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From the 10/15/2021 release of VAERS data:

Found 4,236 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died



Case Details

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VAERS ID: 1737079 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-07-19
Onset:2021-08-19
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939902 / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aneurysm, Death, Fall, Headache, Malaise
SMQs:, Accidents and injuries (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   Days after onset: 37
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: None
Current Illness: None
Preexisting Conditions: None
Allergies: Penicillin
Diagnostic Lab Data: Rushed to emergency hospital 9/25/2021 then air lifted to another HCF
CDC Split Type:

Write-up: Severe headache within 4 hours of shot and after 4 days of feeling very unwell Pt stood up and fell over instantly of and aneurysm and died .I lost my partner of 23 years due to vaccination


VAERS ID: 1737140 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-01-19
Onset:2021-08-28
   Days after vaccination:221
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   Days after onset: 28
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 29 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: MS, HTN
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Diagnosed, hospitalized and expired from COVID-19


VAERS ID: 1737160 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-02-23
Onset:2021-09-21
   Days after vaccination:210
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-26
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Morbid obesity, CKD stage 3, Hx CVA, Lupus, CHF
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Diagnosed, hospitalized and expired from COVID


VAERS ID: 1737167 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-11
Onset:2021-08-19
   Days after vaccination:189
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EM9810 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Bronchiectasis, COVID-19, Cough, Death, Pulmonary embolism, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Anaphylactic reaction (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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-26
   Days after onset: 7
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:
Current Illness:
Preexisting Conditions: Cardiovascular disease
Allergies:
Diagnostic Lab Data: 08/19/2021 PCR+ COVID-19 test
CDC Split Type:

Write-up: Breakthrough COVID-19 case with symptom onset 8/19/2021: Cough. Hospitalized 8/19/2021 for unknown duration. Death 8/26/2021. Vital records COD = ACUTE HYPOXIC RESPIRATORY FAILURE, COVID-19. Per vital records, COD ICD Codes include: Not yet coded ; Other Significant Conditions include: BRONCHIECHIECTASIS PULMONARY EMBOLUS; Place of death: HOSPITAL;


VAERS ID: 1737230 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Missouri  
Vaccinated:2020-12-30
Onset:2021-06-02
   Days after vaccination:154
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK AR / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK AR / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Autopsy, Chest X-ray, Hernia, Laboratory test, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   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: Labetalol arorvastin
Current Illness: None
Preexisting Conditions: None
Allergies: Nka
Diagnostic Lab Data: Labs, chest xray
CDC Split Type:

Write-up: On 06/02/2021 my father started having extreme abdominal pain. He visited er and was sent home with a surgeon follow up in one week. They said he had a hernia However no hernia was noted on autopsy report. He died suddenly on the morning of 6/9/2021 just before surgeon appointment


VAERS ID: 1737314 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-27
Onset:2021-01-30
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure decreased, Blood test abnormal, Malaise
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: My mom had COVID-19 in December 2020 and was determined to be "out of danger" on 12/16. She had had a dry cough on 12/3, and a PCR test returned positive on that day. I believe she had loss of taste a day or two before 12/3. My mom was put on oxygen support during her COVID-19 illness. This was very unusual for my mom to require oxygen.
Preexisting Conditions: My mother had many long-standing health conditions, however none of them were related to respiratory issues or required her to be on oxygen.
Allergies:
Diagnostic Lab Data: See #18.
CDC Split Type:

Write-up: On Jan. 30, 2021, my mom''s blood pressure dropped, she was placed on oxygen support, and a blood panel indicated elevated risk of blood clotting. This was shortly after receiving a dose of Moderna COVID vaccine on or about Jan. 27. These symptoms seemed very similar to what she had experienced in December when she contracted COVID.


VAERS ID: 1737322 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-02-26
Onset:2021-09-26
   Days after vaccination:212
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-26
   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: Pt. developed COVID-19 virus and passed away on 9/26/21


VAERS ID: 1737341 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-14
Onset:2021-09-10
   Days after vaccination:149
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death, Oxygen saturation decreased
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-26
   Days after onset: 16
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:
Current Illness:
Preexisting Conditions: Coronary artery disease with stent, pacemaker, GERD, dyslipidemia, Hypertension, Non-insulin dependent diabetes mellitus, chronic kidney disease stage IIIB
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fully vaccinated on 3/16/21 and 4/14/21 with moderna covid vaccines. Admitted to hospital with COVID pneumonia requiring nasal cannula oxygen initially. Oxygen requirements increased and patient later required high flow oxygen. Patient was admitted on 9/10/21 and expired on 9/26/21


VAERS ID: 1737526 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-09-08
Onset:2021-09-21
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 035C21A / 3 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: General physical health deterioration, Hypotension, Hypoxia, Tachycardia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   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: Voltaren Gel 1 % (Diclofenac Sodium)Apply 1 application transdermally two times a day, Acetaminophen Liquid 160 MG/5ML give 30 ml by mouth three times a day, Refresh Optive Advanced Solution 0.5-1-0.5 % (Carboxymeth-Glycerin-Polysorb)Instil
Current Illness: Resident had been admitted to hospice in April 2021 d/t terminal diagnosis of Alzheimer''s dementia. He continued to have issues with dysphagia and needed a mechanically altered diet. He had increase difficulty was speech and making needs known. He was w/c bound and required total assistance.
Preexisting Conditions: Hypertensive heart and chronic kidney disease with heart failure, Diabetes Mellitus, Parkinson''s Disease, Alzheimer''s dementia, anemia, BPH, TIA
Allergies: TB Skin test
Diagnostic Lab Data: None due to end of life wishes.
CDC Split Type:

Write-up: Resident was administered 3rd dose d/t immunocompromising condition. He was on hospice at the time of vaccination living in a nursing home. He was observed to have a blood pressure lower than normal on 9/21/21 and hypoxia and tachycardia. The resident received morphine. He continued to decline and was provided comfort/end of life care.


VAERS ID: 1738486 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-17
Onset:2021-08-12
   Days after vaccination:148
Submitted: 0000-00-00
Entered: 2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Vaccine breakthrough infection
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-14
   Days after onset: 33
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 27 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol, amlodipine, insulin, vitamin D, Advair, levothyroxine, lisinopril, melatonin, metoprolol, omeprazole
Current Illness:
Preexisting Conditions: Diabetes, hypertension, hyperlipidemia, hypothyroidism, chronic kidney disease
Allergies: Keflex, atorvastatin, niacin, penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient experienced breakthrough COVID infection despite getting vaccine. She passed away on 9/14/21.


VAERS ID: 1738603 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-09-17
Onset:2021-09-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038C21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-18
   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: Ill and weak for at least a month that pushed off 2nd dose
Preexisting Conditions: Immunocompromised
Allergies: Patient and son verified that patient had no allergies, nor any history of allergic reactions or anaphylaxis
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine administration was uneventful. Patient and son confirmed that patient was cleared for vaccine and that she was well during and after the observation period. No signs of distress and no abnormality of breathing.


VAERS ID: 1739176 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-26
Onset:2021-09-10
   Days after vaccination:168
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-10
   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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death


VAERS ID: 1740065 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Texas  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Multiple heart attack patients (4 to 5); 2 people died; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (2 people died) and MYOCARDIAL INFARCTION (Multiple heart attack patients (4 to 5)) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced DEATH (2 people died) (seriousness criteria death and medically significant) and MYOCARDIAL INFARCTION (Multiple heart attack patients (4 to 5)) (seriousness criteria hospitalization and medically significant). The patient died on an unknown date. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, MYOCARDIAL INFARCTION (Multiple heart attack patients (4 to 5)) outcome was unknown. Concomitant medications were not reported. Multiple people had heart attacks after vaccine. Two people died after getting the COVID-19 vaccine. Treatment information was not provided. Company Comment: This case concerns a patient of unknown gender and age, with no relevant medical history, who experienced the unexpected events of myocardial infarction and death. Cause of death was unknown. The events occurred after a dose of mRNA-1273. Very limited information regarding this case and this event has been provided. The benefit-risk relationship of mRNA-1273 is not affected by this report. This case was linked to MOD-2021-323668, MOD21-144997 (Patient Link).; Sender''s Comments: This case concerns a patient of unknown gender and age, with no relevant medical history, who experienced the unexpected events of myocardial infarction and death. Cause of death was unknown. The events occurred after a dose of mRNA-1273. Very limited information regarding this case and this event has been provided. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1740088 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: California  
Vaccinated:2021-06-17
Onset:2021-07-30
   Days after vaccination:43
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood pressure increased, Cerebrovascular accident, Death, Inappropriate schedule of product administration, Pneumonia aspiration, Sepsis, Urinary tract infection
SMQs:, Neuroleptic malignant syndrome (broad), 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), Hypertension (narrow), Medication errors (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-10
   Days after onset: 42
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: elevated blood pressure; Result Unstructured Data: elevated blood pressure
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: stroke; UTI; sepsis; aspiration pneumonia; first dose on 17Jun2021 (048A21A) Second dose was administered on 27Jul2021; Death; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death), CEREBROVASCULAR ACCIDENT (stroke), URINARY TRACT INFECTION (UTI), SEPSIS (sepsis), PNEUMONIA ASPIRATION (aspiration pneumonia) and INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (first dose on 17Jun2021 (048A21A) Second dose was administered on 27Jul2021) in an 88-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 009C21A and 048A21A) for COVID-19 vaccination. No Medical History information was reported. On 17-Jun-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 27-Jul-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 30-Jul-2021, the patient experienced CEREBROVASCULAR ACCIDENT (stroke) (seriousness criteria death, hospitalization and medically significant). On an unknown date, the patient experienced URINARY TRACT INFECTION (UTI) (seriousness criteria hospitalization and medically significant), SEPSIS (sepsis) (seriousness criteria hospitalization and medically significant), PNEUMONIA ASPIRATION (aspiration pneumonia) (seriousness criteria hospitalization and medically significant) and INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (first dose on 17Jun2021 (048A21A) Second dose was administered on 27Jul2021) (seriousness criterion medically significant). The patient died on 10-Sep-2021. The reported cause of death was Stroke. It is unknown if an autopsy was performed. At the time of death, URINARY TRACT INFECTION (UTI), SEPSIS (sepsis), PNEUMONIA ASPIRATION (aspiration pneumonia) and INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (first dose on 17Jun2021 (048A21A) Second dose was administered on 27Jul2021) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Blood pressure increased: elevated blood pressure (High) elevated blood pressure. No concomitant medications information was reported. No treatment medications were provided. This is a case of Inappropriate schedule of vaccine administered concerning an 88-year-old female patient with no reported medical history who experienced the fatal unexpected events of cerebrovascular accident, urinary tract infection, sepsis and aspiration pneumonia. The events of urinary tract infection, sepsis and aspiration pneumonia occurred on an unspecified date after CVA occurred 3 day after the second dose and the subject expired 1 month 4 days after the second dose of mRNA-1273 The rechallenge was not applicable as events occurred after second dose with a fatal outcome. Causality assessment for the event was not provided by the reporter. However, the subject is of an advanced age and UTI is of an infective origin which can lead to sepsis and thus assessment with product used is determined as unlikely. The benefit-risk relationship of mRNA-1273is not affected by this report; Sender''s Comments: This is a case of Inappropriate schedule of vaccine administered concerning an 88-year-old female patient with no reported medical history who experienced the fatal unexpected events of cerebrovascular accident, urinary tract infection, sepsis and aspiration pneumonia. The events of urinary tract infection, sepsis and aspiration pneumonia occurred on an unspecified date after CVA occurred 3 day after the second dose and the subject expired 1 month 4 days after the second dose of mRNA-1273 The rechallenge was not applicable as events occurred after second dose with a fatal outcome. Causality assessment for the event was not provided by the reporter. However, the subject is of an advanced age and UTI is of an infective origin which can lead to sepsis and thus assessment with product used is determined as unlikely. The benefit-risk relationship of mRNA-1273is not affected by this report; Reported Cause(s) of Death: stroke


VAERS ID: 1740112 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Illness
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Patient dies of covid-19 related illness weeks afetr receiving second covid vaccine; This spontaneous case was reported by a consumer and describes the occurrence of ILLNESS (Patient dies of covid-19 related illness weeks afetr receiving second covid vaccine) in a 36-year-old patient of an unknown gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced ILLNESS (Pateint dies of covid-19 related illness weeks afetr receiving second covid vaccine) (seriousness criterion death). The reported cause of death was covid related illness. It is unknown if an autopsy was performed. No concomitant medications were provided. No treatment information was provided. This case concerns a 36-year-old patient of an unknown gender with no reported medical history of who experienced the unexpected fatal event of covid 19 related illness. The event occurred after an unspecified time after administration of the second dose of mRNA-1273. The rechallenge was not applicable as this event occurred after the second dose with a reported fatal outcome. Causality assessment for the event was not reported. However, covid 19 is considered as not applicable due biologically implausible based on known etiology. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Sender''s Comments: This case concerns a 36-year-old patient of an unknown gender with no reported medical history of who experienced the unexpected fatal event of covid 19 related illness. The event occurred after an unspecified time after administration of the second dose of mRNA-1273. The rechallenge was not applicable as this event occurred after the second dose with a reported fatal outcome. Causality assessment for the event was not reported. However, covid 19 is considered as not applicable due biologically implausible based on known etiology. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Reported Cause(s) of Death: covid related illness


VAERS ID: 1740571 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Massachusetts  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Intracranial aneurysm
SMQs:, Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: brain aneurism; This spontaneous case was reported by an other health care professional and describes the occurrence of INTRACRANIAL ANEURYSM (brain aneurism) in an adult female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced INTRACRANIAL ANEURYSM (brain aneurism) (seriousness criteria death and medically significant). The reported cause of death was brain aneurism. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. No concomitant medication details were provided. It was reported that the person around it''s 30''s died from a brain aneurism right after receiving the Moderna Vaccine. No treatment information was mentioned. This case concerns female patient of unknown age with no relevant medical history reported, who experienced the unexpected event of intracranial aneurysm. The event occurred on an unknown number of days after the first dose of mRNA-1273 and had a fatal outcome on an unknown date. No autopsy report was provided. The rechallenge was not applicable, as the event happened after the first dose. The benefit-risk relationship of mRNA-1273 is not affected by this report. Further information was requested.; Sender''s Comments: This case concerns female patient of unknown age with no relevant medical history reported, who experienced the unexpected event of intracranial aneurysm. The event occurred on an unknown number of days after the first dose of mRNA-1273 and had a fatal outcome on an unknown date. No autopsy report was provided. The rechallenge was not applicable, as the event happened after the first dose. The benefit-risk relationship of mRNA-1273 is not affected by this report. Further information was requested.; Reported Cause(s) of Death: brain aneurism


VAERS ID: 1740603 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: California  
Vaccinated:2021-02-05
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Oxygen saturation, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (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? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Drug allergy (The patient was allergic to Bactrim, because hand was turning red and developed a rash on the face, back and itching hands.)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: Oxygen level; Result Unstructured Data: low
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Developed pneumonia after the vaccine; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of PNEUMONIA (Developed pneumonia after the vaccine) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 026B21A and 042L20A) for COVID-19 vaccination. Concurrent medical conditions included Drug allergy (The patient was allergic to Bactrim, because hand was turning red and developed a rash on the face, back and itching hands.). On 05-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 31-Mar-2021, received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On an unknown date, the patient experienced PNEUMONIA (Developed pneumonia after the vaccine) (seriousness criteria death, hospitalization and medically significant). The patient was hospitalized for 8 days due to PNEUMONIA. The patient was treated with ZOLEDRONIC ACID (RECLAST) for Adverse event, at an unspecified dose and frequency. The reported cause of death was Pneumonia. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Oxygen saturation: low (Low) low. No concomitant medications were reported. Company Comment: This case concerns a patient with of unknown age and gender, as well as unknown medical history, who experienced the unexpected event of pneumonia that ended with fatal outcome. The temporal relationship remained unknown having in mind that the date of vaccination and date of the event were not provided. If was unknown if the autopsy was performed. The rechallenge was not applicable, as the event ended with fatal outcome. The benefit-risk relationship of Moderna COVID-19 Vaccine is not affected by this report. This case was linked to MOD-2021-325775, MOD-2021-325636 (Patient Link).; Sender''s Comments: This case concerns a patient with of unknown age and gender, as well as unknown medical history, who experienced the unexpected event of pneumonia that ended with fatal outcome. The temporal relationship remained unknown having in mind that the date of vaccination and date of the event were not provided. If was unknown if the autopsy was performed. The rechallenge was not applicable, as the event ended with fatal outcome. The benefit-risk relationship of Moderna COVID-19 Vaccine is not affected by this report.; Reported Cause(s) of Death: Pneumonia


VAERS ID: 1740833 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-04-02
Onset:2021-09-25
   Days after vaccination:176
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 08B21A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-26
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Covid-19 after complete vaccination. Patient expired on 9/26/2021


VAERS ID: 1741067 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-03
Onset:2021-09-23
   Days after vaccination:232
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Confirmed PCR positive
CDC Split Type:

Write-up: Pt died after contracting COVID-19 in Sep 2021. Pt developed COVID pneumonia


VAERS ID: 1741085 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-03-06
Onset:2021-09-20
   Days after vaccination:198
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 052E21A / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Death, Endotracheal intubation, 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), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-23
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Ulcerative colitis, Cellulitis of RLE CKD, Polycystic Kidney disease, Osteoarthritis, Hyperlipidemia, Post kidney transplant, Long term use of immunosuppressive drug, would of lower extremity, ESRD on dialysis, CVA, Immunosuppressed status,
Preexisting Conditions: Ulcerative colitis, Cellulitis of RLE CKD, Polycystic Kidney disease, Osteoarthritis, Hyperlipidemia, Post kidney transplant, Long term use of immunosuppressive drug, would of lower extremity, ESRD on dialysis, CVA, Immunosuppressed status,
Allergies: NKA
Diagnostic Lab Data: 9/21/2021 SARS CoV RAP RNA (RT RNA) positive 9/23/2021 SARS CoV RNA (RT RNA) positive 9/23/2021 SARS CoV PAN (RT RNA) positive
CDC Split Type:

Write-up: Developed Acute Respiratory Failure leading to intubation and death.


VAERS ID: 1741118 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-09-01
Onset:2021-09-24
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 053E21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Anticoagulant therapy, COVID-19, Cryotherapy, Deep vein thrombosis, Echocardiogram abnormal, Ejection fraction decreased, Exposure to SARS-CoV-2, General physical health deterioration, Hypoxia, Left ventricular dysfunction, Leg amputation, Peripheral ischaemia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), 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), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   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: Diabetes
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted on 9/7/2021 with COVID-19 and sever hypoxia. Known COVID contact several days prior. Treated with remdesivir, dexamethasone, ceftriaxone, and azithromycin. Also started on barictnib on 9/9 but stopped due to ARF. Echocardiogram showed EF of 25-50% with moderately severe LV function. Started on heparin and continued throughout hospital stay. DVT in right lower leg. Seen by infectious disease and continued on cefepime and levofloxacin for 14 days. Underwent cryo-amputation of right ischemic lower extremity and then BKA by vascular surgery. Prognosis poor and not improving. Family elected comfort care.


VAERS ID: 1741301 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-08-30
Onset:2021-09-07
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 053E21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, General physical health deterioration, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-19
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alprazolam, atorvastatin, olmesartan, clonidine, I-CAPS oral multivitamin, metroprolol tartrate, amlodipine, calcium-vitamin D, ferrous sulfate, torsemide, meloxicam, hydrocodone-acetaminophen, potassium chloride, lansoprazole, escitalopram
Current Illness: None
Preexisting Conditions: Anxiety Diarrhea associated with pseudomembranous colitis GERD Heart murmur History of knee problem Hypertension Iron deficiency anemia Morbid obesity Primary osteoarthritis of right foot Vision problem History of MRSA infection
Allergies: propoxyphene - drowsiness
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received first dose of COVID-19 vaccine on 8/30/2021. Patient was then hospitalized on 9/7/2021 with COVID-19 symptoms. Patient was a no code/no intubation at admission. Patient ultimately progressed to high flow oxygen and was made compassionate care and passed away on 9/19/2021.


VAERS ID: 1741384 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-19
Onset:2021-09-27
   Days after vaccination:192
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA N/A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aphasia, COVID-19, Cerebrovascular accident, Confusional state, Contusion, Death, Dysarthria, Face injury, Fall, Feeling cold, Gait disturbance, Lacunar infarction, Magnetic resonance imaging head abnormal, NIH stroke scale abnormal, SARS-CoV-2 test positive
SMQs:, Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient is a 84 y.o. female with dementia who resides in an assisted living facility. She usually ambulates with a walker per her son. She fell OOB almost 2 weeks ago and hit her right cheek - has a bruise there but seemed fine afterwards. Her son reports she had some slurred speech on Sunday but by Monday it had resolved. Caretaker had reported she seemed to be dragging one leg when she walked earlier this weak. Today she was sent to ER for some confusion - her NIH stroke scale was 11 but some of the score was felt to be due to confusion with understanding directions. An MRI shows acute stroke to the Left Posterior Parietal area and also small Left Lacunar infact adjacent to the left lateral ventricle. She does not appear to be on any antiplatelet drugs or statins per her med list. Her son reports she had trouble moving her left leg in the ER and trouble with speech. she is able to follow simple commands for me. There is no facial droop. She does have expressive aphasia but pulls the covers up over herself and says "cold". She easily lifts both legs off the bed for me on command and has good hand grips. Hospital Course: Patient was admitted with expressive aphasia - Neurology was consulted - family requested hospice care as patient had little hope of improvement. She tested + for Covid but was not requiring any oxygen. She was made hospice care only on the Covid unit and died on 9/27/2021 at 10:01 AM


VAERS ID: 1741669 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Utah  
Vaccinated:2021-03-24
Onset:2021-08-16
   Days after vaccination:145
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, Blood creatinine increased, Blood test abnormal, Blood urea increased, Cardioversion, Chills, Complication associated with device, Computerised tomogram, Condition aggravated, Contrast media reaction, Death, Dyspnoea, Feeding disorder, Fluid intake reduced, Full blood count, Infection, Magnetic resonance imaging head, Metabolic function test, Pain, Pain in jaw, Positive airway pressure therapy, Pyrexia, Renal disorder, Renal failure, Renal function test abnormal, Scan with contrast, X-ray
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Osteonecrosis (broad), Chronic kidney disease (narrow), Hypersensitivity (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-22
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor, Diltiazem, Doxycycline, Flonase, Losartan, Metformin, Mutlaq, Novolin 70/30, Prilosec, Proair HFA, Flomax, Aranesp, Magnesium, MultiVitamin One-a-day Men''s 50+
Current Illness: None
Preexisting Conditions: Afib, anemia, HBP, HCL, Diabetes type 2
Allergies: Codeine, Lisinopril, Levofloxacin
Diagnostic Lab Data: (8/16/2021)Blood Test, CBC, Metabolic panel, X-Ray (8/19/2021) Blood work(8/20/2021) CT Scan, MRI (Head) Blood tests.(8/21/2021) Blood test.
CDC Split Type: vsafe

Write-up: On the 16th of Aug., went to ER for fever, chills, and jaw pain. Was given antibiotics but was back on 17th by request because blood test reveled a blood infection. Early on the 18 Afib, Metoprolol given for it. By midday discharged and was upset at care that was given. On the 19th Admitted to Hospital, because racked with pain and felt like he couldn''t breathe. Drew blood for new tests. Couldn''t drink or eat, issues with taking blood(iv lines infiltrated and kept popping out). On the 20th, contrast media given, one was a drink and one was injected for CT scan. Rapid fluids given, and had a bad response with it, Rapid afib(tried convert to sinus rhythm twice and failed), kidney issues. PCU on 21th Kidney started to fail, BiPap, elevated creatinine, BUN elevated. On 8/22 blood test showed kidney failure imminent was then advised a kidney transplant would be needed, patient declined, discharged about 12:30PM MT and patient died under Hospice care by 6:00PM MT


VAERS ID: 1742182 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-01
Onset:2021-03-24
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SYR

Administered by: Other       Purchased by: ?
Symptoms: Cerebral haemorrhage, Death, Pyrexia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: High fever. Died 3 weeks later from spontaneous brain bleed


VAERS ID: 1742990 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-02-01
Onset:2021-06-11
   Days after vaccination:130
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Illness, Laboratory test, Neoplasm malignant, Scan abnormal, Thrombosis
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), Malignancy related therapeutic and diagnostic procedures (narrow), Thrombophlebitis (broad), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-09
   Days after onset: 59
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: Many tests and scans to detect and monitor blood clots, strokes, cancer, etc.
CDC Split Type:

Write-up: Illness, Blood clots, Strokes, Cancer Diagnosis, Death


VAERS ID: 1744331 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-29
Onset:2021-04-01
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028A21A / 1 RA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0421321A / 2 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Ageusia, Anosmia, Death, Decreased appetite, Dizziness, Dyspnoea, Fatigue, Headache, Laboratory test, Nausea, Pericardial effusion
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   Days after onset: 69
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 19 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amiodarone 200 MG Tablet, Atorvastatin 20 MG Tablet, Furosemide 40 MG Tablet, Gabapentin 300 MG Capsule, Glipizide 10 MG Tablet, Magnesium Oxide 400 MG, Metolazone, 2.5 M Tablet, Metoprolol Succinate 100 MG, Nexium 40 MG Capsule, SitaGlipti
Current Illness:
Preexisting Conditions: Congestive Heart Failure, Hypertension, Coronary Artery Disease and Atrial Fibrillation
Allergies: Latex
Diagnostic Lab Data: Too many test and laboratory results to list as my father had extensive list of health issues.
CDC Split Type:

Write-up: Fatigue, Dizzy, Nausea, Loss of taste, Loss of smell (lasted about a week, then disappeared) Fatigue, Dizzy, Nausea, Loss of taste, Loss of smell, trouble breathing, headaches, loss of appetite(05/09/2021, went to hospital twice, was discharged too early the first time; 11 May 2021; returned to the hospital 21 May 2021 due to shortness of breath, fatigue, dizzy, nausea, loss of appetite, which the trouble breathing and shortness of breath was due to fluid build-up around the heart and his lungs). Admitted approximately late afternoon 21 May 2021 and did not get discharged, died on 9 June 2021 in the Hospice house.


VAERS ID: 1744606 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-06-11
Onset:2021-09-28
   Days after vaccination:109
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-28
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt died after contracting COVID in September 2021


VAERS ID: 1744676 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-18
Onset:2021-02-24
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute kidney injury, Arthralgia, Asthenia, Blood pressure decreased, Computerised tomogram abnormal, Death, Dyspnoea, Feeling abnormal, Flank pain, Gait inability, Intensive care, Internal haemorrhage, Mechanical ventilation, Nausea, Pneumonia, Pneumonitis, Positive airway pressure therapy, Pulmonary oedema, Respiratory disorder, Transfusion
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (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), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Hypersensitivity (broad), Arthritis (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 29
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 20 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: See continuation page o Jan 2018 Mom was diagnosed with stage 4 lung/brain/lymph node cancer o Feb 25th: Mom was brought to ER for a respiratory issue. Full set of tests were done, nothing was found and she was sent home. ER was happy she was going to see her primary the next day for follow up. o Feb 27th: Mom woke up feeling ok, by afternoon she was too weak to walk and brought back to the ER. Lungs shown with pneumonia and inflammation. Mom was admitted to ICU that evening. o Feb 28th: Mom seemed ok in ICU, but oxygen demands increased. o Mar 1st: Mom was placed on bi-pap o Mar 2nd: Mom was placed on vent o March 8th: Mom fought back and was able to come off vent o March 12th: Due to lack of rooms in ICU (from my understanding), Mom was moved to medical o March 13th: Mom expressed pain behind knee (maybe referred pain due to bleeding noted on the 14th) o March 14th: Mom had severe side pain, blood work indicated potential internal bleed. Hours later a CT scan was done and confirmed bleeding. Plan was to give her plasma and maybe other drugs to hopefully stop the bleed (that doesn''t make complete sense to me, but I''m not a doctor). Mom said she "Felt like she was dying". The nurse said that given Mom''s condition, it would be best that someone spend the night with her. I relieved my sister around 8:30 that night. Mom was receiving plasma and whole blood. I asked the nurse if her blood pressure and pulse were monitored at the nurses station, she said no but she would come in every hour to check (note additional checks were done every 15 minutes when a blood transfusion was started). Mom''s door was closed due to 4 other psych patients on the floor making a lot of noise, so I was the only one to hear alarms. Mom was too weak and couldn''t press the nurse button when her side pain increased after 10 pm. I pushed the button for her, a couple minutes later a nurse came on the intercom wondering what Mom needed, and what felt like 10 minutes later a nurse arrived. Around 11:15 pain meds were administered but didn''t have any impact initially. I questioned whether Mom should be in the ICU given the internal bleed, pain, and number of units of blood/plasma she was receiving (in my mind she was critical enough not to be on a medical floor where there is a high patient to nurse count and no continuous monitoring of vitals). o March 15th The on call doctor came in around 12:30 am, I think, after pain meds started to settle Mom. His first words, which I felt were said in a stern way, were "I hear you want your Mom moved to ICU". I expressed my concerns and that I was just trying to do what was best for Mom. His voice softened and he said there is nothing more that ICU can do. My impression was that he stated they would give more blood and if vitals drop, then move her to ICU. Nurse came back in after the doctor left (note I felt the nurse did a great job that night) and said the doctor wanted her to discuss with me re-evaluating whether Mom should be a full code... It is very confusing since I felt the doctor was saying she was stable enough to stay on the medical floor, but then have the full code reconsidered at 1:00 in the morning by family... I was in full tears after she left, didn''t sleep, and said a few rosaries. At 3:30 am Mom was moved to ICU. By 6 or 7 am Mom had received 5 units of blood and 5 units of plasmas, which I believe is as much as the body can hold... Around 7:15 am there was a clear indication on the monitor that Mom''s blood pressure was dropping linearly over last hour. Her breathing over night was 18 and normal, but increased to over 20 was very labored. Her heart rate went from 90s to 114. I walked over to ICU nurse with tears and there is a scary trend happening, do I need to call family in. She stated that "Mom is in the right place and no need to call family". But took no action to correct decline. Her only action was to get zophrane (or similar drug) since Mom was nauseous. It wasn''t until after the doctor came in after 8:15 am that the decision was made to transport. At that point family was allowed to come in 1 by 1. It was also the same time that the snow storm started and Mom had to go by ambulance, which by time coordinating wass complete didn''t happen until 11 am. Mom was given blood pressure medication which helped initially, but by time Mom reached it we were told her blood pressure was 37/19. It feels if action was taken over night, Mom could have been flown and the blood pressure might not have dropped that far. Mom''s procedure was successful to stop bleeding. o March 16th: We were told that given the amount of fluid Mom''s lungs were starting to fill with fluid again and given low blood pressure on arrival, her kidneys were shutting down. o March 17th: Mom was placed on hospice o March 18th: Mom was brought home o March 26th: Mom went peacefully to heaven


VAERS ID: 1745008 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-06-04
Onset:2021-08-06
   Days after vaccination:63
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047C21A / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest X-ray, Dyspnoea, Laboratory test, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-19
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Anemia, afib, COPD, DM, hypercholesterolemia, measles, mumps, pancreatitis, sleep apnea, shingles, cancer.
Allergies: NKA
Diagnostic Lab Data: Labs, covid test, cxr.
CDC Split Type:

Write-up: Pt came to ER c/o SOB, onset 4 weeks prior.


VAERS ID: 1745080 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-12
Onset:2021-09-13
   Days after vaccination:244
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID test 9/14/21
CDC Split Type:

Write-up: Patient hospitalized 9/13/21, diagnosed with COVID19 9/14/21, deceased 9/25/21


VAERS ID: 1745112 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-24
Onset:2021-09-03
   Days after vaccination:163
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Alanine aminotransferase increased, Anion gap normal, Anti factor Xa assay normal, Anticoagulant therapy, Aspartate aminotransferase increased, Asthenia, Atrioventricular block complete, Basophil count, Bilirubin conjugated increased, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin increased, Blood calcium decreased, Blood chloride normal, Blood creatine increased, Blood gases abnormal, Blood glucose normal, Blood magnesium normal, Blood pH decreased, Blood phosphorus normal, Blood potassium normal, Blood pressure abnormal, Blood pressure systolic decreased, Blood sodium decreased, Blood urea increased, Body temperature decreased, Brain natriuretic peptide increased, C-reactive protein increased, COVID-19, COVID-19 pneumonia, Carbon dioxide normal, Cardiac arrest, Cardiac failure, Cardiac resynchronisation therapy, Cardiac vein dissection, Chest X-ray abnormal, Condition aggravated, Cough, Death, Delirium, Diarrhoea, Dyspnoea, Endotracheal intubation, Eosinophil count, Fibrin D dimer increased, General physical health deterioration, Glomerular filtration rate, Haematocrit decreased, Haemoglobin decreased, Haemoptysis, Hypotension, Hypoxia, Hypoxic-ischaemic encephalopathy, Immature granulocyte count, Implantable defibrillator insertion, Intensive care, International normalised ratio normal, Ischaemic cardiomyopathy, Laboratory test abnormal, Lymphocyte count decreased, Mean cell volume normal, Mental status changes, Metabolic acidosis, Metabolic encephalopathy, Monocyte count, Neutrophil count increased, Neutrophil percentage increased, Oxygen saturation decreased, PCO2, PO2 decreased, Platelet count decreased, Prothrombin time prolonged, Pulseless electrical activity, Red blood cell count decreased, Red blood cell nucleated morphology present, Red cell distribution width increased, Respiratory failure, Resuscitation, Sputum abnormal, Troponin I increased, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Ischaemic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Pseudomembranous colitis (broad), Acute central respiratory depression (narrow), Biliary system related investigations, signs and symptoms (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Hypertension (broad), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Other ischaemic heart disease (narrow), Chronic kidney disease (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (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? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Losartan (COZAAR) 25 mg Oral Tab Take 1 tablet by mouth daily ? Furosemide (LASIX) 20 mg Oral Tab Take one-half tablet by mouth daily in the morning. May increase to 1 tablet for sudden weight gain and more shortness of breath ? Tamsulosin
Current Illness: None known
Preexisting Conditions: PMH of CHF (EF 20%), hypertension, anemia, seizures, renal calculus s/p ureteral stents placement and removal
Allergies: NKA
Diagnostic Lab Data: Results for patient as of 9/29/2021 10:27 9/9/2021 07:00 NA: 138 K: 4.5 CL: 99 (L) CO2: 23 (L) BUN: 82 (H) CREAT: 2.72 (H) ANION GAP4 SERPL: 16 CA: 7.8 (L) MG: 2.0 PHOS: 4.8 (H) GLUC: 136 ALT: 115 (H) AST: 108 (H) ALKP: 62 TBILI: 1.5 (H) BILID: 0.6 (H) COMMENT, GLOMERULAR FILTRATION RATE: SEE NOTE CRP, SER QL: 9.7 (H) WBC: 13.7 (H) RBC''S: 3.51 (L) HGB: 10.2 (L) HCT: 31.7 (L) MCV: 90 RDW, RBC: 17.2 (H) PLT: 139 (L) IMMAT GRANULO % AUTO: 1 NRBC: 1 (H) NEUTROPHILS % AUTO: 89 (H) ANC: 12.2 (H) LYMPHS % AUTO: 4 (L) MONOS % AUTO: 5 EOS % AUTO: 0 BASO''S % AUTO: 0 D-DIMER: 0.56 (H) 9/9/2021 09:43 ANTI XA, HEP UNFR: 1.06 (AA) 9/9/2021 23:34 XR CHEST: Rpt 9/10/2021 07:05 NA: 136 K: 4.4 CL: 99 (L) CO2: 25 BUN: 96 (H) CREAT: 2.70 (H) ANION GAP4 SERPL: 12 GLUC: 158 ALT: 120 (H) AST: 77 (H) ALKP: 66 TBILI: 1.1 COMMENT, GLOMERULAR FILTRATION RATE: SEE NOTE WBC: 8.9 RBC''S: 3.41 (L) HGB: 9.9 (L) HCT: 30.8 (L) MCV: 90 RDW, RBC: 16.6 (H) PLT: 124 (L) IMMAT GRANULO % AUTO: 0 NRBC: 1 (H) NEUTROPHILS % AUTO: 90 (H) ANC: 7.9 LYMPHS % AUTO: 4 (L) MONOS % AUTO: 6 EOS % AUTO: 0 BASO''S % AUTO: 0 9/11/2021 00:15 ANTI XA, HEP UNFR: <0.10 9/11/2021 07:21 NA: 132 (L) K: 4.7 CL: 96 (L) CO2: 24 BUN: 102 (H) CREAT: 2.79 (H) ANION GAP4 SERPL: 12 MG: 2.3 GLUC: 159 ALT: 76 (H) AST: 34 ALKP: 80 TBILI: 1.1 COMMENT, GLOMERULAR FILTRATION RATE: SEE NOTE CRP, SER QL: 6.1 (H) WBC: 13.3 (H) RBC''S: 3.69 (L) HGB: 10.9 (L) HCT: 33.0 (L) MCV: 89 RDW, RBC: 16.8 (H) PLT: 101 (L) NRBC: 2 (H) PT: 19.6 (H) INR: 1.7 D-DIMER: $g4.00 (H) ANTI XA, HEP UNFR: 1.24 (AA) 9/11/2021 07:21 WBC: 12.8 (H) RBC''S: 3.62 (L) HGB: 10.4 (L) HCT: 33.3 (L) MCV: 92 RDW, RBC: 16.8 (H) PLT: 107 (L) IMMAT GRANULO % AUTO: 1 NRBC: 2 (H) NEUTROPHILS % AUTO: 92 (H) ANC: 11.8 (H) LYMPHS % AUTO: 3 (L) MONOS % AUTO: 4 (L) EOS % AUTO: 0 BASO''S % AUTO: 0 9/12/2021 07:04 NA: 132 (L) K: 5.0 CL: 97 (L) CO2: 22 (L) BUN: 111 (H) CREAT: 2.84 (H) ANION GAP4 SERPL: 13 MG: 2.3 GLUC: 175 (H) BNP: 3,468 (H) COMMENT, GLOMERULAR FILTRATION RATE: SEE NOTE 9/12/2021 09:58 XR CHEST: Rpt 9/12/2021 14:53 NA: 129 (L) K: 5.3 CL: 96 (L) CO2: 21 (L) BUN: 115 (H) CREAT: 2.99 (H) ANION GAP4 SERPL: 12 GLUC: 195 (H) COMMENT, GLOMERULAR FILTRATION RATE: SEE NOTE 9/13/2021 05:09 TEMP: 96.5 (L) INSPIRED O2: 37 PH CORR VEN BLD: 7.31 (L) PCO2 CORR VEN BLD: 44 PO2 ADJUST TO PT''S TEMP, BLD-V: 36 PH VBLD: 7.30 (L) PVCO2: 47 PO2-V: 39 HCO3-V: 20.3 (L) BE-V: -3.4 (L) SO2, BLDV: 55.3 9/13/2021 07:10 NA: 131 (L) K: 5.1 CL: 96 (L) CO2: 15 (L) BUN: 115 (H) CREAT: 3.12 (H) ANION GAP4 SERPL: 20 (H) MG: 2.7 (H) GLUC: 191 (H) COMMENT, GLOMERULAR FILTRATION RATE: SEE NOTE CRP, SER QL: 2.8 (H) 9/13/2021 07:25 TROPONIN I: 0.12 (H) BNP: 1,926 (H) WBC: 20.8 (H) RBC''S: 4.02 (L) HGB: 11.8 (L) HCT: 38.5 (L) MCV: 96 RDW, RBC: 18.2 (H) PLT: 113 (L) IMMAT GRANULO % AUTO: 1 NRBC: 3 (H) NEUTROPHILS % AUTO: 90 (H) ANC: 18.8 (H) LYMPHS % AUTO: 3 (L) MONOS % AUTO: 5 EOS % AUTO: 0 BASO''S % AUTO: 0 D-DIMER: $g4.00 (H) 9/13/2021 08:15 XR CHEST: Rpt 9/13/2021 08:40 TEMP: 98.6 INSPIRED O2: 100 PH CORR ART BLD: 7.11 (AA) PCO2 CORR ART BLD: 34 (L) PO2 ADJUST TO PT''S TEMP, BLD-A: 95 PH ABLD: 7.11 (AA) PACO2: 34 (L) PO2-A: 95 HCO3 BLD: 11.1 (L) BE BLD: -17.2 (L) SO2, CALCULATED, ARTERIAL: 91.9 (L) 9/13/2021 10:30 TEMP: 98.6 INSPIRED O2: 100 PH CORR ART BLD: 7.13 (AA) PCO2 CORR ART BLD: 51 (H) PO2 ADJUST TO PT''S TEMP, BLD-A: 80 PH ABLD: 7.13 (AA) PACO2: 51 (H) PO2-A: 80 HCO3 BLD: 14.8 (L) BE BLD: -11.2 (L) SO2, CALCULATED, ARTERIAL: 88.4 (L)
CDC Split Type:

Write-up: Reason for Hospital Admission (Admitting Diagnosis): Heart Block/COVID Pneumonia Hospital Course and Significant Findings: 75 Y male with hx of HFrEF (EF: 20%), HTN, anemia, seizures (not on antiepileptics), hx of renal calculus s/p ureteral stents and subsequent removal who presented with shortness of breath, weakness and diarrhea and was found to have AKI, 3rd degree AV block which was diagnosed on 9/5/2021 and COVID diagnosed on 9/3/2021. Dual chamber ICD placed on 9/9 by Dr. (couldn''t get coronary sinus lead in so only RV pacing now). Reattempt LV lead placement is scheduled on 10/18 with Dr. . Stopped heparin gtt and start BID Eliquis (2.5mg BID - discussed dosing with pharmacy) Weight up (standing weight 201lbs today and recorded 188lbs on 9/6), BNP is up, oxygen requirement up today. CXR looked a little better (intermpretation complicated by recent COVID diagnosis). BP is soft (SBP low 90s). Cr and BUN up. D/w Cardiology who recommended start hydralazine, start dopamine gtt, resume Lasix, and consider repeat echo giving finding of dissection of coronary sinus on recent pacemaker placement. With regard to COVID, symptom onset 9/3/2021. COVID positive on 9/3/2021. He remained afebrile. He completed 5 day course of remdesivir and was continued on daily decadron. He was not requiring much oxygen, about 2 to 4LMP via NC and appears well without tachypnea. He had a mild dry cough. He is speaking in complete sentences without cough or tachypnea during my exam. - No hypoxia on 9/11, even with activity, but on 9/12 was a bit hypoxic so was on supplemental oxygen. NONTRAUMATIC AKI on CKD. BUN and Cr increasing. BP was low and CXR looked better but other findings concerning for increasing heart failure. See above for recommendations from cardiology. AMS / Delirium. Due to metabolic and hypoxemic encephalopathy. Fluctuated and occurred the first couple of days during the night. Overnight in the early hours of 9/13, his respiratory status deteriorated. He required increasing oxygen, was seen by cross cover. He started coughing up bloody frothy sputum. Required high flow oxygen. Unfortunately he went into PEA arrest in the morning on 9/13. Required CPR, was resuscitated, intubated and transferred to the ICU. Bedside echo showed diminished EF, no pericardial effusion or tamponade. Per ICU note, "Significant metabolic acidemia an refractory PEA despite initial ROSC and complete resuscitation. Finally, patient was prounced dead at 11am on 9/13." Cause of death: Hypoxic respiratory failure from COVID pneumonia and ischemic cardiomyopathy. Primary Procedures: Procedure(s): CARDIAC AICD TOTAL SYSTEM IMPLANTATION, BIVENTRICULAR CHAMBER


VAERS ID: 1745292 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-28
   Days after onset: 185
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Leukemia
Preexisting Conditions: Leukemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt. contracted COVID several months after receiving vaccine.


VAERS ID: 1745353 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-12
Onset:2021-08-10
   Days after vaccination:179
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       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: 2021-09-13
   Days after onset: 34
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 23 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID test 8/12/21
CDC Split Type:

Write-up: Patient admitted to hospital 8/10/21. COVID test positive 8/12/21. Deceased 9/13/21


VAERS ID: 1745378 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-05-18
Onset:2021-09-16
   Days after vaccination:121
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private       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: 2021-09-24
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID test 9/20/21
CDC Split Type:

Write-up: Patient tested positive 9/15/21. ED visit at Hospital 9/16/21, discharged. Patient returned to ED 9/19/21 and admitted. 9/20/21 COVID test positive. Deceased 9/24/21


VAERS ID: 1745669 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-17
Onset:2021-08-07
   Days after vaccination:143
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA NA / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, Asthenia, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Cough, Death, Dyspnoea, Dyspnoea exertional, Lung infiltration, Oedema peripheral, Pneumonia bacterial, Pyrexia, SARS-CoV-2 test positive
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (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), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-20
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: ? Anemia ? Basal cell carcinoma ? CAD - involving coronary bypass graft of native heart without angina pectoris 5/22/2017 S/p CABG ? Cataract ? Cellulitis ? Cerebral infarction WITH SUBDURAL HEMATOMA ? Chronic atrial fibrillation 5/22/2017 ? COPD (chronic obstructive pulmonary disease) ? Coronary artery disease ? Diabetes mellitus ? diabetes type 2, no complications 5/22/2017 ? Diastolic CHF 5/22/2017 ? Dyslipidemia 5/22/2017 ? Essential hypertension 5/22/2017 ? h/o kidney stones 5/22/2017 S/p lithotripsy. ? High cholesterol ? Iritis, chronic 2/22/2019 ? Pneumonia ? Squamous cell carcinoma ? Subdural hematoma 02/2018 AFTER A FALL
Allergies: Unknown
Diagnostic Lab Data: 8/16/2021 and 8/18/2021 CXR Bilateral pulmonary infiltrates 8/7/2021 RAPID SARS-COV-2 BY PCR - detected
CDC Split Type:

Write-up: Client diagnosed with Covid-19 on 8/7/2021, hospitalized with intermittent dyspnea on exertion, cough, LE edema. He was discharged on 8/13/2021 after being treated with IV Decadron and a 5 day course of Remdesivir. He was readmitted on 8/16/2021 with SOB, fevers, cough and weakness. During this admission, he was given high-dose IV steroids. He died on 8/20/2021 due to Acute hypoxemic respiratory failure due to severe bilateral COVID pneumonia and suspected superimposed bacterial pneumonia. Submitter does not have access to full medical record. If further information is required, please contact the admitting hospital.


VAERS ID: 1745752 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-09-16
Onset:2021-09-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050EZ1A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Computerised tomogram, Computerised tomogram thorax, Death, Depressed level of consciousness, Dysphagia, General physical health deterioration, Magnetic resonance imaging head normal, Monoplegia, Pyrexia, Respiratory distress, Speech disorder
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), 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), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amlodipine /pantoprazole /vit d /vit b 12
Current Illness: none
Preexisting Conditions: hypertension
Allergies: none known
Diagnostic Lab Data: magnetic scans of brain x 2 / cat scans x 1 / cat scan of chest /
CDC Split Type:

Write-up: fever and weakness day after vaccine with increasing weakness at home /admitted to hospital 4 days later with weakness /progressive decline with weakness and paralysis of left arm / stroke suspected but could not be confirmed on 2 magnetic resonance scans /inability to speak and then swallow / treated for possible aspiration pneumonia /progressed to being obtunded and respiratory distress / died 9/25/21


VAERS ID: 1747792 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Kentucky  
Vaccinated:0000-00-00
Onset:2021-09-01
Submitted: 0000-00-00
Entered: 2021-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-01
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: died from COVID; This spontaneous case was reported by a consumer and describes the occurrence of COVID-19 (died from COVID) in a 48-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. In September 2021, the patient experienced COVID-19 (died from COVID) (seriousness criterion death). The patient died in September 2021. The reported cause of death was died from covid. It is unknown if an autopsy was performed. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. No concomitant medications were provided by the reporter. No treatment information was provided by the reporter. Company comment: This case concerns a 48-year-old, female patient with no relevant medical history reported, who experienced the unexpected event of COVID-19. The event occurred approximately on an unknown number of days after an unknown number of doses of mRNA-1273 and had a fatal outcome, with death occurring on an unknown date of September. No autopsy report was provided. The rechallenge was unknown. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Sender''s Comments: This case concerns a 48-year-old, female patient with no relevant medical history reported, who experienced the unexpected event of COVID-19. The event occurred approximately on an unknown number of days after an unknown number of doses of mRNA-1273 and had a fatal outcome, with death occurring on an unknown date of September. No autopsy report was provided. The rechallenge was unknown. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Reported Cause(s) of Death: died from COVID


VAERS ID: 1747900 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Brain natriuretic peptide, Cardiac failure congestive, Dyspnoea, Fibrin D dimer, Hepatic enzyme, Myocarditis
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-28
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: Test Name: BNP; Result Unstructured Data: BNP is elevated; Test Name: D-dimer; Result Unstructured Data: D-dimer elevated; Test Name: Liver enzymes; Result Unstructured Data: liver enzymes elevated
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Congestive heart failure; short of breath; Myocarditis; This spontaneous case was reported by a consumer and describes the occurrence of CARDIAC FAILURE CONGESTIVE (Congestive heart failure), DYSPNOEA (short of breath) and MYOCARDITIS (Myocarditis) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced CARDIAC FAILURE CONGESTIVE (Congestive heart failure) (seriousness criteria death and medically significant), DYSPNOEA (short of breath) (seriousness criterion death) and MYOCARDITIS (Myocarditis) (seriousness criteria death and medically significant). The patient died on 28-Aug-2021. The cause of death was not reported. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Brain natriuretic peptide: elevated (High) BNP is elevated. On an unknown date, Fibrin D dimer: elevated (High) D-dimer elevated. On an unknown date, Hepatic enzyme: elevated (High) liver enzymes elevated. No concomitant medications were provided by the reporter. No treatment information was provided by the reporter. Company Comment: This case concerns a consumer of unknown gender and age with no relevant medical history who experienced serious fatal unexpected events of cardiac congestive failure dyspnea, and myocarditis after receiving a second dose of the Moderna Covid 19 vaccine. Autopsy was not performed. Rechallenge is not applicable. The benefit-risk relationship is not affected by this report. Reporter did not allow further contact; Sender''s Comments: This case concerns a consumer of unknown gender and age with no relevant medical history who experienced serious fatal unexpected events of cardiac congestive failure dyspnea, and myocarditis after receiving a second dose of the Moderna Covid 19 vaccine. Autopsy was not performed. Rechallenge is not applicable. The benefit-risk relationship is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1749522 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-29
Onset:2021-09-29
   Days after vaccination:184
Submitted: 0000-00-00
Entered: 2021-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028A21A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death, Vaccine breakthrough infection
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-29
   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: PT EXPIRED; BREAKTHROUGH CASE OF COVID-19


VAERS ID: 1749992 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-23
Onset:2021-08-04
   Days after vaccination:162
Submitted: 0000-00-00
Entered: 2021-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Atrial fibrillation, COVID-19, COVID-19 pneumonia, Cough, Death, Dyspnoea, General physical health deterioration, Hypoxia, Positive airway pressure therapy, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (broad), Supraventricular tachyarrhythmias (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-28
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt tested positive for COVID-19 on 8/4/21, sx of cough and SOB; presented to ED with hypoxia due to COVID pneumonia; experienced A Fib; worsening ARDS; placed on BiPap; transported to in-patient hospice; DNR; respiratory condition worsened and pt passed away in the hospital


VAERS ID: 1750453 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-06
Onset:2021-06-04
   Days after vaccination:149
Submitted: 0000-00-00
Entered: 2021-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 2 AR / SYR

Administered by: Public       Purchased by: ?
Symptoms: Carditis, Chest X-ray, Death, Electrocardiogram, Myocardial necrosis marker, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-01
   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: Mental health meds
Current Illness: Diabetes paraplegic
Preexisting Conditions: Diabetes paraplegic
Allergies: N/A
Diagnostic Lab Data: Chest xray and EKG AND HEART ENZYMES TEST
CDC Split Type:

Write-up: She died from large bilateral pulmonary embolism and had inflammation to her heart


VAERS ID: 1751881 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-08-28
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Passed away; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Passed away) in a female patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 28-Aug-2021 The patient died on 28-Aug-2021. The cause of death was not reported. It is unknown if an autopsy was performed. Concomitant product use was not provided by the reporter. No treatment information was provided. This report concerns a female patient with no relevant medical history who died (unexpected event) due to an unknown cause. The event occurred after an unknown duration following vaccination with the first dose of mRNA-1273. The rechallenge was assessed as not applicable as the patient passed away. The benefit-risk relationship of mRNA-1273 is not affected by this report. This case was linked to MOD-2021-327538 (Patient Link).; Sender''s Comments: This report concerns a female patient with no relevant medical history who died (unexpected event) due to an unknown cause. The event occurred after an unknown duration following vaccination with the first dose of mRNA-1273. The rechallenge was assessed as not applicable as the patient passed away. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1753284 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-17
Onset:2021-08-04
   Days after vaccination:140
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Laboratory test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-13
   Days after onset: 9
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: COVID infection. Specimen collected on 8/11/21. Patient died on 8/13/21.


VAERS ID: 1753291 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-15
Onset:2021-08-24
   Days after vaccination:221
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Laboratory test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-09
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: COVID infection. Specimen collected on 8/27/21. Patient died on 9/9/21.


VAERS ID: 1753307 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-05
Onset:2021-08-24
   Days after vaccination:172
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Laboratory test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-13
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 16 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: COVID infection. Specimen collected on 8/24/21 (per ED notes). Patient died on 09/13/21.


VAERS ID: 1753621 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-22
Onset:2021-05-01
   Days after vaccination:99
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-03
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Case had lymphedema, diabetes, hypertension, in an immunocompromised condition, and obese.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalization and death. Symptoms unknown


VAERS ID: 1753844 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-04
Onset:2021-03-09
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   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: No
Current Illness: Diabetes, Type II, Uncontrolled - 1995 HTN/Hyperlipidemia-2002 Coronary Artery Disease (CAD) - 2002 Cerebrovascular Accident (CVA) - Lt Post Medullary Infarct 5/2008. Left leg is more weaker than right. moderate persistent asthma, Peripheral Vascular Disease (PVD) Retinopathy - (2005) 2015: proliferative retinopathy OU Neuropathy - 2002 Kidney Stones, GERD/HH/Dysphagia Prostate cancer - (7/26/2016) Tx: Radical prostatectomy 9/16/2016 Urinary incontinence - (2016) Acute renal failure - (1/24/2017) GB stone - (5/7/2017) Sleep apnea on Cpap - (2001) Influenza B infection - (11/23/2017) Lumbar epidural fibrosis s/p spine stimulator trial - (11/28/2017)
Preexisting Conditions: Above
Allergies: No
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Death


VAERS ID: 1753893 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-08-11
Onset:2021-08-21
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002F21A / 1 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anticoagulant therapy, Computerised tomogram thorax abnormal, Dyspnoea, Endotracheal intubation, Mechanical ventilation, Multiple organ dysfunction syndrome, Positive airway pressure therapy, Pulmonary embolism, Vena cava filter insertion
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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-09-29
   Days after onset: 39
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 24 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Humira Prednisone
Current Illness:
Preexisting Conditions: Diabetic Rheumatoid Arthritis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 10 days after receiving the first dose of Moderna, patient presented at the ER with difficulty breathing. CT revealed bi-lateral pulmonary embolisms. A few days on anti-coagulants and was released. She returned a couple days later with worsening breathing. Patient received bi-pap oxygen then underwent procedure to place filter to prevent blood clots from traveling. Patient was intubated and placed on mechanical ventilation and diagnosed with multiple system organ failure. Patient succumbed to the vaccine injury September 29, 2021.


VAERS ID: 1754078 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-05
Onset:2021-04-15
   Days after vaccination:100
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 UN / SYR

Administered by: Public       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-12
   Days after onset: 27
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: Death due to COVID-19 PNEUMONIA


VAERS ID: 1754275 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-06-04
Onset:2021-09-30
   Days after vaccination:118
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002C21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017C21A / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-30
   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: None stated.


VAERS ID: 1754283 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-09-24
Onset:2021-09-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939901 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   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: Acetaminophen Tablet 650 MG Give 1 tablet by mouth every 6 hours as needed for General Discomfort Pharmacy Active 8/19/2021 17:38 8/19/2021 Furosemide Tablet 40 MG Give 1 tablet by mouth one time a day for Edema Pharmacy Active 8/20/2021
Current Illness: None
Preexisting Conditions: CKD, COPD, Diabetes, dementia
Allergies: Sulfa
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death


VAERS ID: 1755790 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Alanine aminotransferase, Brain natriuretic peptide, Cardiac failure congestive, Dyspnoea, Fibrin D dimer, Hepatic enzyme
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-28
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: ALT; Result Unstructured Data: elevated; Test Name: BNP; Result Unstructured Data: elevated; Test Name: D-Dimer; Result Unstructured Data: elevated; Test Name: Liver Enzymes; Result Unstructured Data: elevated
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: congestive heart failure; short of breath; This spontaneous case was reported by a consumer and describes the occurrence of CARDIAC FAILURE CONGESTIVE (congestive heart failure) and DYSPNOEA (short of breath) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced CARDIAC FAILURE CONGESTIVE (congestive heart failure) (seriousness criteria death, hospitalization and medically significant) and DYSPNOEA (short of breath) (seriousness criteria death, hospitalization and medically significant). The patient died on 28-Aug-2021. The reported cause of death was Congestive heart failure and Short of breath. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Alanine aminotransferase: elevated (High) elevated. On an unknown date, Brain natriuretic peptide: elevated (High) elevated. On an unknown date, Fibrin D dimer: elevated (High) elevated. On an unknown date, Hepatic enzyme: elevated (High) elevated. No concomitant medication details was provided. No treatment medication details was provided. Company comment: This case concerns a male patient of an unknown age with no previous relevant medical reported, who experienced the unexpected events of cardiac failure congestive and dyspnoea. The events occurred on an unknown number of days after the second dose of mRNA-1273 and had fatal outcome after on an unknown number of days with date 28-Aug-2021. No autopsy report was provided. The rechallenge was not applicable since the events happened after the second dose. The benefit-risk relationship of mRNA-1273 is not affected by this report. Further information was requested.; Sender''s Comments: This case concerns a male patient of an unknown age with no previous relevant medical reported, who experienced the unexpected events of cardiac failure congestive and dyspnoea. The events occurred on an unknown number of days after the second dose of mRNA-1273 and had fatal outcome after on an unknown number of days with date 28-Aug-2021. No autopsy report was provided. The rechallenge was not applicable since the events happened after the second dose. The benefit-risk relationship of mRNA-1273 is not affected by this report. Further information was requested.; Reported Cause(s) of Death: congestive heart failure; short of breath


VAERS ID: 1755938 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Pennsylvania  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Malaise, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-23
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: hurt his leg; didn''t feel well; had COVID-19; This spontaneous case was reported by a consumer and describes the occurrence of COVID-19 (had COVID-19), PAIN IN EXTREMITY (hurt his leg) and MALAISE (didn''t feel well) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced COVID-19 (had COVID-19) (seriousness criterion death), PAIN IN EXTREMITY (hurt his leg) (seriousness criteria death and hospitalization) and MALAISE (didn''t feel well) (seriousness criterion death). The patient died on 23-Sep-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No relevant concomitant and treatment medications were reported. Company Comment - This case concerns an unknown age male with no medical history provided. Limited information regarding this case is provided. The patient experienced Covid-19, Pain in Extremity, and Malaise. He died on on 23-Sep-2021. No date for which the vaccination is provided, nor is the date of any of the events provided.The benefit-risk relationship of Moderna COVID-19 Vaccine in not affected by this report.; Sender''s Comments: This case concerns an unknown age male with no medical history provided. Limited information regarding this case is provided. The patient experienced Covid-19, Pain in Extremity, and Malaise. He died on on 23-Sep-2021. No date for which the vaccination is provided, nor is the date of any of the events provided.The benefit-risk relationship of Moderna COVID-19 Vaccine in not affected by this report.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1756001 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-03-17
Onset:2021-04-16
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Adverse event, Chronic obstructive pulmonary disease, Joint stiffness, Malaise, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-09-20
   Days after onset: 157
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: USMODERNATX, INC.MOD20213

Write-up: Heart attack; Arthrosclerosis; COPD; Other terms on autopsy report caller does not understand after the second dose; Not feeling well after the second dose; This spontaneous case was reported by a consumer and describes the occurrence of MYOCARDIAL INFARCTION (Heart attack), JOINT STIFFNESS (Arthrosclerosis), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) and ADVERSE EVENT (Other terms on autopsy report caller does not understand after the second dose) in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On 17-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 14-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 16-Apr-2021, the patient experienced MALAISE (Not feeling well after the second dose). On 20-Apr-2021, the patient experienced MYOCARDIAL INFARCTION (Heart attack) (seriousness criteria death, medically significant and life threatening), JOINT STIFFNESS (Arthrosclerosis) (seriousness criteria death, medically significant and life threatening), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (seriousness criteria death, medically significant and life threatening) and ADVERSE EVENT (Other terms on autopsy report caller does not understand after the second dose) (seriousness criteria death, medically significant and life threatening). The patient died on 20-Sep-2021. The reported cause of death was Heart attack, Arthrosclerosis and copd. An autopsy was performed, but no results were provided. At the time of death, MALAISE (Not feeling well after the second dose) outcome was unknown. No concomitant medical information were reported. No treatment information was reported. Company comment: This case concerns a 74-year-old, male patient with no relevant medical history, who experienced the unexpected events of Myocardial infarction, Arthrosclerosis, Chronic obstructive pulmonary disease, and other Adverse event (Nos). Patient initially experienced malaise (not feeling well) approximately 3 days after the second dose of mRNA-1273 (Moderna Covid-19 vaccine). The patient reportedly passed away approximately 7 days after the second dose of mRNA-1273 (Moderna Covid-19 vaccine); and autopsy revealed cause of death as Myocardial infarction, Arthrosclerosis, Chronic obstructive pulmonary disease, and Other unspecified terms on autopsy (Adverse event Nos). The rechallenge was not applicable as events occurred after second dose with fatal outcome. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report.; Sender''s Comments: This case concerns a 74-year-old, male patient with no relevant medical history, who experienced the unexpected events of Myocardial infarction, Arthrosclerosis, Chronic obstructive pulmonary disease, and other Adverse event (Nos). Patient initially experienced malaise (not feeling well) approximately 3 days after the second dose of mRNA-1273 (Moderna Covid-19 vaccine). The patient reportedly passed away approximately 7 days after the second dose of mRNA-1273 (Moderna Covid-19 vaccine); and autopsy revealed cause of death as Myocardial infarction, Arthrosclerosis, Chronic obstructive pulmonary disease, and Other unspecified terms on autopsy (Adverse event Nos). The rechallenge was not applicable as events occurred after second dose with fatal outcome. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report.; Reported Cause(s) of Death: Heart attack; arthrosclerosis; COPD


VAERS ID: 1756876 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-10
Onset:2021-09-17
   Days after vaccination:191
Submitted: 0000-00-00
Entered: 2021-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, Fall, Fracture, SARS-CoV-2 test positive
SMQs:, Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-23
   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: Norco, duloxetine, midodrine, melatonin, calcium carbonate, amitriptyline, senna, lidocaine, nitrofurantoin, nystain,
Current Illness: depression, iron deficiency, repeated falls, constipation, dementia
Preexisting Conditions: dementia, anemia, depression
Allergies: morphine
Diagnostic Lab Data: Abbot rapid nasal covid swab on 09/17/2021 X 2, both with + results
CDC Split Type:

Write-up: Received covid vaccine at another (unknown) location prior to admission to facility. experienced multiple falls with significant fractures (prior to facility admission), which put her in the hospital, then needing rehab. transferred to this facility, facility sent to the hospital r/t medical concerns on 09/05/2021, returned to the facility on 09/10/2021, tested positive for covid 19 on 09/17/2021. was treated per facility APRN and MD, however, despite efforts, expired on 09/23/2021. Death is under investigation with health department for cause.


VAERS ID: 1757610 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-09-24
Onset:2020-11-18
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Localised infection
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-22
   Days after onset: 245
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Prostate cancer (Received enzalutamide)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Deceased; Toe infection; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Deceased) in a 90-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Co-suspect product included non-company product ENZALUTAMIDE (ENZALUTAMIDE ASTELLAS) capsule for Prostate cancer. Concurrent medical conditions included Prostate cancer (Received enzalutamide). On 24-Sep-2020, the patient started ENZALUTAMIDE (ENZALUTAMIDE ASTELLAS) (Oral) 160 mg once a day. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 18-Nov-2020, the patient experienced LOCALISED INFECTION (Toe infection). The patient died on 22-Jul-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, LOCALISED INFECTION (Toe infection) outcome was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. Concomitant product use was not provided by the reporter. No treatment information was provided. This case concerns a 90 year-old male patient with history of prostate cancer, who experienced the unexpected serious event of Death (unknown cause) and the unexpected non-serious event of Localised infection. The events occurred an unknown number of days after the first and second doses of mRNA-1273 vaccine. The history of prostate cancer with unknown onset may have contributed to the events. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report. The seriousness of criteria of Medically significant was overridden for the event of Localised infection based on medical judgement and review of source document that does not include information supporting seriousness criteria.; Sender''s Comments: This case concerns a 90 year-old male patient with history of prostate cancer, who experienced the unexpected serious event of Death (unknown cause) and the unexpected non-serious event of Localised infection. The events occurred an unknown number of days after the first and second doses of mRNA-1273 vaccine. The history of prostate cancer with unknown onset may have contributed to the events. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report. The seriousness of criteria of Medically significant was overridden for the event of Localised infection based on medical judgement and review of source document that does not include information supporting seriousness criteria.; Reported Cause(s) of Death: Deceased


VAERS ID: 1757761 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: 3 deaths after the second dose of the Moderna vaccine; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (3 deaths after the second dose of the Moderna vaccine) in a female patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. Concomitant medications were not reported. Treatment medications were not reported. This case concerns a unspecified patient with no reported medical history experienced serious events of death after unspecified days after the second dose of Spikevax. The event''s causality considered possible by reporter. Patient experienced AEs after second dose and no information about the first dose is available rechallenge is not applicable . The benefit-risk relationship of Spikevax is not affected by this report. This case was linked to MOD-2021-334634, MOD-2021-334642 (Patient Link).; Sender''s Comments: This case concerns a unspecified patient with no reported medical history experienced serious events of death after unspecified days after the second dose of Spikevax. The event''s causality considered possible by reporter. Patient experienced AEs after second dose and no information about the first dose is available rechallenge is not applicable .The benefit-risk relationship of Spikevax is not affected by this report.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1757762 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: 3 deaths after the second dose of the Moderna vaccine; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (3 deaths after the second dose of the Moderna vaccine) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. Concomitant products were not provided. Treatment medication were not reported. Further information has been requested. This case concerns a patient of unknown age and gender, with no relevant medical history, who experienced the unexpected serious event of death (reported as 3 deaths after the second dose of the Moderna vaccine). The event occurred at an unknown day after the second dose of Spikevax. The rechallenge was not applicable as the events happened after the second dose and no additional dosing will be given (due to the outcome). The benefit-risk relationship of Spikevax is not affected by this report. This case was linked to MOD-2021-334634, MOD-2021-334640 (Patient Link).; Sender''s Comments: This case concerns a patient of unknown age and gender, with no relevant medical history, who experienced the unexpected serious event of death (reported as 3 deaths after the second dose of the Moderna vaccine). The event occurred at an unknown day after the second dose of Spikevax. The rechallenge was not applicable as the events happened after the second dose and no additional dosing will be given (due to the outcome). The benefit-risk relationship of Spikevax is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1758643 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-08-27
Onset:2021-09-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 054C21A / 3 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-01
   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: nystatin, Lasix, Toprol LX, Norco, Vitamin D3, mycophenolate, hydroxyzine, Protonix, Aldactone, Synthroid, betamethasone dipropionate
Current Illness: Chronic Lung disease, AS, right sided heart failure, LE edema, On oxygen via NC, mucositis,
Preexisting Conditions: Interstitial lung disease, right-sided heart failure, leg edema, neuralgia, dyslipidemia, hypertension, NASH
Allergies: Lisinopril, Morphine Sulfate, Oxycodone-acetaminophen, Sulfonamide Antibiotics
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient died.


VAERS ID: 1758912 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-26
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Inappropriate schedule of product administration, SARS-CoV-2 test positive
SMQs:, Medication errors (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-02
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 tested positive for COVID-19 9/23/2021. Hospitilized 9/23/2021. Patient was fully vaccinated 2/26/21 and 04/03/2021 with Moderna. Paitnet expired 10/02/2021


VAERS ID: 1759083 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-12
Onset:2021-03-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: HEADACHES
Preexisting Conditions: NO
Allergies: NO
Diagnostic Lab Data: DEATH CERTIFICATE SAYS HEART ATTACK... STATED COULD HAVE BEEN BLOOD CLOTS
CDC Split Type:

Write-up: SON REPORTED THAT PATIENT DIED 2 DAYS AFTER GETTING THE VACCINE


VAERS ID: 1759157 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2020-12-22
Onset:2020-12-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Communication disorder, Death, Decreased appetite
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650mg @ 9 AM/1 PM/5 PM
Current Illness: None
Preexisting Conditions: Dementia
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cessation of talking and eating followed by death.


VAERS ID: 1759308 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-04-01
Onset:2021-05-04
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Adult failure to thrive, Asymptomatic COVID-19, COVID-19, Death, Dementia, Dementia Alzheimer's type, Glaucoma, Hyperlipidaemia, Pulmonary hypertension, SARS-CoV-2 test positive, Sepsis, Vaccine breakthrough infection
SMQs:, Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Dementia (narrow), Pulmonary hypertension (narrow), Noninfectious encephalopathy/delirium (broad), Glaucoma (narrow), Lipodystrophy (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-22
   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:
Current Illness:
Preexisting Conditions: Cardiovascular disease, Renal disease
Allergies:
Diagnostic Lab Data: 05/04/2021 PCR+ COVID-19 test
CDC Split Type:

Write-up: Asymptomatic breakthrough COVID-19 case. Death 5/22/2021. From Records cod = ALZHEIMER''S DEMENTIA, COVID 19, HYPERLIPIDEMIA, PULMONARY HYPERTENSION. Other patient details: pt has dementia, adult failure to thrive . glaucoma, and sepsis. place of death: HOSPITAL-EMERGENCY ROOM/OUTPATIENT; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN; occupation: PLAYGROUND DIRECTOR-BOARD OF ELECTIONS


VAERS ID: 1759418 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-19
Onset:2021-10-02
   Days after vaccination:225
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Intensive care, Positive airway pressure therapy, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (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), Guillain-Barre syndrome (broad), 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: 2021-10-02
   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: Aspirin, lipitor, calcium carbonate, Zyrtec, temovate, vitamin B12, Avodart, Ferocon, Flonase, Neurontin, Zestril, Glucophage, Aleve, Saw Palmetto, Flomax, ultram, kenalog cream.
Current Illness:
Preexisting Conditions: Chronic back pain, HTN, DM2, extracranial carotid artery stenosis, arthritis, hyperlipidemia, B12 deficiency, cerebral thrombosis with cerebral infarction, vitiligo, obstructive pattern present on pulmonary function testing, aortic extasia (abdominal), monoclonal gammopathy of unknown significance, spinal stenosis, neuropathy, anemia, history of cerebrovascular accident, benign prostatic hyperplasia.
Allergies: "Seasonal allergies"
Diagnostic Lab Data: COVID positive swab on 09/19/21.
CDC Split Type:

Write-up: Fully COVID vaccinated patient who admitted through emergency department with COVID positive test on 09/19/21. Patients respiratory status continued to decline, he required CCU admission high flow oxygen, and subsquently BiPAP. Medical team reviewed ongoing respiratory decline and grave status with patient and family who declined intubation. Patient moved to comfort care and died on 10/02/21.


VAERS ID: 1759420 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-06
Onset:2021-09-20
   Days after vaccination:226
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A1A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Chemotherapy, Decreased appetite, Fatigue, SARS-CoV-2 test positive
SMQs:, Malignancy related therapeutic and diagnostic procedures (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-30
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had a history of right lower lobe small cell lung cancer and emphysema. He reports a feeling of fatigue and loss of appetite. He is still receiving chemotherapy. He was found to be COVID positive.


VAERS ID: 1759458 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-03-28
Onset:2021-05-06
   Days after vaccination:39
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028A21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Intestinal perforation, Multiple organ dysfunction syndrome, SARS-CoV-2 test positive, Septic shock, Vaccine breakthrough infection
SMQs:, 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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Gastrointestinal perforation (narrow), Ischaemic colitis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-07
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 05/06/2021 PCR+ COVID-19 test at Hospital
CDC Split Type:

Write-up: Breakthrough COVID-19 case. Hospitalized on unknown date for unknown duration. Death 5/7/2021. From Records COD = SEPTIC SHOCK, MULTISYSTEM ORGAN FAILURE, BOWEL PERFORATION. place of death: HOSPITAL-INPATIENT; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN; occupation: MAINTENANCE, HEAT AND AIR CONDITION


VAERS ID: 1759576 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-25
Onset:2021-07-26
   Days after vaccination:151
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Death, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Anaphylactic reaction (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), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-27
   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: OBESITY
Allergies:
Diagnostic Lab Data: 07/27/2021 PCR+ COVID-19 test at pharmacy
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Death 7/26/2021. From Vital Records COD = ACUTE HYPOXIC RESPIRATORY FAILURE, COVID 19 INFECTION. Per vital records, COD ICD Codes include: Not yet coded ; Other Significant Conditions include: OBESITY UNKNOWN BUT SIGNIFICANT CARDIAC HISTORY. place of death: HOSPITAL-INPATIENT, HEALTH SYSTEM; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN; occ/ind: CERTIFIED NURSE ASSISTANT, NURSE ASSISTANT


VAERS ID: 1759593 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-04-13
Onset:2021-09-06
   Days after vaccination:146
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044B21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-18
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalized for COVID-19 on 9/6/21. Passed away on 9/18/21.


VAERS ID: 1759634 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-09-22
Onset:2021-09-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050E21A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939902 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acquired diaphragmatic eventration, Adult failure to thrive, Basophil count normal, Basophil percentage, Chest X-ray abnormal, Death, Dyspnoea, Eosinophil count normal, Eosinophil percentage, Fatigue, Haematocrit decreased, Haemoglobin decreased, Lung infiltration, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Monocyte count normal, Monocyte percentage, Neutrophil count normal, Neutrophil percentage increased, Platelet count decreased, Prealbumin decreased, Red blood cell count decreased, Red cell distribution width increased
SMQs:, Anaphylactic reaction (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-01
   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: 4 oz. house supplement with meals. Administer SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5 mL dose, 2-dose vaccine (Moderna) To receive dose #1 on 8/11/21 1 Administer SARS-COV-2 (COVID-19) vacc
Current Illness: Diagnoses: ANEMIA, UNSPECIFIED(D64.9), UNSPECIFIED PROTEIN-CALORIE MALNUTRITION(E46), ADULT FAILURE TO THRIVE(R62.7), PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF STOMACH(Z85.028), TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS(E11.9), ANXIETY DISORDER, UNSPECIFIED(F41.9), UNSPECIFIED FALL, SUBSEQUENT ENCOUNTER(W19.XXXD), DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE(K44.9), DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED(R26.2), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12), LOW BACK PAIN(M54.5), IDIOPATHIC HYPOTENSION (I95.0), CONSTIPATION, UNSPECIFIED(K59.00), PRESSURE ULCER OF OTHER SITE, STAGE 1(L89.891), CHRONIC KIDNEY DISEASE, STAGE 3 UNSPECIFIED(N18.30)
Preexisting Conditions: Diagnoses: ANEMIA, UNSPECIFIED(D64.9), UNSPECIFIED PROTEIN-CALORIE MALNUTRITION(E46), ADULT FAILURE TO THRIVE(R62.7), PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF STOMACH(Z85.028), TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS(E11.9), ANXIETY DISORDER, UNSPECIFIED(F41.9), UNSPECIFIED FALL, SUBSEQUENT ENCOUNTER(W19.XXXD), DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE(K44.9), DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED(R26.2), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12), LOW BACK PAIN(M54.5), IDIOPATHIC HYPOTENSION (I95.0), CONSTIPATION, UNSPECIFIED(K59.00), PRESSURE ULCER OF OTHER SITE, STAGE 1(L89.891), CHRONIC KIDNEY DISEASE, STAGE 3 UNSPECIFIED(N18.30)
Allergies: No Known Allergies
Diagnostic Lab Data: |AGE: 78 GENDER: M | DATE&TIME: | 07/16/21 11:49 | |RCVD: 07/16/21 | |RPTD: 07/16/21 | RM 133 R E S U L T S RBC 3.71(L) 4.10-6.20 10^6/uL HEMOGLOBIN 10.0(L) 13.5-17.5 g/dL HEMATOCRIT 29.8(L) 41.0-53.0 % MCV 80 80.0-97.0 fL MCH 27.0 26.0-32.0 pg/cell MCHC 33.6 32.0-37.0 g/dL RDW 17.9(H) 11.5-14.5 % MPV 10.3 7.5-11.2 fl PLATELET COUNT 97(L) 130-400 10^3/uL NEUTROPHIL% 81.1(H) 40.0-74.0 % LYMPHOCYTE% 11.3(L) 19.0-48.0 % MONOCYTES% 6.2 2.0-11.0 % EOSONOPHIL% 0.7 0.0-7.0 % BASOPHIL% 0.7 0.0-1.5 % NEUTROPHIL# 5.7 1.7-7.7 10^3/uL LYMPHOCYTE# 0.8(L) 1.0-4.8 10^3/uL MONOCYTE# 0.4 0.0-1.0 10^3/uL EOSINOPHIL# 0.1 0.04-0.45 10^3/uL BASOPHIL# 0.1 0.00-0.20 10^3/uL MI PRE-ALBUMIN 11(L) 17.0-34.0 mg/dL INTERPRETATION: Reason for Study: R06.02 SHORTNESS OF BREATH XRAY CHEST 1 VIEW See Note FINDINGS: The heart is normal in size and configuration. The mediastinum is normal without adenopathy. There is a minimal right lower lobe infiltrate. There is no venous congestion. The osseous structures are unremarkable. CONCLUSION: Minimal right lower lobe infiltrate . The right hemidiaphragm is elevated
CDC Split Type:

Write-up: Guest passed/expired within 10 days of dose #2 of COVID-19 vaccine series. Began transitioning on 9/27/21-- 5 days s/p Dose #2. Guest was a hospice resident prior to COVID-19 vaccine and overall was having general decline prior to vaccination. Signed on to hospice on 8/6/21. Had active diagnosis of adult failure to thrive and hx of gastric CA--declined PEG tube. Only acute side effect 2 days s/p dose 2 noted was fatigue. No side side effects were reported with dose #1.


VAERS ID: 1759662 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-16
Onset:2021-08-05
   Days after vaccination:170
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Cardio-respiratory arrest, Death, End stage renal disease, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (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), Chronic kidney disease (narrow), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-19
   Days after onset: 14
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: 08/05/2021 PCR+ COVID-19 test at Hospital
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Death 8/19/21. From Vital Records COD = CARDIOPULMONARY ARREST, COVID 19, END STAGE RENAL FAILURE. Per vital records, COD ICD Codes include: Not yet coded ; Other Significant Conditions include: None listed. place of death: HOSPITAL-INPATIENT, HOSPITAL; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN; occ/ind: COMANPY


VAERS ID: 1761422 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-04
Onset:2021-09-14
   Days after vaccination:194
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Anaemia, B-cell lymphoma, Blood bilirubin increased, Blood glucose increased, COVID-19, Condition aggravated, Cough, Dehydration, Dyspnoea, Evans syndrome, Hypokalaemia, Hyponatraemia, Hypoxia, Leukopenia, Liver function test increased, Pancytopenia, Pneumonia, Pyrexia, SARS-CoV-2 test positive, Splenomegaly, Tachycardia, Vaccine breakthrough infection
SMQs:, Liver related investigations, signs and symptoms (narrow), Haemolytic disorders (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Agranulocytosis (narrow), Asthma/bronchospasm (broad), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (narrow), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Malignant lymphomas (narrow), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Haematological malignant tumours (narrow), Infective pneumonia (narrow), Dehydration (narrow), Hypokalaemia (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-03
   Days after onset: 19
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: Evan''s Syndrome, Cytomegalovirus, B-Cell Lymphoma
Allergies: No Known
Diagnostic Lab Data: Covid + 9/16/2021
CDC Split Type:

Write-up: Breakthrough Covid + 35 year old female with a Past Medical History of Evans Syndrome, Immune Deficiency Disorder, Lymph Node Abscess, B-cell Lymphoma, Cytomegalovirus, Pneumonia, Pneumothorax, Bone Marrow Biopsy, Port, and Lymph Node Biopsy. Admitted to Medical PCU for Low Grade Fever, COVID19, B-Cell Lymphoma, Evans Syndrome, Pneumonia, Splenomegaly, Elevated LFT''s, Elevated Bilirubin, Dehydration, Hypoxemia, Tachycardia, Leukopenia, Anemia, Pancytopenia, Elevated Blood Glucose, Hyponatremia, Hypokalemia, and Questionable Small Lesions within the Liver. Patient was admitted to the hospital for shortness of breath cough and fever. Symptoms have been progressively getting worse over last 1-2 days.


VAERS ID: 1761528 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-10
Onset:2021-10-05
   Days after vaccination:209
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA N/A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA N/A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Anticoagulant therapy, Atrial fibrillation, COVID-19 pneumonia, Cardiac failure, Chest tube insertion, Condition aggravated, Death, Endotracheal intubation, General physical health deterioration, Hypoxia, Intensive care, Multiple organ dysfunction syndrome, Pneumothorax, Renal failure, Respiratory failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Interstitial lung disease (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (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 (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-05
   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:
Current Illness:
Preexisting Conditions: Hypertension, anxiety, vitamin D deficiency, obesity class 3, obstructive apnea, allergic rhinitis, chronic kidney disease, atrial fibriliation.
Allergies: Hydrocodone (itching), Robitussin (chest tightness), soaps, animal dander, cosmetics.
Diagnostic Lab Data: COVID positive test on 09/20/21.
CDC Split Type:

Write-up: Fully vaccinated patient admitted for COVID pneumonia. Provider discharge note: "Admitted to the hospital on September 20, 2021 for hypoxia. She was fully vaccinated against COVID-19. At that time she is requiring high-flow nasal cannula oxygenation. On 09/20 for a CT scan was done which showed a possible nonocclusive emboli in the left lower lung. She was started on heparin. She was transferred to the intensive care unit on the morning of 09/30/2021. She developed bilateral pneumothoracies that time. She was intubated and chest tubes were placed. Over the next 5 days she developed worsening ARDS with multiorgan system failure. This presented initially with AFib with RVR and progressed to kidney failure. On the morning of 10/04/2021 the patient''s family decided that they did not want to pursue additional care. Her respiratory cardiac function decreased until 9:45AM on 10/5/2021 when she passed away."


VAERS ID: 1761541 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-10-03
Onset:2021-10-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039D21A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-03
   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: Oxycodone Apap 10-325, Tizanidine 4mg, Gabapentin 300mg, Zolpidem 10mg, Alprazolam 1mg
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: unknown patient representative contacted pharmacy to report the patient had died hours after getting the moderna vaccination


VAERS ID: 1761576 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-03
Onset:2021-08-09
   Days after vaccination:187
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 28L20A0 / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-24
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Chronic sinus infections
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fully vaccinated and later hospitalized then died due to Covid related causes.


VAERS ID: 1761633 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-04-20
Onset:2021-09-21
   Days after vaccination:154
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B21A / 2 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, Death, Renal failure, Respiratory failure, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (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), Guillain-Barre syndrome (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 09/08/2021 PCR+ COVID-19 test at Hospital; 09/16/2021 PCR+ COVID-19 test at Medical Center
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Death 9/21/2021. From Records COD= RESPIRATORY FAILURE, RENAL FAILURE, ATRIAL FIBRILLATION. Per records, Other Significant Conditions include: N/A. place of death: HOSPITAL-INPATIENT, MEDICAL CENTER; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN; occupation: MACHINIST, MACHINERY ."Did the patient die?"marked YES; "Is this a COVID-related death?" marked YES.


VAERS ID: 1761641 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-12
Onset:2021-09-17
   Days after vaccination:217
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-29
   Days after onset: 12
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: Covid antigen test on 9/17/21 for admission and sx
CDC Split Type:

Write-up: pt was admitted on 9/17/21 with increased shortness of breath, pt was a DNR/DNI at time of hospitaliztion, pt was made hospice on 9/29/21 pt expired 9/29/21


VAERS ID: 1761752 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-10
Onset:2021-09-24
   Days after vaccination:226
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   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: Norco, Zaroxolyn, Mag-ox, Imdur, Cozaar, Vit D3, metformin, aspirin, Namenda, Klor-Con, Lasix, Aricept, Pravachol, Lopressor, Dulcolax, Guaisfensin, Nitroglycerin, Tylenol
Current Illness:
Preexisting Conditions:
Allergies: Benazepril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 09/24/2021.


VAERS ID: 1761787 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-04-09
Onset:2021-09-25
   Days after vaccination:169
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027B21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   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: Roxicodone, Colace, Lopressor, Lasix, Tylenol, Atarax, Senokot, Lyrica, Protonix, Pepcid, Effexor, Forteo, Pamelor, calcium carbonate, Vit D3. Abilify, Lipitor, Keppra, Narcan, Voltaren, Tums
Current Illness:
Preexisting Conditions:
Allergies: Tramadol, Duloxetine, Tizanidine, Motrin, Spironolactone
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 09/25/2021.


VAERS ID: 1761801 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-03
Onset:2021-09-29
   Days after vaccination:210
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036A21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-29
   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: Ceclor, Codeine, Penicillin, Sulfa drugs, Tramadol
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 09/29/2021


VAERS ID: 1761871 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-10
Onset:2021-09-02
   Days after vaccination:176
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21 / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032B21A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Dyspnoea, Endotracheal intubation, Positive airway pressure therapy, SARS-CoV-2 test positive, Septic shock, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Toxic-septic shock conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-12
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: antigen Covid test positive on 9/2
CDC Split Type:

Write-up: pt admitted on 9/2 syncopy and sob, pt placed on cpap in er condition continued to worse, pt intubated pt went into septic shock and expired on 9/12/21


VAERS ID: 1761895 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-04
Onset:2021-08-25
   Days after vaccination:174
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-25
   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:
Current Illness:
Preexisting Conditions:
Allergies: Penicillin''s, tape
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 08/25/2021.


VAERS ID: 1761994 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-09-15
Onset:2021-09-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest discomfort, Chest pain, Cough, Death, Dyspnoea, Feeling abnormal, Malaise, Respiratory tract congestion, Somnolence
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin, Busiprone, cyclobenzaprine, insuline
Current Illness:
Preexisting Conditions: Type-2 Diabetes with well maintained blood sugar levels.
Allergies: NKA
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: 09/16/2021-09/19/2021 Patient remained in bed coughing, feeling ill, drinking fluids and eating but slept mostly. 09/20/2021-Patient complained about being congested so she took mucus relief and cough drops 09/21/2021-09/23/2021-Patient began moving around the house feeling short of breath and a little foggy but symptoms felt to be slowly disipating and she was glad to be out of bed. Took a shower and sat outside to get fresh air and discussed how 09/16-09/19 she had never felt the burning in her chest and tightness like anything before and was glad it was over with. She was given water and left to her own accord at 10:30 pm. 09/24/21- At approximately 9:30 patient was discovered in her bed having died sometime throughout the night.


VAERS ID: 1762046 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-04-01
Onset:2021-09-22
   Days after vaccination:174
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: COVID illness and death.


VAERS ID: 1762101 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-17
Onset:2021-08-03
   Days after vaccination:167
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Acute kidney injury, Acute respiratory failure, Asthenia, Atrial fibrillation, Blood creatinine increased, Blood culture, Blood lactic acid, Blood pressure decreased, Blood sodium decreased, Body temperature increased, Brain natriuretic peptide increased, Breath sounds abnormal, Bronchial wall thickening, COVID-19, Cardiac failure, Cardiac telemetry, Catheterisation cardiac abnormal, Cellulitis, Chest X-ray abnormal, Chills, Chronic kidney disease, Condition aggravated, Confusional state, Coronary artery stenosis, Culture urine, Death, Decreased appetite, Dizziness, Dyspnoea, Echocardiogram abnormal, Ejection fraction decreased, Endotracheal intubation, Erythema, Fall, Feeding tube user, Heart rate increased, Hypotension, Hypoxia, Injury, Intensive care, Left ventricular end-diastolic pressure increased, Legionella test, Lung opacity, Mechanical ventilation, Mental status changes, Metabolic function test, Mitral valve incompetence, Mitral valve prolapse, Oxygen saturation decreased, Palpitations, Peripheral swelling, Pneumonia, Respiratory failure, SARS-CoV-2 test positive, Sepsis, Septic shock, Skin lesion, Skin warm, Skin weeping, Slow response to stimuli, Sputum culture, Tachycardia, Tachypnoea, Viral infection, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (narrow), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Hostility/aggression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Vestibular disorders (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-04
   Days after onset: 32
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 18 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol, minocyline, ondansetron, pantoprozole, ibrutinib
Current Illness:
Preexisting Conditions: PMH of A-fib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF, Waldenstrom macroglobulinemia (on imbruvica) past surgical history that includes Cardiac catheterization (N/A, 07/22/2021); cardiac stent (N/A, 02/11/2005); Rotator cuff repair (Left); Total knee arthroplasty (Left); and Back surgery (N/A).
Allergies: Amoxicillin (Rash) 2/2019
Diagnostic Lab Data: 8/3/2021 COVID-19 Tested positive 8/23/2021 COVID-19 Tested positive
CDC Split Type:

Write-up: Patient vaccinated for COVID on 2/17/2021, admitted on 8/3/2021, tested positive for COVID 8/3/2021. discharged 8/8/2021 patient admitted again on 8/23/2021, tested positive for COVID 8/23/2021. Patient passed away on 9/4/2021 History Of Present Illness a 80 y.o. male with a PMH of A-fib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF, Waldenstrom macroglobulinemia (on imbruvica) who presents with worsening weakness, dizziness, SOA, chills and decreased appetite over the past 1.5 wks. Associated with mild abdominal pain. Symptoms started back in June, but acutely worsened. He was evaluated for these issues. His cardiologist performed a LHC showing 50% LAD stenosis, severe MR, LVEF 30-35%, LVEDP of 40. Given these findings, he was referred to another doctor for evaluation for potential MV replacement. However, given his worsening symptoms, he presented to the ED. Patient denies recent sick contacts. No fevers, N/V/D. He is vaccinated against COVID. He was given lasix to take for 2 wks if he had significant weight gain- states he only took it 3 times and had not since. Compliant with all meds. Review of Systems Constitutional: Positive for activity change, appetite change and chills. Negative for fever. HENT: Negative for trouble swallowing. Respiratory: Positive for shortness of breath. Negative for cough, chest tightness and wheezing. Cardiovascular: Positive for palpitations and leg swelling. Negative for chest pain. Gastrointestinal: Positive for abdominal pain. Negative for constipation, diarrhea, nausea and vomiting. Assessment and Plan He is an 80 y/o male with PMH of A-fib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF, Waldenstrom macroglobulinemia (on imbruvica) who presents with worsening weakness, dizziness, SOA, chills and decreased appetite over the past 1.5 wks noted to have Covid Infection. #COVID Infection -Now needing 3 l of O2 -CXR- Peribronchial thickening and interstitial opacification may be associated with viral infection -Patient states he was previously vaccinated. -Given patient''s hypoxia, will start dexamethasone 6 for 10 days and also Remdesivir -Encourage Pul toilet, BD and Proning -Monitor AKI on CKD -baseline Cr 1.6 -Likely due to prerenal in the context of IV lasix on admission with N BNP -Monitor in the background of Remdesivir -Hold further diuresis -avoid nephrotoxic agents -Repeat CMP in AM #Severe Mitral Regurgitation #Mitral Valve Prolapse #HFrEF #CAD s/p DES - Baptist LHC 6/22/2001 - 50% LAD stenosis, severe MR, LVEF 30-35%, LVEDP of 40 - ECHO 12/2015 - bileaflet prolapse with posterior mitral cleft with severe MR. - ECHO 8/2018- shows MV prolapse with severe MR. - ECHO 6/30/2021- severe MR. No sig mitral valve stenosis is present. LVEF 45-50%. - BNP- 864, Na 135, Cr 1.6 (baseline). - CXR- Peribronchial thickening and interstitial opacification may be associated with viral infection A/ Overall believe patient''s symptoms are 2/2 to Covid infection and his worsening, severe MR. He was diuresed well with 40 of IV lasix. Will have evaluation from CT surgery. If they believe valve is the root cause of his issues and do not feel surgical intervention is warranted, will consider interventional cardiology consultation. Plan: - CT Surgery Consulted - Hold further diuresis given severe MR and improvement in symptoms #A-fib - Patient on eliquis and atenolol -C/w eliquis and atenolol #Waldenstrom macroglobulinemia - Started on imbruvica for treatment. Patient states he does not take venclexta Plan: - Consult oncology in AM for approval of imbruvica Chronic Conditions -Benzodiazepine dependence- Tranxene 15 mg nightly; recommended weaning and discontinuing as outpt -Skin Lesions- multiple lesions on abdomen and UEs- continue doxycycline. -HLD- pravastatin 40 -HTN- on atenolol only -GERD- PPI F: po E: po N: Cardiac, low salt; DVT Ppx: Hold eliquis, heparin 5000 q8hrs Code:code status: do not resuscitate, okay to intubate. POA- Son. Has living will. Hospitalization Admit Date/Time: 8/3/2021 9:47 AM Discharge Date: 08/08/21 Chief Concern, Brief History of Present Illness, and Hospital Course He is an 80 y.o. male with a history of A-fib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF, Waldenstrom macroglobulinemia (on imbruvica) who presents with worsening weakness, dizziness, SOA, chills, mild abdominal pain and decreased appetite over the past 1.5 wks and noted to have Covid Infection. He was here for the mitral valve surgery and found to have COVID. He transiently required oxygen and was off oxygen at the time of discharge. He was treated with dexamethasone and remdesivir. Hematology advised to hold ibrutinib in the setting of COVID infection and upcoming surgery and follow up with patients OSH hematologist to decide about ibrutinib. CTS will follow up with the patient regarding surgery which is likely to be in a month as per my discussion with CTS. The details of A&P while in the hospital is listed below. #COVID Infection # Acute Hypoxic Respiratory failure (resolved) -discharged on room air. -CXR- Peribronchial thickening and interstitial opacification may be associated with viral infection -Patient states he was previously vaccinated. -Given patient''s hypoxia, c/w dexamethasone 6mg for 10 days and Remdesivir AKI on CKD-Resolved. Discharge Disposition/Condition Disposition: Home Condition: Stable (s/sx potential problems absent or manageable) second admission 8/23/2021 Patient admitted for altered mental status Chief Complaint Chief Complaint Patient presents with ? Trauma Alert ? Fall ? Epidemic Concern ? Altered Mental Status History Of Present Illness He is an 80 yo male with PMH waldenstrom macroglobulinemia (on imbruvica), Afib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF. Who presented to the Emergency Department after a fall at home. History is obtained from son who is at bedside and prior records as patient is currently altered and minimally responsive to exam. Per the son the patient had become increasingly confused over the past 2 days where he was "talking off the wall". After falling to his left side, son brought him to emergency department for further evaluation. On arrival the patient was saturating in the low 80s on room air and tachycardic to 120s with normotension. He was administered 2 L of fluid and placed on high-flow nasal cannula. His oxygenation improved, however he developed A-fib RVR with HR up to 180s. His blood pressure dropped with this to maps in the low 70s. At this time MICU was consulted for further evaluation. On exam the patient is altered, alert to person only. He also has notable swelling and erythema to his left forearm which is hot to touch. Noteworthy labs include WBC 20.67, Creatinine 2.15, and Lactate 4.5. Patient will be admitted to ICU with plan for Amio gtt for A-fib RVR and management of Sepsis. Pulmonary: Breath sounds: No stridor. Decreased breath sounds present. No wheezing or rhonchi. An 80 y/o male with PMH of Afib on Eliquis, severe MVR, HTN, HLD, CAD s/p DES. PE (in 2007), HFrEF (50% EF), CKD, Waldenstrom macroglobulinemia, recent COVID infection who is being admitted for sepsis likely 2/2 SSTI of L arm. #Sepsis and Septic Shock - Patient presented with F 101.2F, Tachycardia, tachypnea, hypotension and had elevated WBC at 20.67 - L arm swollen, erythematous, warm to touch and weeping. L arm cellulitis appears to be the likely source. - Blood cultures pending. Check urine cultures, sputum cultures, S pneumo and legionella. - S/p Vanc and Zosyn. Continue broad spectrum antibiotics and tailor them pending culture results. - 2L fluid given in boluses. Due to HFrEF will hold off on any more IV boluses. Can give gentle maintenance fluids. - Lactic acid elevated at 4.5. Follow post resuscitation levels. Dispo - Admit to ICU - DNR/I a 80 y.o. male with past medical history significant for atrial fibrillation on Eliquis, severe mitral valve regurgitation, hypertension, hyperlipidemia, chronic systolic heart failure, CAD, previous saddle PE, Waldenstrom macroglobinemia, and critical aortic stenosis, who presented to ED with after a fall at home. Per report, the patient was diagnosed with COVID-19 on the 3rd of this month and has been living with his son while he has been recovering. Of note, the patient was due to undergo evaluation for surgical repair of his symptomatic valvular heart disease, however this was postponed due to his COVID-19 infection. His son states that for the past 2 days, he has become increasingly confused with worsening mentation from his baseline. His son noticed that his father became acutely tachypneic today and suffered a mechanical fall from standing, landing on his left side. He was brought to the ED as a trauma alert with subsequent workup significant for oxygen saturation of 84% on room air, tachycardia with HR between 150-180, and breathing at 30-35 breaths per minute. He was given 2L of fluid, IV antibiotics per sepsis protocol, and Tylenol for symptomatic relied. He continues to be tachycardic in the 170''s on average at this time with high flow nasal cannula required for adequate oxygen saturations above 90%. Hospital medicine was consulted for admission given concern for this patient''s clinical presentation and unstable vital signs. He was eventually endotracheally and transferred to the ICU for further care. He was treated for assumed pneumonia and on workup was found to have severe mitral regurgitation. With diuresis and antibiotics, the patient''s mechanical ventilation was eventually weaned and the patient was extubated. CTS was consulted for his severe MR and potential surgical options, however given the patient''s age and level of illness and debilitation, this was not possible. The family was consulted at every stage of the decision making process and they elected to make him DNR/DNI and palliative care was consulted. On 9/3 comfort care measures were instituted and the patient passed away peacefully with his family at bedside. Hospitalization Admit Date/Time: 8/23/2021 11:42 AM Discharge Date: 9/3/2021 1. Severe mitral regurgitation with respiratory failure- patient and his son understand that there are longer medical or surgical options for his valve disease. Their goal is to focus on comfort care duing his last days of life. It is important to them that he lives for the next several days in order for his son to complete the sell of patients home on Tuesday. This will allow them to avoid escrow and gift the house to a family that is important to him. Should he decline to dying before then we will not attempt to prolong his life. However in the interrim we will continue hi flo oxygen as any attempt at weaning will shorten life now. Will also continue tube feeds but allow to eat and drink for pleasurer and not replace tube if becomes removed. Comfort Care Only Goals of care- comfort care plan, allow natural death with no escalation of care -can dc lab draws -do not increase oxygen supplementation past current hi flo setting -can stop telemetry, rapid response -dc scd -allow food and drink for pleasure Patient Expired during this admission and was discharged to morgue.


VAERS ID: 1762703 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-10-04
Onset:2021-10-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 019F21A / 1 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UT7319KA / 1 RA / IM

Administered by: Pharmacy       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: 2021-10-04
   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: None discussed or known.
Preexisting Conditions: Pt discussed having heart issues and diabetes during administration, as we discussed possibly considering other vaccines such as pneumonia and shingles vaccines in the future. Nothing documented. Pt did not fill maintenance medications at our pharmacy. Was a new patient to us at time of vaccination.
Allergies: None
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Pt received vaccines at our pharmacy the morning of 10/4/21. She was monitored for 15 minutes after vaccination and no reactions were noted or observed in the patient waiting time. She left without any known complications. On 10/5/21, the Coroner came to the pharmacy with documents to retrieve medical records for the patient as she had "went into cardiac arrest yesterday and needed these records for the autopsy investigation." After contacting my direct supervisor and he contacted necessary persons to confirm the release of the PHI, we called him back to inform him he could come to pick up records. There was no communication in between the time the patient left the pharmacy without complications from the vaccines and the time the coroner came to pharmacy to retrieve patient records for her death.


VAERS ID: 1763094 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: California  
Vaccinated:2021-05-12
Onset:2021-05-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 021C21A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-14
   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: ALCOHOL USE DISORDER, MEDICATION NON-COMPLIANCE, ESRD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 48 hours of vaccine


VAERS ID: 1763098 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-15
Onset:2021-03-22
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   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: Morbid obesity, OSA, DM2, CKD, renal anasarca
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 7 days of vaccine


VAERS ID: 1763101 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-01
Onset:2021-06-08
   Days after vaccination:127
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-08
   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: Persistent Atrial Fibrillation, LOWER EXTREMITY EDEMA OPEN WOUND HYPOTENSION
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fully vaccinated and died of Covid related causes.


VAERS ID: 1763115 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: California  
Vaccinated:2021-04-26
Onset:2021-04-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014C21A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-30
   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: CHR, CKDIII, DM2
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 7 days of receiving vaccine


VAERS ID: 1763122 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-17
Onset:2021-03-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 7 days of vaccination


VAERS ID: 1764092 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: 1 person died after regular shots; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (1 person died after regular shots) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medications were provided by the reporter. No treatment information details was provided by the reporter. It was reported that one person died after regular shots and reporter thinks it was moderna vaccine but was not sure about it. This case concerns a patient of unknown age and gender with no relevant medical history, who experienced the expected fatal event of Death, with no cause of death provided. The event occurred at an unknown date after a dose of Spikevax (unknown dose). The rechallenge was not applicable due to the fatal outcome. The benefit-risk relationship of Spikevax is not affected by this report. This case was linked to MOD-2021-332581 (Patient Link).; Sender''s Comments: This case concerns a patient of unknown age and gender with no relevant medical history, who experienced the expected fatal event of Death, with no cause of death provided. The event occurred at an unknown date after a dose of Spikevax (unknown dose). The rechallenge was not applicable due to the fatal outcome. The benefit-risk relationship of Spikevax is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1764194 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-05-11
Onset:2021-07-20
   Days after vaccination:70
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebrovascular accident, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), 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), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Swelling and bumps; Double stroke; This spontaneous case was reported by a consumer and describes the occurrence of CEREBROVASCULAR ACCIDENT (Double stroke) in a 79-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On 11-May-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 20-Jul-2021, the patient experienced CEREBROVASCULAR ACCIDENT (Double stroke) (seriousness criteria death and medically significant). On an unknown date, the patient experienced SWELLING (Swelling and bumps). The patient died on 20-Jul-2021. The reported cause of death was double stroke. It is unknown if an autopsy was performed. At the time of death, SWELLING (Swelling and bumps) outcome was unknown. Patient passed away after getting Moderna COVID-19 Vaccine. No relevant concomitant medications were reported. No treatment information was reported.; Sender''s Comments: This case concerns a 75 year old male with no relevant medical history who experienced serious unexpected fatal event of CVA approximately 2 months after the first dose of the vaccine. Rechallenge was not applicable. The benefit-risk relationship is not affected by this report.; Reported Cause(s) of Death: Double Stroke


VAERS ID: 1764846 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-25
Onset:2021-03-19
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Atrial fibrillation, Biopsy lung, Cough, Death, Dyspnoea, Lung neoplasm malignant, Nasal congestion, Oropharyngeal pain, Oxygen saturation decreased, Positive airway pressure therapy, Pyrexia, Rhinorrhoea, Tachypnoea
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), 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), Non-haematological malignant tumours (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 12
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:
Current Illness:
Preexisting Conditions: Chronic lung disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever, Runny Nose/Congestion, Sore Throat, Cough recent diagnosis of lung cancer on the left side. He had a left lung biopsy yesterday. Last night he developed shortness of breath. He is very dyspneic. He normally is on oxygen from 2-4 L. On 4 L he was in the mid 70s on EMS arrival. They placed him on oxygen but his oxygen status was still low and he was tachypneic. He was placed on CPAP with improvement. He also received steroid, Solu-Medrol as well as breathing treatments. No chest pain. No abdominal pain. No nausea vomiting. No fever. patient reports having his 2nd dose of COVID vaccine 2 weeks ago In ER, patient was noted to be in AFib with RVR. The per patient and wife was at bedside, he does not have any history of atrial fibrillation. Death on 3/31/2021


VAERS ID: 1764856 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-14
Onset:2021-09-22
   Days after vaccination:251
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Metastatic Lung Cancer
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt died after contracting COVID-19 in early August 2021.


VAERS ID: 1764880 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-24
Onset:2021-09-03
   Days after vaccination:163
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-03
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Uknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died after contracting COVID-19 in Aug 2021.


VAERS ID: 1764920 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-05-14
Onset:2021-06-17
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNAVAILABLE (PL / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-17
   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: Blood pressure medication
Current Illness:
Preexisting Conditions: Vascular dementia
Allergies:
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Patient died about a month later. Unknown whether she had a second vaccination for COVID. She was resident at Rehab Facility.


VAERS ID: 1765070 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Oklahoma  
Vaccinated:2021-04-06
Onset:2021-05-26
   Days after vaccination:50
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-26
   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: Hypertensive cardiovascular disease CVA
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Onset of severe shortness of breath and death within several minutes.


VAERS ID: 1765475 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-13
Onset:2021-09-29
   Days after vaccination:200
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain, Biopsy liver, COVID-19, Colonoscopy, Computerised tomogram abdomen abnormal, Condition aggravated, Death, Dyspnoea, General physical health deterioration, Hypoxia, Intestinal perforation, Laparotomy, Leukocytosis, Mass, Metastatic squamous cell carcinoma, Neuroendocrine tumour, Oesophagogastroduodenoscopy, SARS-CoV-2 test positive, Sepsis
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal perforation (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Skin malignant tumours (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Non-haematological malignant tumours (narrow), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-04
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 21 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: acetaminophen (TYLENOL) 500 MG tablet Adhesive Tape (KENDALL PAPER 2"X10YD) TAPE albuterol HFA (PROVENTIL HFA, VENTOLIN HFA, PROAIR HFA) 108 (90 Base) MCG/ACT inhaler amitriptyline (ELAVIL) 100 MG tablet aspirin 81 MG EC tablet azaTHIOprine
Current Illness: 8.26.21: EGD/Colonoscopy 9.9.21: Office visit - follow-up Crohn''s disease 9.10.21: Infusion - vedolizumab (ENTYVIO) 300 mg in sodium chloride... 300 mg 9.14.21: ED - abdominal pain; perforated viscus; sepsis; leukocytosis; new cancer - transferred to another hospital - admitted
Preexisting Conditions: PVD (peripheral vascular disease) Other osteoporosis without current pathological fracture Diverticulosis of sigmoid colon Vitamin D deficiency Colitis Right upper quadrant abdominal pain Crohn''s disease of small intestine with complication Closed pilon fracture of left tibia Essential hypertension, benign Crohn''s disease and perforation s/p right colon resection and end ileostomy with long hartmann''s pouch, liver biopsy 9/14/21 Bowel perforation Mass of heart Leukocytosis Allergy to trimethoprim/sulfamethoxazole COVID-19
Allergies: BaclofenOther, Difficulty concentrating Septra [Sulfamethoxazole W-trimethoprim]Hives AtorvastatinOther Boniva [Bisphosphonates]Other CodeineOther Fosamax [Alendronic Acid]Other Hydrocodone-acetaminophenConfusion Ileostomy Restricted Foods Sulfamethoxazole Trimethoprim
Diagnostic Lab Data:
CDC Split Type:

Write-up: Deceased (10.4.21); Hospitalized (9.14.21); COVID-19 positive (9.29.21); fully vaccinated Admission Date: 9/14/2021 Date of Death: 10/4/21 Time of Death: 6:56 AM Preliminary Cause of Death: Hypoxia DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Perforated abdominal viscus Bowel perforation a 68 y.o. female with past medical history significant for Crohn''s disease on immunosuppressive therapy, history of stroke, and PAD who presented to the emergency department with severe abdominal pain. CT concerning for bowel perforation and Colorectal took patient for urgent laparotomy and was treated with broad spectrum antibiotics and antifungals. CT also with concern for liver metastasis and biopsy done in the OR showing metastatic neuroendocrine tumor. Workup further showed a cardiac mass which was biopsied via RHC showing metastatic SCC indicating patient having two primary metastatic diseases. Patient continued to decline and developed dyspnea; unfortunately she tested positive for COVID19. Patient ultimately wished to be made comfort care and so hospice was consulted and comfort care orders initiated. Medicine service took over care to facilitate this on 10/2. Patient expired on 10/4/2021 at 6:56am.


VAERS ID: 1765490 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-05-27
Onset:2021-08-18
   Days after vaccination:83
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027C21A / 2 LA / IM

Administered by: Public       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: 2021-08-27
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: lung cancer, COPD
Allergies: unknown
Diagnostic Lab Data: Tested positive for COVID on 8-14-21
CDC Split Type:

Write-up: Patient contracted COVID, was hospitalized, and died


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