he had a fall about 1 hr. prior. It is unknown if this fall contributed to patient''s death. An autopsy has been requested.


VAERS ID: 934263 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Malaise, 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: 2021-01-02
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Again, I cannot confirm the results of any test, i.e., COVID or other, because the patient is independent and sought care independent of the center.
CDC Split Type:

Write-up: The resident resides in an independent living facility/apartment. The reporter at the center was informed by his daughter he was not feeling well on 1/1/2021 (specific symptoms could not be ascertained). He reportedly went to be COVID tested on 1/1/2020 and observed to be deceased in his apartment on 1/2/2020. I do not have confirmation of his COVID results, although the reporter indicates his daughter reports his test was positive.


VAERS ID: 934539 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA D12L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Autopsy, Blood test, Culture tissue specimen, Death, Toxicologic test, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   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: Singulair, Oxybutynin, Fosamax, Prednisone, Meloxicam, Eliquis, Bumetanide, Triamcinolone cream, Klor-Con, Lisinopril, Promethazine,
Current Illness: Cellulitis of left lower limb (12/2020)
Preexisting Conditions: Hypertension
Allergies: No known allergies
Diagnostic Lab Data: Postmortem examination was performed at the State Medical Examiner Office on January 10, 2021 (MEC21-0019). Tissue samples were obtained for histology and red top/tiger top/purple top tubes of blood were obtained for potential further studies. Samples of blood and vitreous humor were also obtained and submitted to AXIS Laboratories for toxicologic analysis.
CDC Split Type:

Write-up: Patient received COVID-19 (Moderna) vaccine from the Health Department on afternoon of January 8, 2021 and went to sleep approximately 2300 that night. Was found unresponsive in bed the following morning and pronounced dead at 1336 on January 9, 2021


VAERS ID: 935222 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-12-30
Onset:2021-01-07
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   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: Oxybutynin Chloride, Lasix 80mg, hydyralazine 50mg, amlodipine 10mg, amitriptyline 10mg, ASA, Klor-Con 20meq, Tylenol, allopurinol 100mg, Vit D3, turmeric 400mg, Lipitor 80mg, gabapentin 100mg, baclofen 5mg, candesartan 32mg, insulin lispro
Current Illness: No acute illnesses
Preexisting Conditions: Diabetes, CKD, CHF, HTN
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was reported to be deceased at home by law enforcement on 1/7/21


VAERS ID: 935350 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Texas  
Vaccinated:2020-12-31
Onset:2021-01-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me
Current Illness: Dyspnea, Shortness of breath
Preexisting Conditions: Paroxysmal atrial fibrillation Hypertension Chronic iron deficiency anemia Congestive heart failure with chronic diastolic
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive at home with SpO2 20% 1/2/2021


VAERS ID: 935511 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MODERNA / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   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: none known of
Preexisting Conditions: history of vaginal adenocarcinoma- removed with surgery in 2019
Allergies: latex (skin reaction)
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received the 1st dose of Moderna and was found deceased in her home the next day.


VAERS ID: 936043 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-04
Onset:2021-01-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   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: atorvastatin,senna,MultiVitamin,Metamucil,metformin,Levothyroxine
Current Illness: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Preexisting Conditions: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Allergies: PENICILLINS
Diagnostic Lab Data:
CDC Split Type:

Write-up: RESIDENT 1ST DOSE OF MODERNA VACCINE ADMINISTERED ON 01/04/2021 AT 8:30PM, RESIDENT FOUND UNRESPONSIVE ON 01/05/2021.


VAERS ID: 936805 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2020-12-22
Onset:2021-01-11
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   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: See Continuation Field
Current Illness: Whiplash injury to neck. Sprain of ligaments of cervical spine
Preexisting Conditions: Septal defect (heart), chronic sinusitis
Allergies: Ceftriaxone
Diagnostic Lab Data: None associated.
CDC Split Type:

Write-up: Patient received the vaccine on 12/22/20 without complication. It was reported today that the patient was found unresponsive and subsequently expired at home on 1/11/21.


VAERS ID: 937127 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, 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: 2021-01-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Mirtazapine, Fentanyl Patch,
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The facility had positive cases of COVID when we were able to begin vaccinating residents. Within about a week of vaccination, patient was tested positive for COVID. He was 91 years old and his immune system did not have the time to allow the vaccine to begin working before exposure. His age was a major contributing factor to his death.


VAERS ID: 937152 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: 2021-01-11
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol, Cephalexin, Brimonidine, Donepezil, Losartan, Latanoprost, Timolol
Current Illness: High blood pressure, pain, eye issues
Preexisting Conditions: Blood pressure, pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The facility had positive cases for COVID 19 when the vaccine was received and administered to patient. With her advanced age and chronic conditions, she did not have time to build immunity between the time of vaccination and her testing positive.


VAERS ID: 937186 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: 2021-01-10
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrocodone-Acetamenaphin, Lidocaine, Cefritriaxone, Citalopram
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The facility had a number of positive COVID 19 cases prior to patients vaccination. Due to her advanced age, chronic condition, and exposure, patient did not have the time to build immunity after exposure before becoming positive.


VAERS ID: 937434 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-01-07
Onset:2021-01-11
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20 / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   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: None known
Preexisting Conditions: only had 1 lung
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt expired due to possible cardiac arrest. Unsure if this was vaccine related.


VAERS ID: 937569 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-01-02
Onset:2021-01-07
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   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 reported expired 1/7/2021


VAERS ID: 937818 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-07
Onset:2021-01-09
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   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: HTN CAD Stemi with stent placement BPH
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This is being reported because of the incident occurring 2 days after the Moderna Covid-19 vaccination. It was reported that the patient expired on 1/9/21, 2 days after receiving the Moderna vaccine. Upon screening of patient prior to administration on 1/7/21, the patient completed paperwork answering NO to the following "Do you currently have any active infections or acute respiratory illness or fever."


VAERS ID: 939050 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: New York  
Vaccinated:2020-12-28
Onset:2020-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aphasia, Cough, Death, Endotracheal intubation, Hemiparesis, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), 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), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 6
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: Morbid obesity and hypothyroidism
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient vaccinated on 12/28. Approximately one day later, develops cough and on azithromycin x 1 week. On 1/3, patient develops left-sided weakness and aphasia. Taken to the hospital, tested COVID+, required intubation -- acute hypoxic respiratory failure secondary to COVID - on H&P. Patient died on 1/4/21 at 7:20am.


VAERS ID: 963163 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-01-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative:


VAERS ID: 940602 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-08
Onset:2021-01-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K209 / 5 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Injection site pain, Myocardial infarction, Pain, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (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: see attached
Current Illness: None reported
Preexisting Conditions: HTN, Type II DM, High cholesterol
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine on 1/8/2021. On 1/9/2021 I checked on patient via phone for symptoms or problems and he reported none but mild soreness at injection site. On 1/10/2021 family friend called me to tell me that patient had expired at about 8:00 pm. Patient reportedly complained of "pain" unspecific and collapsed at home. Hospital reportedly told family that it appeared to be a "heart attack".


VAERS ID: 940855 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / SYR

Administered by: Senior Living       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? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LORazepam Solution 2 MG/ML
Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.
Preexisting Conditions: Resident on hospice care due to end of life.
Allergies: None
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received her vaccination on 1/12/21 administered by pharmacy*+. She expired on 1/12/21 an approximately 7:30pm. Resident did not have any adverse reactions and was a hospice patient.


VAERS ID: 940866 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-01-07
Onset:2021-01-09
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Cardiac arrest, Cardio-respiratory arrest, Death, Pulse absent, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   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: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr
Current Illness: None
Preexisting Conditions: Hypothyroidism, Bipolar, Profound ID, HTN, Osteopenia, dysphagia, aphasia, TBI as a young adult,Muscle spasm, Hernia
Allergies: Loxapine, Thioridazine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found "acting abnormal" on 1/9/2021 at 1215. VS HR 20-30''s. EMS activated. EMS arrived and patient was found pulseless in PEA/ asystole, CPR and ACLS initiated and then transported to the MC. Unsuccessful resuscitation and expired on 1/09/2021 at 1348. Clinical impression Cardiopulmonary arrest.


VAERS ID: 941561 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Decreased appetite, Grip strength decreased, Hemiplegia, Hypotonia, Speech disorder, Weight decreased
SMQs:, Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   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: Escitalopram Oxalate, Metformin ER, Systane balance, Colace, Refresh tears, Milk of Magnesia, Diltiazem
Current Illness: Resident was on hospice for Alzheimer''s disease.
Preexisting Conditions: Alzheimer''s Disease, Type II diabetes, Major depression disorder, Elevated B/P readings with Hypertension, history of stroke (7/22/2019 - Acute Lacunar Stroke)
Allergies: No known Allergies
Diagnostic Lab Data: Resident was declining for some time. He normally had a high heart rate. Appetite was poor with a significant weight loss noted.
CDC Split Type:

Write-up: Staff walked into resident''s room around 10:00am and noted resident''s left side of his face was flaccid. Nurse was called and upon assessment resident noted to have an unequal hand grasp with left worse. He was able to talk but was mumbled and hard to understand. Physician, hospice, and family were notified. Resident had a stroke at 10:06 am on 1/8/2020. He lost all ability to use his left side. Resident passed away on 1/11/2020.


VAERS ID: 941607 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Anal incontinence, Death, Hypotonia, Unresponsive to stimuli
SMQs:, Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Tylenol 325mg, Lasix 20mg, Senna 8.6mg, Aspirin 81mg, Levothyroxine 75mcg
Current Illness: N/A
Preexisting Conditions: End stage dementia, cerebro vascular disease, Hx left vertebral artery aneurysm
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: The patient passed away today, 1/13/2021. She was a hospice patient. She showed no adverse effects after receiving the vaccine on 1/12/2021. This morning she woke up as normal and during her morning shower she had a bowel movement, went limp and was non-responsive. The patient passed away at 7:45 am.


VAERS ID: 941743 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Amitiza, Anastrozole, Calcium Carbonate, Levemir, Novolog, Docusate, Fiber Lax, Fluvoxamine Maleate, Gavilax, Glucerna, Ketoconazole, levetiracetam, loratadine, Selenium sulfide lotion, vimpat, vitamin D3, Prolia AS needed medications: fle
Current Illness: None
Preexisting Conditions: Benign polycythemia, Type II DM, Anxiety, Epilepsy, Blepharitis (bilateral), cataract (not specified), Allergic rhinitis, constipation, scoliosis, osteoporosis, dyspahgia, urinary incontinence, Dermatitis, breast cancer (right breast lumpectomy), history of respiratory infection, DNR AND MOLST were in place at time of death
Allergies: No known drug or food allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: This person was found to be deceased on routine rounds during the night, 3am. No symptoms of reaction noted post vaccine. No injection site reaction. No reports of any allergic reaction.


VAERS ID: 941811 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-04
Onset:2021-01-11
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Albumin urine present, Bacterial test positive, Chest X-ray abnormal, Death, Hypoxia, Lung infiltration, Pyrexia, Respiratory distress, Respiratory failure, SARS-CoV-2 test negative, Sepsis, Urine leukocyte esterase positive, White blood cell count normal, White blood cells urine positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), 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 (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (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: Haldol 2mg TWICE DAILY, DEPAKENE 750MG THREE TIMES
Current Illness: NONE
Preexisting Conditions: HUNTINGTON''S CHOREA, HTN, HLP, HYPOTHYROID, DEPRESSION, CONSTIPATION, AND DYSPHAGIA
Allergies: NKDA & NO FOOD ALLERGIES
Diagnostic Lab Data: CXR on 1/11/21: Suspicion of minimal infrahilar infiltrates bilaterally. U/A on 1/11/21: Leuk Esterase 3+, Albumin 2+, Few Bacteria, White cells 10 CBC on 1/11/21: WBC 8.9
CDC Split Type:

Write-up: Resident began having fever on 1/11/21 @0600. VS= T-102 B/P- 100/57 P- 112 RR- 24 O2 Sat 92% on RA. MD called. Rapid COVID Test was negative. CBC,CMP, U/A were ordered as well as CXR. Resident''s condition declined. At 3:00pm resident started having respiratory distress and hypoxia O2 Sat 89%. Supplemental O2/mask @ 5LPM. Neb TX, EKG, and Rocephin 1 GM ordered. Condition worsened. Resident sent to nearest ER for evaluation. Later in the evening the staff AT Medical Center called to inform staff that resident had expired @ 2230 as a result of Respiratory Failure and Sepsis.


VAERS ID: 943362 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-13
Onset:2021-01-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Autopsy, Death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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 none reported
Current Illness: none known
Preexisting Conditions: none
Allergies: none reported
Diagnostic Lab Data: currently undergoing preliminary autopsy
CDC Split Type:

Write-up: Pt collapsed at home approx 5:30 pm and died


VAERS ID: 943889 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Other       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: 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: Alvesco, Amiodarone, Lipitor, Atrovent, Coreg, Cymbalta, Guaifenesin, Keppra, Levothroid, Megace, Protonix, Potassium, Prednisone, Rifampin, Carafate, Bactrim, Flomax
Current Illness: Rigth femur fracture, GI bleed
Preexisting Conditions: Hypertension, seizure, hypothyroidism, CHF
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse reactions observed after administration of medication. Patient starting complaining of shortness of breath around 0500 the following morning. SP02 checked in the 80s. Patient expired 01/09/2021;


VAERS ID: 944641 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Atorvastatin 80mg daily, biotin 2500mg daily, Calcium-Mag-Zinc tab daily, Restasis eye drop q12hr, ezetimibe 10mg qhs, gabapentin 100mg bid, lysine 1000mg daily, metoprolol tart 50mg bid, fish oil 1000mg daily, prilosec 20mg daily, ranola
Current Illness: CAD, angina, coronary bypass in 1990''s, Cardiac Cath on 12/28/2020
Preexisting Conditions: CAD
Allergies: Sulfa
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient died on 1/21-2021


VAERS ID: 944732 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K2OA / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pulse absent, Unresponsive to stimuli
SMQs:, 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), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cholecalciferol, furosemide, metoprolol tartrate, tamsulosin, amlodipine, finasteride
Current Illness: Covid-19 infection from 12/31-01/10/2021
Preexisting Conditions: CHF, atrial fibrilation, Dysphagia, macular degeneration, Vitamin D deficiency, impaired fasting glucose, benign prostatic hyperplasia, osteoporosis, retention of urine, anemia
Allergies: hydrocodone
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Resident found unresponsive and without pulse at 05:45am.


VAERS ID: 963167 (history)  
Form: Version 1.0  
Age: 88.0  
Sex: Male  
Location: Delaware  
Vaccinated:2021-01-02
Onset:2021-01-04
   Days after vaccination:2
Submitted: 2021-01-08
   Days after onset:4
Entered: 2021-01-14
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE


VAERS ID: 1349711 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2020-12-22
Onset:2021-01-07
   Days after vaccination:16
Submitted: 2021-01-11
   Days after onset:4
Entered: 2021-01-14
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD039K20A / 2 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Cardio-respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   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: Symptoms: & cardiopulmonary arrest Treatment: EPINEPHRINE 8 MG Unknown during code


VAERS ID: 1349910 (history)  
Form: Version 1.0  
Age: 85.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-07
Onset:2021-01-07
   Days after vaccination:0
Submitted: 2021-01-08
   Days after onset:1
Entered: 2021-01-14
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Symptoms: & Death


VAERS ID: 946293 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-07
Onset:2021-01-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, Death, Hypoxia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), 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 (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alvesco inh, Mepron susp, Coreg, Zetia, Tricor, Umeclidinum, Cellcept, Zyprexa, Prilosec, paxil, Miralax, prednisone, trazodone, xopenex inh
Current Illness: Pulmonary fibrosis on O2
Preexisting Conditions: COPD,Severe pulmonary fibrosis,HTN,GERD
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: 51 year old M with h/o O2 dependent COPD, Severe pulmonary fibrosis became increasingly hypoxic around 1800hours 1/7/2021. He was transported to hospital for acute on chronic hypoxia respiratory failure. On 1/12/2021 he decompensated further, and after discussing with family and palliative care, He was changed to comfort care. He expired on 1/12/2021@2325 at medical center.


VAERS ID: 947129 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Georgia  
Vaccinated:2020-12-23
Onset:2020-12-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Death
SMQs:, 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: 2021-01-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Digoxin, Diltiazem CR, Namenda CR, Toprol XL, Acetaminophen, Vitamin D, Zyrtec
Current Illness: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Preexisting Conditions: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received Moderna vaccine on 12/23/2020 around 5 pm. At approximately 3:35 am on 12/25/2020, resident had a CVA and died on 1/1/2021 at 3:00 am.


VAERS ID: 947662 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, Hypophagia, Hyporesponsive to stimuli, Somnolence
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC Split Type:

Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death


VAERS ID: 947841 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: unknown.
CDC Split Type:

Write-up: Patient had no immediate effects from the vaccine, but died approximately 8 hours after receiving first dose of vaccine.


VAERS ID: 947891 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2020-12-29
Onset:2021-01-08
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus, Benzapril, Metoprolol, Fluticasone, Aspirin, Tylenol, Miralax, Multiple Vitamin, Glipizide, Gabapentin, Vitamin D
Current Illness: Diabetes, Dementia, Hypercholesterolemia, Malignant Neoplasm of Pancreas, Hypertensive Chronic Kidney Disease, Athlerosclerotic Heart Disease
Preexisting Conditions: As above
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident experienced an overall decline in condition on 1/8/21 and continued to decline until he passed away on 1/13/21.


VAERS ID: 948164 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-06
Onset:2021-01-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 02SL20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Chest X-ray, Chest pain, Computerised tomogram, Computerised tomogram abdomen, Confusional state, Decreased appetite, Full blood count, Headache, Hepatic enzyme increased, Metabolic function test
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 7
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: Multivitamin, Zinc, Doxycycline, Ultram, Xanax, Pepcid, Nitroglycerin, Tylenol, Simethicone, Metoprolol Succinate ER, Loperamide, Levothyroxine,
Current Illness: UTI and Sinus infection
Preexisting Conditions: Encephalopathy, Type 2 diabetes, Morbid obesity, hypothyroidism, CKD, HTN, iron deficiency anemia, Atrial fibrillation, IBS,
Allergies:
Diagnostic Lab Data: CT- 1/14/21, chest x-ray 1/14/21 & 1/15/21, abdomen CT 1/14/21; CBC, CMP, Liver panel 1/14/21
CDC Split Type:

Write-up: Abdominal pain, Headaches, chest pain, loss of appetite, confusion, elevated liver enzymes 1/8-1/15/21


VAERS ID: 948181 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Michigan  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Heart rate irregular
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

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: ANORA, Albuterol, Flovent, Bumex, Carvediol; omeprazole
Current Illness:
Preexisting Conditions: COPD, CHF, renal; ASCVD; MI hx
Allergies: 0
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Chest pain; irreg heart rhythm; evening of vaccine; death on toilet on 1/13/21


VAERS ID: 948428 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / SYR

Administered by: Pharmacy       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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: We got a call from a home health nurse Brandu Talamo, stating that the patient passed away.


VAERS ID: 949474 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Respiratory arrest, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Respiratory failure (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Melatonin 3mg PO QHS Amlopidine Besylate 5mg PO QD Atorvastin Calcium 20mg PO QHS Carbidopa-Levodopa 25-100mg PO TID Multiple Vitamin 1 PO QD Senna 8.6mg PO BID Calcium-Vitamin D 600mg PO BID Metformin HCl 500mg PO BID Rivastigmine patch 9
Current Illness: None but he has History of COVID-19 previously when initially admitted to the facility.
Preexisting Conditions: Parkinson''s Disease, Diabetes Mellitus Type 2, Hyperlipidemia, Dementia, ASHD, Psychosis, Hypertension, Dysphagia, Acute Sinusitis
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident had lunch on 01/14/21 and after lunch around 2:00pm, he vomited and stopped breathing. We coded the resident and 911 paramedics came. They pronounced him dead at 2:18pm.


VAERS ID: 949523 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-13
Onset:2021-01-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical condition abnormal, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

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: Ascorbic Acid Tablet 500 MG GT QD Multi-Vite Liquid (Multiple Vitamins-Minerals) 15 ml GT QD Famotidine Tablet 20 MG GT BID Memantine HCl Tablet 10 MG GT BID Polyethylene Glycol 3350 Kit 7gm GT QD Senna Tablet 8.6 MG (Sennosides) 2 tablets
Current Illness: None
Preexisting Conditions: History of Stroke, Diabetes Mellitus Type 2, Dementia, Dysphagia, Depression, Pressure Injuries Sacral and Left Heel
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Around 00:50am on 01/15/21, C.N.A. reported that the resident looked different and not responding. Initiated Code Blue and started CPR. 911 arrived and pronounced resident dead at 1:01 am.


VAERS ID: 949630 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-01-02
Onset:2021-01-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure decreased, Death, Hypophagia, Hypotension, Hypoxia, Oxygen therapy, Tachypnoea
SMQs:, Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Senna-S, cranberry pills
Current Illness: Redness to left foot about 1 week prior to vaccination that resolved a few days prior
Preexisting Conditions: Advanced Dementia, Seizure disorder, CAD, prior stroke, HTN
Allergies: Simvastatin
Diagnostic Lab Data: None as she was under hospice care
CDC Split Type:

Write-up: This patient has been under hospice care for over 2 years at the nursing home. She has had a steady decline with gradual weight loss. She was totally dependent in her care needs. She received the vaccine on 1/2/2021 as part of the facility vaccination campaign. No adverse events noted initially. On 1/3/2021 at 6:06 pm, she was noted on vital sign checks (done every 4 hours for first 72 hours after vaccination) with BP 64/52 but otherwise asymptomatic. Subsequent BP improved. On 1/4/2021 at 4:45 am, pt found with respiratory rate of 30 with otherwise normal vital signs. Tachypnea persisted, so she received liquid morphine 2.5 mg without improvement. Supplemental oxygen was applied. Tachypnea persisted. She had poor oral intake after that point had persistent tachypnea and worsening hypoxemia despite clear lungs on exam. She remained under hospice care and comfort measures were continued. No blood testing or imaging tests were done. She required increasing amounts of oxygen, became hypotensive, and died peacefully on 1/8/2021 at 7:45 pm.


VAERS ID: 950057 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

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:
Current Illness:
Preexisting Conditions: Hydrocephalus with ventricular shunting Prior history of leukemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient suffered a cardiac arrest and was unable to give details about her symptoms. Per husband, patient did not complain of any symptoms after vaccine administration. She began seizing without warning which was complicated by cardiac arrest of uncertain etiology


VAERS ID: 950073 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Body temperature increased, Death, Headache, Lethargy, Mycobacterium tuberculosis complex test negative, Neck pain, Respiration abnormal, Tremor, Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Arthritis (broad), Respiratory failure (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: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC Split Type:

Write-up: On 1/15/2021 at 1800, resident noted to be lethargic and shaking, stating "I don''t care." repeatedly. C/O head and neck pain. T100.6. Given Tylenol with no relief of pain. Order received for Aleve and administered.. Assisted to bed as usual in evening. Monitored during night shift and noted to be resting comfortably/sleeping.. Noted agonal breathing at 4:10 AM 1/16/2021 , T 99.4, Absence of vital signs at 4:15AM 1/16/21 and death pronounced at 4:40AM 1/16/21.


VAERS ID: 950108 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-12
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Catheterisation cardiac abnormal, Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 3
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: Unknown
Current Illness: Pt. stated she was not ill at the time of vaccination.
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: "Moderna COVID-19 Vaccine EUA" It has been reported to me that pt. had gone into hospital for a heart catheterization on 1/12/2021. It was found during this procedure that pt. had suffered a MI. She was release to home the following day and passed away at her residence on 1/15/2021.


VAERS ID: 967747 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-13
Onset:2021-01-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt passed away evening of 1/13 - unknown reason currently Narrative:


VAERS ID: 950979 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / SYR

Administered by: Public       Purchased by: ?
Symptoms: Death, Headache
SMQs:

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: allopurinol -Zyoprim 3000 mg amlodipine Norvasc 5 mg Lispro 100/unit /ml ups us to 150 unit daily per insulin scale Levemir U-100 - 100/unit/ml - (3ML) 55 units nightly Levothryoxine -Synthroid - 137 mcg - daily Simvastatin 25 mg - d
Current Illness:
Preexisting Conditions: IPF - Idoipathic Pulmonary Fibrosis Diabetic
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Headache after dose was given at 10:00 a.m Died at after 7:30 pm the same night the dose was given.


VAERS ID: 951688 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-01-02
Onset:2021-01-17
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: Diclofenac Sodium Gel 1 %, Atorvastatin Calcium Tablet 40 MG, Acetaminophen Tablet 325 MG, Melatonin Tablet 3 MG, Vitamin D3 Tablet 25 MCG, Iron Tablet 325, Multivital-M Tablet, Eliquis Tablet 5 MG, metFORMIN HCl Tablet 500 MG, NIFEdipine
Current Illness: 11/25/20 Lower mid back abscess 11/4/20 toenail removal
Preexisting Conditions: CEREBRAL INFARCTION DUE TO UNSPECIFIED OCCLUSION OR STENOSIS OF LEFT MIDDLE CEREBRAL ARTERY, PRESENCE OF AUTOMATIC (IMPLANTABLE) CARDIAC DEFIBRILLATOR, UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE, APHASIA, DYSPHAGIA, UNSPECIFIED, WEAKNESS, COVID-19, OTHER REDUCED MOBILITY, URINARY TRACT INFECTION, SITE NOT SPECIFIED, ABNORMAL WEIGHT LOSS, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, VITAMIN DEFICIENCY, UNSPECIFIED, VITAMIN D DEFICIENCY, UNSPECIFIED, ANEMIA, UNSPECIFIED, CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE, CHRONIC KIDNEY DISEASE, STAGE 2 (MILD), ESSENTIAL (PRIMARY) HYPERTENSION, GOUT, UNSPECIFIED, INSOMNIA, UNSPECIFIED
Allergies: No Known Allergies
Diagnostic Lab Data: na
CDC Split Type:

Write-up: Resident expired 1/17/21


VAERS ID: 952713 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Missouri  
Vaccinated:2020-12-30
Onset:2021-01-12
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 4
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: Diabetes, Parkinson Disease
Allergies: PCN, Zithromax, Flomax
Diagnostic Lab Data: PCR and antigen test
CDC Split Type:

Write-up: Weakness, Low O2, death. Positive for COVID on 1/12/21, dies on 1/16/21


VAERS ID: 952881 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-10
Onset:2021-01-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Blood albumin decreased, Blood chloride decreased, Blood potassium normal, Blood sodium decreased, Blood urea normal, Brain natriuretic peptide increased, Carbon dioxide increased, Death, Dyspnoea, Glomerular filtration rate, Haematocrit decreased, Haemoglobin decreased, Lymphocyte count decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Neutrophil count normal, Oedema, Red blood cell count decreased, Red cell distribution width increased
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasix, Timolol Maleate, Benefiber, Pravastatin, Multivitamin, Carbidopa ER 50-Levodopa 200 daily; Carbidopa ER 50-Levodopa 200 2 tabs daily, I-vite, Lactobacillus; Metoprolol Succinate; Tamsulosin, Finasteride, Oxubytynin
Current Illness: Edema, Hypokalemia, Hypertensive heart with heart failure
Preexisting Conditions: Parkinson''s Disease; COPD; Heart failure unspecified; Old myocardial infarction, Overactive bladder, Hyperlipidemia, Adult Failure to thrive, Urinary retention, Constipation unspecified, Unspecified urinary incontinence, Benign prostatic hyperplasia, other seasonal allergies rhinitis, unspecified glaucoma, mild cognitive impairment, Pressure ulcer of right heel, history of falling, dependence in wheelchair, COVID-19 on 11/23/2020
Allergies: No known allergies
Diagnostic Lab Data: RBC 3.72; HGB 9.8; HCT 32.7; MCH 26.3; MCHC 30; RDW 15.2; Neut # 7.18; Lymph # 0.97; NA 135; K 5.0; CL 97; CO2 34; BUN 11; CRT 0.76; ALB 1.9; ALT/SGPT 6; GFR $g60; BNP 415
CDC Split Type:

Write-up: Resident was seen by MD on 1/11/2021 due to increasing in edema and shortness of breath. Lasix 40 mg STAT given. New orders to get a STAT CBC, CMP, and BNP. Resident has been dependent on Oxygen since his diagnosis of COVID-19 on 11/23/2020. Labs were abnormal. Continued on the lasix 40 mgs. Resident remained short of breath with exertion and on oxygen. He was assisted to the toilet on 1/15/2021 in the morning where he subsequently passed away.


VAERS ID: 953129 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-09
Onset:2021-01-18
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Arthralgia, Back pain, Cardiac arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: none known
Preexisting Conditions: hypertension; colon cancer (recovered); smoker
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient presented to our Emergency Department via EMS in full code status; asystole. Patient expired. Per nursing, husband stated patient awoke this AM and reported pain in back between shoulders and in bilateral shoulders. Patient then went unresponsive and husband called EMS.


VAERS ID: 953348 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Ibuprofen, Oxybutinin, Morphine Sulfate
Current Illness:
Preexisting Conditions: Chronic pain, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was living in a nursing home with positive cases when administered. His age and chronic condition was such that he did not have time after the vaccination to avoid exposure or develop immunity.


VAERS ID: 953785 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-07
Onset:2021-01-16
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, 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: Hypersensitivity/ anaphylaxis to standard flu vaccine (egg containing) ~ 20 years ago. Of note, did tolerate FluBlok this past
Other Medications: No scheduled medications Tylenol and Zyrtec as needed
Current Illness: None
Preexisting Conditions: None Known
Allergies: Egg (anaphylaxis) Chicken
Diagnostic Lab Data: Autopsy pending
CDC Split Type:

Write-up: Death


VAERS ID: 953858 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-08
Onset:2021-01-13
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Seroquel, ibandronate, atenolol, Lexapro, simvastatin, acetaminophen, estradiol, famotidine, calcium citrate, antacid, donepezil, ferrous sulfate, Probiotic Pearls Complete, memantine, Antifungal cream, potassium chloride, Creon, bisacodyl
Current Illness: COVID-19, ARDS, enterocolitis, Sepsis, UTI, Acute renal failure
Preexisting Conditions: Chronic kidney disease, dementia with lewy bodies, COPD, GERD, anxiety, anemia, osteoarthritis, unspecified heart failure, paroxysmal atrial fibrillation
Allergies: nka
Diagnostic Lab Data: general decline starting 1/10/2021 - patient deceased 1/13/2021
CDC Split Type:

Write-up: patient started to decline 1/10/2021, patient seen at facility by medical professional - patient deceased 1/13/2021


VAERS ID: 954780 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-05
Onset:2021-01-13
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Vomiting
SMQs:, Acute pancreatitis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Norvasc 10mg daily Multivitamin daily Vitamin C 500mg twice daily Folic Acid 1mg daily Aspirin 81mg daily Thiamine 100mg daily Coreg 6.25mg twice daily Ativan 0.5mg three time daily Cymbalta 30mg daily ProStat 30ml three time daily D
Current Illness: None
Preexisting Conditions: Essential Hypertension Anxiety Disorder Unspecified Convulsions Pulmonary Candidiasis Paroxysmal atrial fibrillation Occlusion and stenosis of carotid arteries Congestive Heart Failure Left below the knee amputation Peripheral Vascular Disease Hypokalemia Urinary Retention
Allergies: Shellfish/Seafood
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: On 1/13/2021, resident had sudden emesis. Immediately following emesis he was noted without a pulse and pronounced deceased. No acute symptoms noted prior to this episode. Resident does have a significant cardiac history.


VAERS ID: 955425 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-05
Onset:2021-01-15
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031C20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Depressed level of consciousness
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: amlodipine, aricept, bactrim, namenda, remeron
Current Illness: pressure ulcer
Preexisting Conditions: alxheimer''s, depression, vitamin D deficience, BPH
Allergies: PCN
Diagnostic Lab Data: none
CDC Split Type:

Write-up: resident had a pressure ulcer to RT hip, was getting treatment on. Was scheduled to have wound debrided and wound vac applied on 1-19-2021. Appetite was poor, not wanting to get out of bed, and decline in alertness. Passed away on 1-16-2021


VAERS ID: 955959 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-01-11
Onset:2021-01-18
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0399K20-2A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: alfuzosin, allopurinol. amlodipine, aspirin, Sinemet, vitamin D, multivitamin, Lexapro, finasteride, mirtazipine, ropinirole, trospium
Current Illness: recently diagnosed with progressive supranuclear palsy
Preexisting Conditions: BPH, HTN, gout, GERD, hyperlipidemia
Allergies: none
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died 1 week after vaccination. According to family was having very rapid decline in status in recent weeks and they did not think related to vaccination.


VAERS ID: 956811 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-18
Onset:2021-01-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Resident was noted unresponsive, no respiration, no blood pressure, no pulse, code blue called according to facility protocol, resident is full code, CPR started, 911 called, arrived and took over from staff. Resident was pronounced dead at 1:16pm 1/18/21


VAERS ID: 956994 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Dyspnoea, Rash
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cholecalciferol, duloxetine, fenofibrate, gabapentin, hydrocortisone suppository, melatonin, metformin, metoprolol succinate, mineral oil, nitroglycerin, omeprazole, pravastatin, quetiapine, selenium sulfide shampoo, quetiapine, sumatriptan
Current Illness:
Preexisting Conditions: Hypertension, Type II diabetes, hyperlipidemia, GERD
Allergies: Aspirin, penicillin, vicodin, acetaminophen, niacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient had severe shortness of breath resulting in cardiac arrest on the 5th day after the vaccine. Shortness of breath started 12 hours after injection. On the 5th day, the patient was discovered to also have a rash throughout his body, but it is unknown when this rash started.


VAERS ID: 957116 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-01-14
Onset:2021-01-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Military       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: 2021-01-18
   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: Atovastatin, Ferrous sulfate, Finasteride, Flomax, Humulin N, Pantoprazole, ProAir, Reglan, Spiriva, Turmeric
Current Illness: Diabetes, Chronic renal failure on hemodialysis, Atrial fibrillation, Quadriplegia, Thrombocytopenia, Gastroparesis, Vitamin D deficiency, BPH, Neurogenic bladder, distant history of small intestine carcinoid tumor, right cerebral artery aneurysm, Barrett''s esophagus, MGUS, Hypertension, obstructive sleep apnea, Pulmonary hypertension, Junctional tachycardia.
Preexisting Conditions: see above. Sudden death without warning likely due to medical problems above but spouse feels it was somehow related to the vaccine 4 days before and it is a new vaccine.
Allergies: Cipro caused nausea, Coreg caused bradycardia, Hydrocodone, calcium acetate
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Sudden death without warning symptoms 4 days after vaccine. Many medical problems which most likely explain the outcome but spouse feels it is related and it is a new vaccine. Monitor for pattern?


VAERS ID: 957799 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-14
Onset:2021-01-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Confusional state, Death, Electrocardiogram, Full blood count normal, Metabolic function test, Troponin normal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Respiratory failure (broad), Hypoglycaemia (broad)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: sotaloL (BETAPACE) 80 mg Tablet omeprazole (PRILOSEC) 20 mg Capsule, Delayed Release(E.C.) sevelamer carbonate (RENVELA) 800 mg Tablet polyethylene glycol 3350 (MIRALAX PO) acetaminophen (TYLENOL EXTRA STRENGTH PO) fluticasone propionate (F
Current Illness:
Preexisting Conditions: HTN AAA with endovascular stent ESRD COPD
Allergies: Lipitor
Diagnostic Lab Data: CBC - unremarkable CMP - stable known renal disease otherwise unremarkable Troponin normal EKG - non acute
CDC Split Type:

Write-up: Presented to Urgent Care for weakness and confusion, transferred to ED, patient had a cardiac arrest and was unable to be resuscitated


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