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From the 9/10/2021 release of VAERS data:

Found 14,925 cases where Vaccine is COVID19 and Patient Died



Case Details

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VAERS ID: 979773 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Texas  
Vaccinated:2020-12-30
Onset:2021-01-16
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none as far as i know
Current Illness: none per care giver
Preexisting Conditions: none that was reported
Allergies: none reported
Diagnostic Lab Data: none that i know of
CDC Split Type:

Write-up: Not sure if it has to do with the COVID vaccine but her caregiver reported to me today (1/27/20201) that she passed away on 01/16/2021 from a pulmonary embolism that was 18 days after vaccine


VAERS ID: 979796 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-08
Onset:2021-01-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: metoprolol, atorvastatin, furosemide, metformin, trulicity, glipizide, omeprazole, gabapentin, loratadine, losartan, amlodipine
Current Illness: not known. I spoke with his wife when he was in the hospital a couple of days after the first dose of Moderna vaccine. She mentioned that he felt ill a few days before and up to the vaccine date. Despite feeling ill, he checked off "no" on the questionnaire section that asked if patients were feeling ill that day.
Preexisting Conditions: Diabetes, hyperlipidemia, hypertension
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient went to hospital with COVID symptoms on 01/10/2021 and passed away on 01/22/2021


VAERS ID: 979818 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Death, Dyspnoea, Resuscitation, SARS-CoV-2 test positive, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Adult one daily multivitamin Vitamin B12 Vitamin D Acetaminophen - Codeine 300-30 prn acyclovir levothyroxine
Current Illness: Malignant neoplasm of colon dx Stage IIB in 2018. Surgery in 2018 to remove mass Inguinal hernia (rt) CT follow up in 12/2020 r/t above found no evidence of metastatic disease in abdomen or pelvis, inguinal hernia still present. Distension in abdomen reported in 11/2020 through 12/2020 at office visit
Preexisting Conditions: Malignant neoplasm of colon dx Stage IIB in 2018. Surgery in 2018 to remove mass Inguinal hernia (rt) CT follow up in 12/2020 r/t above found no evidence of metastatic disease in abdomen or pelvis, inguinal hernia still present.
Allergies: None
Diagnostic Lab Data: Rapid COVID 19 test positive at ED. OF NOTE: Wife tested positive for COVID 2 weeks prior to patient vaccination and subsequent death. It is unclear if patient had symptoms or tested for COVID during that time frame. No other labs collected.
CDC Split Type:

Write-up: Patient arrived at ER with complaints of CPR in progress. Per EMS, patient became short of breath while performing yard work on 1/26/2021. At arrival, patient was in fine v fib with a total of 6 shocks delivered along with 300 mg amiodarone followed by 150 mg amiodarone, 1 amp epinephrine and 2 epinephrine drips adminstered en route to ED. CPR initiated at 1755 and EMS reports asystole at 1829. TOD 1909 pronounced by ED DO Dx: Cardiac arrest


VAERS ID: 979837 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Nevada  
Vaccinated:2021-01-25
Onset:2021-01-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Death, Hypotension, Presyncope, Pulseless electrical activity, Resuscitation, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: History of benign prostatic hyperplasia, hypertension, urinary tract infection, cerebrovascular accident. 1/25/21 Brought to Hospital ED by EMS from Health District for near syncope and hypotension post Pfizer vaccine administration. 1/27/21 Brought to Hospital ED by EMS from home after wife found.
Preexisting Conditions: History of benign prostatic hyperplasia, hypertension, cerebrovascular accident.
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per EMS, the patient was last seen walking and talking to wife 10 minutes prior to EMS arrival. EMS reports via patients wife, that patient was upstairs to change for his doctor appointment then patient''s wife found him down. The patient received his COVID-19 vaccine on 1/25/21. EMS states they gave 5 rounds of EPI then patient moved into vfib then was shocked once but returned to asystole. In ED, the patient initially in asystole CPR was started immediately. The patient was given 3 rounds EPI, 1 round bicarb. The patient stayed in PEA throughout. Patient was given tPA. Patient continued to be in asystole and time of death was called at 11:35 am.


VAERS ID: 979841 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-01-07
Onset:2021-01-09
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Evaluated for L flank pain in ED on 1/1/2021, no acute findings on CT. Noted to be in mild CHF, discharged home from local ED.
Preexisting Conditions: HTN, CKD stage 5, hemodialysis dependent, DM type II, hx renal transplant
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt likely presented to vaccine appt with asymptomatic/early infection of COVID-19, as he presented 2 days post-vaccination and tested positive for COVID-19 on rapid and PCR test. He was hospitalized where he eventually died of complications from COVID-19 while in ICU. Date of death was 1/15/2021.


VAERS ID: 979926 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: California  
Vaccinated:2020-12-30
Onset:2021-01-02
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   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: N/A
Current Illness: Pt was on hospice in LTCF at time of death, but expired 3 days after receiving vaccine. She exhibited shortness of breath the morning of death. 12/7-12/17 covid positive but seemed to be recovering HTN Alzheimer?s
Preexisting Conditions: HTN Health Conditions
Allergies: N/A
Diagnostic Lab Data: Pt was covid positive from 12/7-12/17
CDC Split Type:

Write-up: Pt began experiencing shortness of breath 3 days after vaccine and expired later that day.


VAERS ID: 979990 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-07
Onset:2021-01-09
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: sudden cardiac arrest


VAERS ID: 980107 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Lethargy, Livedo reticularis, Mental status changes, Oxygen saturation decreased, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient noted to have a change in status at 11:23PM that night. Her oxygen saturation had dropped from normal on room air to 82% and required oxygen. She was also noted to be lethargic with altered mental status and not responding verbally. She then began to mottle. Her oxygen saturation worsened to 51% on 4Liters of oxygen by the next day and she expired on 1/14/21.


VAERS ID: 981938 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-22
Onset:2021-01-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Cardiac arrest, Cardio-respiratory arrest, Chest X-ray abnormal, Cyanosis, Death, Lung infiltration, Lung opacity, Pulse absent, Respiratory arrest, Resuscitation, SARS-CoV-2 test negative, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Covid negative: 12/27/20, 1/20/21, 1/25/21 Covid Negative 1/11/21
CDC Split Type:

Write-up: UNKNOWN/ASYTOLE Narrative: Please refer to section 6. 68y/o male with h/o severe peripheral vascular disease with previous left AKA 2/3/20, s/p bilateral bypasses in the past. Pt recently underwent right AKA on 1/12/21. Per Hospital remote data 1/10/21 pt c/o shortness of breath, CXR demonstrated right lower lobe opacity & left basilar infiltrate. Pt s/p $g10 days emperic IV abx. Moderna vaccine 0.5ml IM was administered via left deltoid on 1/22/21 around 16:21. On 1/23/21@05:14 code blue was called as pt found to be unresponsive, breathless and pulseless, facial cyanosis noted, CPR started immediately.Pt found to be in asystole. ACLS guideline followed but no return of spontaneous circulation, At 05:32 pt remained pulseless and breathless and was pronounced. Autopsy currently pending.


VAERS ID: 981945 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-13
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, COVID-19, Death, Fall, SARS-CoV-2 test positive
SMQs:, Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID positive on 01/13/21
CDC Split Type:

Write-up: weakness and fallsNarrative: 95 yo male w/ a PMH significant for Afib, legal blindness, Hx of CVA, cognitive impairment, GERD, HTN, pseudogout, BPH, chronic knee infection, and DJD who received his first dose of the Moderna COVID-19 vaccine on 01/08/21. The pt''s COVID-19 screening questionnaire prior to receiving the vaccine was negative. The pt presented to the ED on 01/13/21 for weakness and m PCR test on ultiple recent falls (since receiving his first dose of the COVID-19 vaccine). The pt''s COVID-19 01/13/20 was positive and he was admitted. He was started on treatment with remdesivir + dexamethasone on 1/14. The pt initially required supplemental oxygen via low-flow NC, however his oxygen requirements increased to 100% NRB. On 01/16/21 his MPOA elected for hospice care. The pt passed on 01/17/21. Unclear if the COVID-19 vaccine attributed to the patient''s hospitalization and eventual death, or whether these events occurred from COVID-19 itself, however this case is being reported the FDA since this vaccine is under an emergency use authorization (EUA).


VAERS ID: 983720 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-30
Onset:2021-01-20
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient had Parkinson''s and advanced Dementia. He was on a palliative care unit and a DNR.


VAERS ID: 983721 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-13
Onset:2021-01-23
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient with Severe Dementia and on Hospice for end of life care.


VAERS ID: 981061 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-22
Onset:2021-01-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Unsure
Current Illness: None
Preexisting Conditions: Unsure
Allergies: Unsure
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 3 days post Moderna vaccine.


VAERS ID: 981225 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-27
Onset:2021-01-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Death, Pulse absent, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen Suppository Insert 650 mg rectally every 6 hours as needed for pain 1-3 Bisacodyl Suppository 10 MG Insert 1 suppository rectally every 24 hours as needed for constipation COVID-19 mRNA Vaccine (Pfizer) Suspension 30 MCG//0.3M
Current Illness:
Preexisting Conditions: C25.9 MALIGNANT NEOPLASM OF PANCREAS, UNSPECIFIED B19.20 UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA S82.002D UNSPECIFIED FRACTURE OF LEFT PATELLA, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED F03.90 UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE D64.9 ANEMIA, UNSPECIFIED Z91.81 HISTORY OF FALLING E46 UNSPECIFIED PROTEIN-CALORIE MALNUTRITION G31.84 MILD COGNITIVE IMPAIRMENT, SO STATED I10 ESSENTIAL (PRIMARY) HYPERTENSION G40.89 OTHER SEIZURES F32.9 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED F41.9 ANXIETY DISORDER, UNSPECIFIED M62.81 MUSCLE WEAKNESS (GENERALIZED) R26.89 OTHER ABNORMALITIES OF GAIT AND MOBILITY R41.841 COGNITIVE COMMUNICATION DEFICIT Z11
Allergies: Imipenem, Penicillins, Peanut
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient with inoperable pancreatic cancer received second Pfizer vaccine approximately 12:30 pm on 1/27/21. At approximataely 16:30, patient complained of abdominal pain and was given Levsin 0.125mg and morphine 5mg orally. At approximately 19:30 patient was found on the floor covered in a large amount of emesis, unresponsive without a pulse.


VAERS ID: 981406 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-15
Onset:2021-01-18
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebrovascular accident, Death
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: multiple, unknown
Current Illness:
Preexisting Conditions: COPD, smoker
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stroke, death


VAERS ID: 981407 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-01-24
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Expired in sleep on 1/24/21


VAERS ID: 981790 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-26
Onset:2021-01-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 AR / IM

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

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

Write-up: Systemic: Other- Death


VAERS ID: 981849 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-13
Onset:2021-01-16
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: died 01/16/2021


VAERS ID: 981912 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-23
Onset:2021-01-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Cardiac arrest, Chest pain, Cold sweat, Death, Endotracheal intubation, Hypotension, Laboratory test, Pallor, Pulmonary embolism
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: albuterol, fluticasone nasal spray, hydrochlorothiazide, losartan
Current Illness:
Preexisting Conditions: hypertension
Allergies: none
Diagnostic Lab Data: 1/27 in the ED patient underwent a CTA chest to reveal PE, basic labs, alteplase 100 mg, amiodarone 150 mg followed by infusion, was intubated with rocuronium, and placed on a norepinephrine drip.
CDC Split Type:

Write-up: Patient presented to the Emergency Department complaining of chest pain, pale, cool diaphoretic, and hypotensive. The patient was discovered to have a large saddle pulmonary embolism, went into cardiac arrest and expired. Of note, the patient received her second Moderna COVID vaccine on 1/23, which would place her first one approximately 12/25 if she received them at the appropriate interval. This information is from the patient''s daughter and the ED record, the information is not available in CAIR. Per the daughter, the patient started feeling ill on 1/21, improved on 1/25, and then acutely worsened on 1/27, resulting in the ED visit.


VAERS ID: 982218 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-08
Onset:2021-01-13
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012120A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: On hospice: morphine, ativan, trazodone, tylenol
Current Illness: failure to thrive, pressure ulcer, pneumonitis d/t aspiration, dementia, COPD, alzheimer''s disease,
Preexisting Conditions: HTN, see above
Allergies: aspirin: severe unknown reaction
Diagnostic Lab Data:
CDC Split Type:

Write-up: resident was on hospice, chronically ill w dementia, COPD, HTN, failure to thrive, passed away 1/13/21. Not certain injection related as he was declining already.


VAERS ID: 982354 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-29
Onset:2021-01-23
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient received COVID vaccine on 12/29/2020 and passed away on 1/23/2021


VAERS ID: 982370 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-14
Onset:2021-01-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Patient fell at home night before vaccination.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died at hospital on j/16/2021 approximately 48 after receiving vaccination. Believe death related to fall at home prior to vaccination.


VAERS ID: 982417 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kansas  
Vaccinated:2020-12-30
Onset:2021-01-07
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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:
Current Illness: This person had been on HOSPICE for Failure to Thrive since November 2019. She was treated for weight loss with nutritional supplements and served meals of her choice. She had noted increase in sleep in weeks prior to death, but would have times she wanted out of bed for meals and to attend some activity.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident tested positive for COVID on 1/7/2021.


VAERS ID: 982472 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-19
Onset:2021-01-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory failure
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), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Eliquis, Lasix, metoprolol
Current Illness: Chf, CKD
Preexisting Conditions: CHF, CKD, DM
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Worsening respiratory failure 1/20/2021 death 1/27/2021


VAERS ID: 982495 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-01-15
Onset:2021-01-19
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: diclofenac
Current Illness: none
Preexisting Conditions: none
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Client''s sister called crying and said the family just found out yesterday that Client had died some time last week. The last time any family talked to him was on the 19th of January, missed calls show on the phone on the 21st. His last internet search was sternum pain. . She will also call the Agency and report this. The vaccine isn''t in Registery at this time, do I don''t know the lot number but she said he was due back in one month. She said he was very healthy and ran triathalons.


VAERS ID: 982517 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-01-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient received COVID vaccine on 1/11/2021 and passed away on 1/25/2021


VAERS ID: 982541 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-22
Onset:2021-01-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Endotracheal intubation, General physical health deterioration, Hypotension, Lethargy, Mechanical ventilation, Mental status changes, Respiratory distress
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: COVID pneumonia 12/2020
Preexisting Conditions: Coronary artery disease s/p PCI prxima and mid left circumflex in July 2011, carotid stenosis, peripheral vascular disease, dyslipidemia, hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 36 hours after vaccination, the patient had increased respiratory distress. He was placed on high flow nasal cannula oxygen with mild improvement. He then continued to be hypotensive requiring IV fluids and subsequently IV vasopressors. Patient''s BP was stabilized with vasopresor, however he continued to deteriorate clinically with altered mental status and lethargy, concerned for bowel peroration based on physical exam by MD. He was then emergency intubated and placed on mechanical ventilation. He was then transferred to acute care hospital near by.


VAERS ID: 982826 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Nevada  
Vaccinated:2021-01-21
Onset:2021-01-26
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: unknown
Current Illness: immunocompromised with reportable conditions
Preexisting Conditions: immunocompromised with reportable conditions, positive for COVID-19 September 2020
Allergies: unknown
Diagnostic Lab Data: not available
CDC Split Type:

Write-up: Was at work on 1/26/21 and collapsed, no known complaints a the time. CRP was initiated immediately, transported to ER and pronounced dead


VAERS ID: 982890 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-01-22
Onset:2021-01-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, Death, Endotracheal intubation, Pulse absent, Resuscitation, SARS-CoV-2 test positive, Troponin increased, White blood cell count increased
SMQs:, Angioedema (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Crestor 10 mg po daily Norvasc 10 mg po daily benazepril 20 mg po daily Gabapentin 600 mg po daily Toprol XL 100 mg po daily
Current Illness: GI Bleed and Anemia- DX: 1/31/2021
Preexisting Conditions: ASCVD, HTN, Blindness, Diverticulous
Allergies: No Known Drug Allergies
Diagnostic Lab Data: 1/25/2021- Troponin 3.010; WBC 19.6
CDC Split Type:

Write-up: Pt presented to ER via EMS at 1556 3 days after receiving vaccine. pt was breathing approximately 50 times a minutes and o2 sats in the 70''s upon arrival. NP decided to intubate, Rocuronium and Versed given. Pt became bradycardic and 1 amp of Atropine was given without improvement. No pulse felt, CPR started per ACLS protocol. 7 Epi''s given. Time of death- 1632. After TOD pt was swabbed for COVID-19 and the results were positive.


VAERS ID: 982891 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Kansas  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Apnoea, Blood glucose increased, Death, Exposure to SARS-CoV-2, Fall, Mental status changes, Respiration abnormal, SARS-CoV-2 test negative, SARS-CoV-2 test positive, Skin laceration, Unresponsive to stimuli, Wound closure
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 17
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: Heart Failure, unspecified, Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease, Morbid (Severe) Obesity with Aveolar Hypoventilation, Essential Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism, Obstructive Sleep Apnea
Allergies: NKDA
Diagnostic Lab Data: Rapid COVID tests with negative results 1/11, 1/13 and 1/15/21. PCR COVID testing with negative results 12/29/2020, 1/6/2021 and 1/13/2021. COVID swab obtained upon death1/16/2021 resulted positive.
CDC Split Type:

Write-up: All residents had been in isolation due to multiple cases of COVID in the facility. Resident voiced no health related complaints. He continued to visit with staff and required moderate assist with toileting. Resident had fall 0130 on 1-15-2021, which resulted in laceration with surgical repair. Resident was noted to change in mental status and respirations on morning of 1-16-2021 during morning blood sugar check. Resident had O2 @1.5l/m via n/c and respirations of 10 with periods of apnea and unresponsive to verbal stimuli. Blood sugar was 583. Resident deceased upon re-check after calling PCP to report status change.


VAERS ID: 982929 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Maryland  
Vaccinated:2020-12-30
Onset:2021-01-27
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cetirizine 10 mg, Haloperidol 5 mg, Sertraline 50 mg, Albuterol HFA 90 mcg (PRN), Diphenhydran 25 mg (PRN), Fluticasone 50cg PRN, Lactulose 10 gm/15 (PRN), Polyeth Glycol 17 gm (PRN), Neomycin/Polymyxin drop, Amoxicillan 500 mg, Methyldredn
Current Illness: Ongoing Sinus and ear infections being treated by PCP
Preexisting Conditions: COPD, Hypothyrodism, non-alcoholic fatty liver, diabetes type 2, hypertension, diverticulitis
Allergies: Quetiapine, Zyprexa
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Client was being treated with antibiotics by her PCP for diverticulitis flare up. It had not been resolved on the date of her death which occurred 01/27/21, She was found unresponsive by staff, 911 contacted, and paramedics pronounced her deceased at 7:48 AM. After consultation with PCP manner of death was noted as cardiac arrest. PCP was to sign off on death certificate.


VAERS ID: 982942 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-21
Onset:2021-01-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: peanuts
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: per recipient spouse - vaccine recipient became ill during the night of 1/21/21 or early morning of 1/22/21 and was deceased in the morning of 1/22/21.


VAERS ID: 983169 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clopidogrel, Lexapro, Gabapentin, Synthroid, Prilosec, Zinc, Vitamin C, Vitamin D, Tuberculin Skin Test
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, AAA, PVD, Neuropathy, RLS, Hypothyroidism HTN, GERD
Allergies: Olanzapine, Risperidone, Aggrenox
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client received the COVID-19 vaccine on 1/5/21 by the Vaccine clinic. Plans were for Hospice services. Client tested positive for COVID-19 by rapid testing on 1/8/21. On 1/10/21 at 0900 Client was unresponsive and without vital signs. Orders were for DNR, and CPR was not initiated.


VAERS ID: 983173 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-21
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Diarrhoea, Hypophagia, Pain, SARS-CoV-2 test positive, Speech disorder, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Pseudomembranous colitis (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 (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Losartan-HCTZ, Memantine, Metformin, Macrobid, Prilosec, Risperidone, Zocor, Detrol, Benedryl, Aspirin, Centrum, Donepezil, Farxiga, Gabapentin, Vitamin B-12, Vitamin D3, Tylenol
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Anemia, DM type 2, Hyperlipidemia, HTN, GERD
Allergies: Avandia
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client recevied the COVID-19 vaccine on 1/5/21 by the Vaccine clinic. Client tested positive for COVID-19 by rapid testing on 1/21/21, with c/o hurting all over and loose stools. She became non-verbal on 1/23/21 with poor intake. On 1/24/21 at 0537 Client was unresponsive and without vital signs. Orders were for DNR, and CPR was not initiated.


VAERS ID: 983184 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-11
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Airway secretion clearance therapy, Dyspnoea, SARS-CoV-2 test positive, Salivary hypersecretion, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norco, Morphine Sulfate, Levsin
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, Anxiety, Ischemic Heart Disease, Hypertension, Hypercholesterolemia
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient has been under Hospice services for almost a year. She began to demonstrate a large amount of oral secretions on 1/10/21 at 2130. She was suctioned and a Rapid COVID-19 test was performed, which was negative. The COVID-19 Rapid test was repeated on 1/11/21 and was positive. Oxygen saturation was noted to be 78% on 1/12/21, and oxygen was initiated at 1133 at 3L per nasal cannula. Oxygen was increased to 4L at 1635 d/t shortness of breath. On 1/15/21 @ 0645 patient was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.


VAERS ID: 983187 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Apnoea, Cough, Oxygen saturation decreased, Oxygen therapy, Rales, SARS-CoV-2 test positive, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: Allopurinol, Eliquis, Allegra, Synthroid, Sodium Chloride, Trazadone, Zinc, Vitamin C, Vitamin D, Dexamethasone, Tylenol
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, Encephalopathy, Syndrome of Inappropriate Secretion of Antidiuretic hormone
Allergies: Risperidone, Memantine, Haldol
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client tested positive for COVID-19 by rapid test on 1/8/21. On 1/9/21 at 1405 his oxygen saturation dropped to 86% and oxygen was initiated at 2L per nasal cannula. A non-productive cough was noted on 1/10/21 and oxygen was increased to 3L. On 1/12/21 Client became non-responsive with 30 second periods of apnea. Dexamethasone was initiated on 1/13/21. Lung sounds were noted with crackles on 1/15/21 at 1158 and at 2120 Client was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.


VAERS ID: 983189 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-11
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Oxygen saturation decreased, SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Alprazolam, Amlodipine, Lexapro, Cozaar, Metoprolol, Tylenol
Current Illness: COVID-19
Preexisting Conditions: ASHD, Hyperlipidemia, Hypertension, Dementia, Anxiety, Dysphagia
Allergies: Fosomax
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient tested positive for COVID-19 by rapid test on 1/6/21. She began to demonstrate a dry cough on 1/11/21. On 1/12/21 at 1723 her oxygen saturation dropped to 79% and oxygen was applied at 4L per nasal cannula. On 1/19/21 at 2130 Patient was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.


VAERS ID: 983192 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Decreased appetite, Dyspnoea, Fluid intake reduced, Hypophagia, SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 16
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: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, Dementia
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient recevied the COVID-19 vaccine on 1/5/21 by the Vaccine clinic #1. Patient tested positive for COVID-19 by rapid testing on 1/6/21. She demonstrated poor appetite and fluid/food intake and an IV of Normal Saline was initiated on 1/7/21. Oxygen saturation was initiated on 1/12/21 at 4L per nasal cannula. for shortness of breath. On 1/22/21 at 0310 Patient was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.


VAERS ID: 983193 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Decreased appetite, Dyspnoea exertional, Hypophagia, Lethargy, Oxygen saturation decreased, SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Citalopram, Divalproex, Levothyroxine
Current Illness: COVID-19
Preexisting Conditions: Dementia, Atrial Fibrillation, Hypothyroidism, Dysphagia
Allergies: Atorvastatin, Donepezil, Corticosteroids
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient began to demonstrate a cough the evening of 1/5/2021, after receiving the COVID-19 vaccine earlier in the afternoon. A rapid COVID-19 test was performed and was positive. She began to demonstrate shortness of breath with exertion on 1/7/21, and lethargy on 1/12/21. Appetite and oral intake began to decline on 1/12/21, and Oxygen saturation dropped on 1/16/21 to 82%, and oxygen was initiated at 3L per nasal cannula. On 1/19/21 at 0414 patient was unresponsive and without vital signs. Orders were for DNR, and CPR was not initiated.


VAERS ID: 983428 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2020-12-24
Onset:2021-01-06
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Anaemia, Aortic stenosis, Asthenia, Atelectasis, Atrioventricular block complete, Blood creatinine increased, Blood potassium decreased, Blood pressure fluctuation, Blood sodium decreased, Blood urea increased, C-reactive protein increased, Cardiomegaly, Chest X-ray abnormal, Condition aggravated, Death, Dehydration, Fatigue, Haemoglobin decreased, Hypertension, Lung infiltration, Procalcitonin increased, Sepsis, Staphylococcal bacteraemia, Vomiting, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Conduction defects (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), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (narrow), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Bystolic - started on 12/21/20, Crestor started on 11/09/2020, Qzemoic subq weekly, Advair diskus, Fish oil, ASA, Vitamin E, Multivitamin
Current Illness: Denied any illness at time of the vaccination. November 2020 was diagnosed with Covid-19. Admitted to Hospital on 01/6/2021 with c/o weakness. Reported that her weakness was over her entire body. Reports having episodes of vomiting once or twice a week.
Preexisting Conditions: Erysipelas, Aphthous pharyngitis, Sixth nerve palsy, Heart mumur, Acute renal insufficiency, Hypertension, Diabetes Mellitus
Allergies: NKA to medications
Diagnostic Lab Data: See above for further inform. 1/8/2021 WBC - 14.4, Hgb - 9.2, K+ - 2.9, BUN - 34, Creatitine -1.8, C-Reactive Protein - 12.8, Procalcitonin - 0.64, CXR - 01/07/2021 - Mild increased bibasilar atelectasis or infiltrate. No pleural effusion, no pneumothorax, stable mild cardiomegaly.
CDC Split Type:

Write-up: Pt. was admitted to hospital on 1/6/21 with fatigue, weakness. Pt. was Covid positive in November of 2020. Impression upon admission was fatigue may be due to her aortic stenosis and some hypertensive issues with blood pressure changes. She was anemic. WBC was elevated to 19.2, HBG 10.5, NA-131, K+ - 3.1, Rule out bacterial infection. Potential source could be her heart valve. Also noted to have acute renal failure with BUN of 47 and Creatinine of 2.2 noted. Pt. was transferred to Hospital on 1/8/2021 with dx of aortic stenosis, bacteremia, ARF, Dehydration and anemia. Discharged with dx. of sepsis. Pt. expired on 1/18/21 with dx. of severe sepsis, complete heart block, staphylococcus epidermidis bacteremia.


VAERS ID: 983766 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-16
Onset:2021-01-21
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood pH decreased, Cardiac failure acute, Chest discomfort, Death, Dyspnoea, International normalised ratio increased, N-terminal prohormone brain natriuretic peptide increased, SARS-CoV-2 test negative
SMQs:, Cardiac failure (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide 20mg 2poBID, Warfarin 5mgQD, Omeprazole 20mg BID, Propanolol 10mg BID, atorvastatin 40mg QD, vitamin D 1000IUQD
Current Illness: Heart failure with reduced EF, history of moderate pulmonary hypertension, history of moderate mitral valve regurgitation and moderate pulmonary valve regurgitation. History of A. fib.
Preexisting Conditions: Heart failure with reduced EF, history of moderate pulmonary hypertension, history of moderate mitral valve regurgitation and moderate pulmonary valve regurgitation. History of A.fib.
Allergies: No known allergies to drugs or food
Diagnostic Lab Data: ProBNP: 5000 on 1/21/21 Covid-19 test: negative on 1/21/21 INR: 3.2 on 1/21/21 pH: 7.33 on 1/21/21
CDC Split Type:

Write-up: Pt started complaining of chest heaviness and shortness of breath on the afternoon of 1/21/21. EMS was called to the patients home and she was found to have an O2 sat in the 70''s. She was admitted to hospital and found to have a proBNP of 5000. She tested negative for Covid-19. She was determined to be in acute-on-chronic heart failure and was referred for hospice care. She passed away on the evening of 1/24/21.


VAERS ID: 983919 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-21
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

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

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

Write-up: death


VAERS ID: 1296823 (history)  
Form: Version 1.0  
Age: 50.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 2021-01-28
   Days after onset:1
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Death, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies:
Diagnostic Lab Data: NOT APPLICABLE
CDC Split Type:

Write-up: According to facility representative on 1/27/2021 at approximately 7:15 am, pt was discovered not breathing with no pulse. Resident was pronounced dead at 7:44 am on 1/27/2021. Resident was previously tested positive for COVID-19 on 12/9/2020.


VAERS ID: 984617 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-16
Onset:2021-01-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cholecystitis, Death, Malaise, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Infectious biliary disorders (narrow), Gallbladder related disorders (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021063974

Write-up: Patient passed su hospital on 23Jan2021 stopped breathing; complained of not feeling well; had an inflamed gall bladder; This is a spontaneous report from a contactable consumer. A 98-year-old female patient received bnt162b2 (BNT162B2, PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL8982 and expiry date unknown), via an unspecified route of administration on 16Jan2021 at single dose for covid-19 immunisation. The patient medical history was not reported. The patient concomitant medication reported as has received other medications (unspecified) within 2 weeks. The patient passed in hospital on 23Jan2021 with stopped breathing. Day after vaccine on 17Jan2021, the patient complained of not feeling well, went to hospital where was told she had an inflamed gall bladder. The events caused patient hospitalization for 4 days. The cause of death reported as stopped breathing. It was unknown if autopsy done. Prior to vaccination, the patient not diagnosed with COVID-19. The outcome of the event breathing arrested was fatal, outcome of the other events was unknown.; Reported Cause(s) of Death: Stopped breathing


VAERS ID: 985004 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-08
Onset:2021-01-27
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Constipation, Death, Fatigue, Hyperhidrosis, Impaired work ability, Resuscitation, Unresponsive to stimuli
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: none
Preexisting Conditions: Cardiac Issues. Hx of cardiac Stent but unknown in-depth.
Allergies: Codeine Penicillin V
Diagnostic Lab Data:
CDC Split Type:

Write-up: The week of 1/18/2021 The patient complained of Abdominal pain and called off work (we are also her employer) She was seen for constipation on 1/20/2021. Employee returned to work on 1/25/2021 Had occasional episodes during work where she would sweat and become tired but would rest until she felt better. On the Night of 1/27/2021 she was feeling fine no issues, later in the shift a co worker found her unresponsive, CPR was initiated but unsuccessful.


VAERS ID: 985205 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dizziness, Malaise
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Yes, but caller does not know what they are.
Current Illness: No
Preexisting Conditions: None
Allergies: No
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient was feeling dizzy and under the weather after the vaccination. The following day he died in his sleep during a nap.


VAERS ID: 985367 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-06
Onset:2021-01-18
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Mucinex Tablet Extended Release 12 Hour 600 MG (guaiFENesin ER) Acetaminophen Tablet 500 MG cloZAPine Tablet 25 MG Remeron Tablet (Mirtazapine) Aspercreme Lidocaine Patch 4 % (Lidocaine) Cyanocobalamin Tablet 500 MCG Cholecalciferol
Current Illness: COVID-19 + DAY AFTER THE FIRST DOSE OF THE VACCINE
Preexisting Conditions: PARKINSON''S DISEASE HTN BPH CROHN''S DEMENTIA ANXIETY OA DDD ALLERGIC RHINITIS VITAMIN D DEFICIENCY
Allergies: ATIVAN GEODON
Diagnostic Lab Data:
CDC Split Type:

Write-up: TESTED POSITIVE FOR COVID-19 1-7-2021, TRANFERRED TO HOSPITAL ON 1-18-2021. HE READMITTED TO THE FACILITY ON 1-21-2021 WITH HOSPICE SERVICES AND EXPIRED ON 1-25-2021.


VAERS ID: 985449 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Computerised tomogram abdomen abnormal, Death, Intestinal dilatation, Large intestinal obstruction, Pupil fixed, Septic shock, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Toxic-septic shock conditions (narrow), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific dysfunction (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: colonic obstruction with dilatation of large and small bowel
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was an 87 y/o female admitted for septic shock. She was started on and eventually maxed on 3 pressors. CT abd showed colonic obstruction with dilatation of large and small bowel. Patient was made DNR in the ED. Palliative care consulted on case. Family opted for comfort care. Patient was asystole on monitor. No spontaneous breath/cardiac sounds ausculted. Patient did not withdraw to pain. Pupils fixed and dilated. She was pronounced and 1230 on 1/28/21


VAERS ID: 985451 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-06
Onset:2021-01-24
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: predniSONE Tablet 20 MG Mucinex Tablet Extended Release 12 Hour 600 MG (guaiFENesin ER) Acetaminophen Tablet 500 MG RisaQuad Capsule (Probiotic Product) BISACODYL 10MG SUPPOSITORY Morphine Sulfate (Concentrate) Solution 100 MG/5ML H
Current Illness:
Preexisting Conditions: VASCULAR DEMENTIA HEART FAILURE BULLOUS PEMPHIGOID
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: COVID-19 + 1/11/2021, EXPIRED ON 1-24-2021


VAERS ID: 985501 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-18
Onset:2021-01-22
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Fatigue, Nausea, Respiratory arrest, Resuscitation, Sluggishness
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fish oil Aspirin Calcium + D Lisinopryl 10 mg methimazole 5 mg colase 100 mg Hydrochlorathiazide 25 mg amlodipine 5 mg atenolol 25 mg trazadone 50 mg
Current Illness: none
Preexisting Conditions: hypertension, hyperlipidemia, hyperthyroidism, thyroid nodules, constipation, osteopenia, insomnia, incontinence
Allergies: none
Diagnostic Lab Data: none, no autopsy
CDC Split Type:

Write-up: family states seemed short of breath since after the covid vaccine. Staff said beginning on 1/22/21 the patient seemed sluggish, more tired, and nausea noted. She stayed in her room more after the vaccine because worried about giving/getting COVID to others. was talking on the phone at 11:30 PM on 1/26/21 to staff person about temperature of room. at 12:15 AM on 1/27/21 staff noted not breathing, started CPR and called EMS. When EMS arrived they stopped the code because she was too long deceased.


VAERS ID: 985527 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-06
Onset:2021-01-23
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Full blood count, Hyponatraemia, Metabolic function test
SMQs:, Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: ALLOPURINOL CHOLECALCIFEROL DEBROX DOCUSATE SODIUM FLOMAX FLONASE GABAPENTIN KONSYL PACKET LASIX LORATIDINE MELATONIN MIRALAX SENNA
Current Illness:
Preexisting Conditions: NEUROPATHY HYPONATREMIA HTN BPH CKD ANEMIA GOUT
Allergies: ROCEPHIN
Diagnostic Lab Data: CBC, BMP 1-23-2021
CDC Split Type:

Write-up: COVID-19 + ON 1-13-2021, TRANFERRED TO HOSPITAL ON 1-23-2021 DUE TO HYPONATREMIA


VAERS ID: 985715 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-12-29
Onset:2021-01-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 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: 2021-01-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metoprolol 25mg vitamin D3 1000IU furosemide 80mg Norvasc 5mg aspirin 81mg Renvela 800mg atorvastatin 20mg vitamin B12 1000mcg
Current Illness: high blood pressure dialysis GI bleed/ symptomatic anemia
Preexisting Conditions:
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received the vaccine on 12/29/20 and presented at the ER at the Hospital on 12/30/20 stating that he wasn''t feeling well. It is stated that his health had declined over the past few weeks and currently on hospice. Visit was unremarkable. Patient stated that wanted to stop dialysis. Patient passed away on 01/02/2021.


VAERS ID: 985814 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Aspiration, Asthenia, Blood creatinine increased, Blood glucose normal, Blood potassium increased, Blood urea increased, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Cough, Dyspnoea, Echocardiogram abnormal, Ejection fraction decreased, Emphysema, Endotracheal intubation, Fatigue, Haematocrit decreased, Haemoglobin decreased, Left atrial dilatation, Lung consolidation, Lung opacity, Nausea, Oropharyngeal pain, Pulmonary granuloma, Pulmonary hilum mass, Pulmonary mass, Red blood cell count decreased, Respiratory tract congestion, SARS-CoV-2 test negative, Vomiting, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen 500 mg amoxicillin 1 gm aspirin furosemids 40 mg glucosamine-chondroitin 1 tab cozaar 25 mg multivitamin potassium chloride 20 meq tamsulosin 0.4 mg furosemide 40 mg zofran 4 mg
Current Illness: started with a sore throat the day before vaccination
Preexisting Conditions: anemia, BPH with obstruction, cervical neuritis, cervical spondylosis, cervicalgia, enlarged prostate, HLD, HTN, left sciatic nerve pain, low back pain, lumbar spinal stenosis, osteoarthritis, pacemaker, pancytopenia
Allergies: morphine, oxycodone, hydrocodone, hydromorphone, coumadin
Diagnostic Lab Data: 1/25/21 had CBC which showed WBC at 0.1, RBC 2.52, Hgb 8.8, Hct 27.2, Chem profile done showed high potassium, high glucose of 129, elevated BUN and Creatinine. Was negative for SARS-CoV 2 on 1/25/21. CXR showed right perihilar masslike opacity which may reflect infiltrate or neoplasm. Did CT of the chest which showed bilateral upper lobe chronic emphysematous lung changes, dense right upper lobe airspace disease, left lower lobe bronchial filling defects suggesting aspiration, scattered bilateral upper lobe nodular densities, scattered left lower lobe calcified granulomas, and left hilar calcified granuloma
CDC Split Type:

Write-up: started having generalized weakness on 1/21/21, fatigued., nausea/vomiting. went to doctor on 1/25/21 with complaint of sore throat, cough, and felt congested. Went to ER on 1/25/21 with complaints of increased shortness of breath, worsening nausea and vomiting. started on oxygen for sats of 87%. admitted on 1/25/21. On 1/26/21 needed intubated, CXR showed worsening consolidative change right lung at right hilar level. Echocardiogram showed ejection fraction 35-40%, left atrium is moderately dilated.


VAERS ID: 985933 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Chest X-ray abnormal, Death, Dyspnoea, Erythema, Influenza virus test negative, Leukocytosis, Lung infiltration, Pulmonary congestion, Pyrexia, Respiratory rate increased, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Dementia; Walking disability
Allergies:
Diagnostic Lab Data: Test Date: 20201231; Test Name: creatinine; Test Result: Inconclusive ; Test Date: 20201231; Test Name: BUN; Test Date: 20201231; Test Name: Temperature; Result Unstructured Data: ?F; Test Date: 20201231; Test Name: CXR; Test Result: Inconclusive ; Result Unstructured Data: mild left lower lung infiltrate; Test Date: 20201231; Test Name: Pulse; Test Result: Inconclusive ; Result Unstructured Data: Heart beats per minute; Test Date: 20201231; Test Name: Flu swab; Test Result: Negative ; Result Unstructured Data: negative; Test Date: 20201231; Test Name: O2; Test Result: Inconclusive ; Result Unstructured Data: Percent Room air; Test Date: 20201231; Test Name: WBC
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died; Increased respirations (22 and labored at times); Pulse 105; 94% O2 on RA; Labored breathing at times; leukocytosis; elevated BUN; left lower lung congestion; elevated creatinine; Temperature of 102.0F; Redness on face; A spontaneous report was received from a nurse concerning a 92-year-old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced redness on face, increased respirations, labored breathing at times, temperature of 102F, pulse of 105, 94 percent O2, leukocytosis, elevated BUN, left lower lung congestion, elevated creatinine, and death. The patient''s medical history, as provided by the reporter, included dementia and reduced mobility. No relevant concomitant medications were reported. On 29 Dec 2020, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 30 Dec 2020, the patient began to experience redness on her face, increased respirations (reported as 22 and labored at times), pulse of 105, and 94 percent oxygen saturation on room air. The patient had a fever of 102 degrees Fahrenheit. Laboratory tests revealed a negative influenza swab, elevated white blood cell count of 14.1, elevated BUN at 113, and creatinine 2.7. Chest x-ray showed mild, left lower lung infiltrate. On 31 Dec 2020, the patient went under hospice care per her family request.. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 01 Jan 2021, the cause of death was unknown.; Reporter''s Comments: This case concerns a 92-year-old, female subject with medical history of dementia and reduced mobility, who experienced the serious unexpected events of death, respiratory rate increased, heart rate increased, oxygen saturation decreased, elevated BUN, elevated creatinine, left lung congestion and dyspnoea and the non-serious events of erythema and pyrexia. The events of respiratory rate increased, heart rate increased, oxygen saturation decreased, dyspnoea, erythema and pyrexia occurred 2 days after the first dose of the study medication administration, and the event of death occurred 4 days after the first dose of the study medication administration. Very limited information regarding the events is available at this time and no definite diagnosis or autopsy report have been provided. Additional information has been requested.; Reported Cause(s) of Death: Died


VAERS ID: 986063 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Utah  
Vaccinated:2021-01-12
Onset:2021-01-16
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cholestyramine, Duloxetine, Fiber, Haloperidol, Hyoscyamine, Lisinopril, Lorazepam, Metoprolol, Morphine, Nystatin powder, Pepto Bismol, Seroquel, Spiriva, Symbicort, Tramadol, Tylenol, Vistaril, Zolpidem
Current Illness: COPD, CHF, Major Depressive Disorder, Anxiety, Respiratory Failure, Insomnia, OsteoArthritis, Hypertension, Irritable Bowel Syndrome, Atrial Fibrillation, COVID recovered
Preexisting Conditions: Resident was a Hospice Patient as of: 11/17/2020
Allergies: No Known Allergies
Diagnostic Lab Data: No tests/results pertaining to this incident.
CDC Split Type:

Write-up: Resident was vaccinated on 1/13/21. Resident passed away on 1/16/21


VAERS ID: 986123 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-19
Onset:2021-01-24
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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: 2021-01-24
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021072348

Write-up: passed away-heart attack; This is a spontaneous report from a contactable consumer, the daughter of the patient from a Pfizer Sponsored program Pfizer First Connect. A male patient of an unspecified age received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Lot Number: UNKNOWN), via an unspecified route of administration on 19Jan2021 as a single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. On 24Jan2021, the patient passed away due to a heart attack. It was not reported if an autopsy was performed. The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.; Reported Cause(s) of Death: passed away-heart attack


VAERS ID: 986200 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: New Mexico  
Vaccinated:2020-12-30
Onset:2021-01-15
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Metformin and Atenolol.
Current Illness: None.
Preexisting Conditions: Uncontrolled DMII and HTN.
Allergies: NKA.
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death


VAERS ID: 986631 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-14
Onset:2021-01-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Senior Living       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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hypertension, hyperthyroidism
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Suspected myocardial infarction on 01/15/2021. Patient passed away on 01/15/2021.


VAERS ID: 986672 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-01
Onset:2021-01-15
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cough, Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), 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: 2021-01-28
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: 125 MG/5ML Suspension 5 ml in AM and 10 ml in PM Orally thru feeding tube Seroquel 50 MG Tablet 1 tablet Orally Once a day (crush and mix with water and thru feeding tube) Naproxen 125 MG/5ML Suspension 10 ml with food or milk Orally
Current Illness: none
Preexisting Conditions: CVA, seizures, Lung nodule
Allergies: iodine topical betadine
Diagnostic Lab Data: Covid-19 nasal swab
CDC Split Type:

Write-up: Patient tested Covid positive, cough, low oxygen levels, COVID Pneumonia, patient is now deceased


VAERS ID: 986773 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Virginia  
Vaccinated:2020-12-31
Onset:2021-01-14
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute respiratory failure, Bilevel positive airway pressure, COVID-19, Death, Exposure to SARS-CoV-2, Hospice care, 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), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Acetylcysteine Solution 10 % 3 ml inhale orally two times a day BUDESONIDE 30''S,U-D,SDV UD 0.25MG/2ML AMPUL-NEB 2 ml inhale orally two times a day DIVALPROEX SOD ER 500MG TAB.SR 24H Give 1 tablet by mouth at bedtime IPRATROPIUM-ALBUTEROL O
Current Illness: Intermittent episodes of acute on chronic worsening of multi-factorial chronic respiratory failure with clear goals established through advance care planning. Overall, was stable in the month prior to vaccination.
Preexisting Conditions: 1. Status post TBI as a young child resulting in a cerebral palsy like syndrome w/ ID and spastic quadriparesis, R$gL 2. Seizure disorder 3. OBS/Psychiatric disorder with bipolar aspects and psychosis, better on Lithium. Symptoms well-controlled on Paxil, Risperdal and Lithium. 4. Asthmatic bronchitis w/ poor baseline respiratory function (chronic respiratory failure) and chronic cough, stable on regimen of inhaled budesonide, Duonebs and VEST therapy. 5. Complex Sleep apnea, controlled with Bi-PAP 6. GERD, stable on daily PPI. 7. Hypertension, controlled with spironolactone and terazosin. 8. CHF?, stable on spironolactone. Unable to get more records. 9. Hypothyroidism, stable on levothyroxine. 10. Dysphagia with Recurrent Aspiration (Does not want a Peg tube). Stable on puree diet and thickend liquids.
Allergies: Quinolones, Latex, Natural rubber
Diagnostic Lab Data: Nasal swab sample obtained 1/14/21 and sent for PCR testing was positive for SARS-CoV-2.
CDC Split Type:

Write-up: Resident was vaccinated on 12/31/20. Then on 1/14/21 he tested positive for SARS-CoV-2 on routine surveillance PCR testing. Another resident on the same hall was COVID positive on 1/11/21. Results of the PCR test were obtained on 1/16/21. He appeared asymptomatic at that time. Given his COVID positive status, all aerosol generating procedures had to be stopped. Overnight on 1/16/21 into 1/17/21, he had the onset of acute respiratory failure and was transported to the hospital. Per notes, he was put on BiPAP for several hours, but his CO2 level did not improve. Per prior advance directives completed with the resident and his two brothers, he had DNR/DNI orders. The hospital physician spoke with his brother and the decision was made to move to comfort care. He was discharged to inpatient hospice and died around 4pm on 1/18/21. This outcome does not appear to be vaccine-related, but death from COVID-19 infection is listed as a reportable event following COVID-19 vaccination.


VAERS ID: 986857 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Texas  
Vaccinated:2020-12-28
Onset:2020-12-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Mental status changes, Nausea
SMQs:, Acute pancreatitis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tresiba Flextouch Insulin Pen Victoza Pen Gabapentin Symtuza Sertraline HCL Anoro Inhaler Atorvastatin Risperidone Aspirin Men''s Multivitamin Melatonin Pioglitazone
Current Illness: Uncontrolled insulin levels (high glucose)
Preexisting Conditions: HIV COPD Diabetes Mellitus Type II Schizophrenia Psychosis Suprapubic catheter
Allergies: Fish / seafood
Diagnostic Lab Data:
CDC Split Type:

Write-up: Extreme bouts of nausea first few days after vaccine. Estimated that patient died at home within 3-4 days after receiving the vaccine. Last phone call to daughter expressed extreme nausea and seemed to have altered mental status. Found dead by daughter on 01/04/2021.


VAERS ID: 986869 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-03
Onset:2021-01-10
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELI284 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Prednisone, Miralax, Labetalol, Gas-X, Gabapentin, Folic Acid, Fluconazole, Famotidine, Eliquis, Crestor, Bactrim
Current Illness: Pembro associated pneumonitis and nuronal inflammation, Candida Esophagitis
Preexisting Conditions: HTN, MVP/Mod MR, Prior Renal Ca s/p R nephrectomy, Active Lung Ca (Prior lobectomy/SRT on pembrolizumab)
Allergies: NKA
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient noted with respiratory distress on 1/10/2021, transferred to hospital via 911.


VAERS ID: 986901 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-28
Onset:2021-01-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Copaxone
Current Illness:
Preexisting Conditions: Optic neuritis; asthma
Allergies: None
Diagnostic Lab Data: Autopsy pending
CDC Split Type:

Write-up: Patient received vaccine uneventfully with no acute concerns. Left clinic and by report went out with friends. Spoke to father on phone at or around 9:00 pm. Failed to show up to work and was found dead at home. Other details pending


VAERS ID: 986948 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-22
Onset:2021-01-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Diltiazem CD, Gabapentin, Hydroxychloroquine, Levothyroxine, Omeprazole, Oritavancin, Potassium Chloride, Propylene Glycol Eye Drops, Sertraline
Current Illness: alcoholic cirrhosis, thrombocytopenia, anemia, lymphedema
Preexisting Conditions: hypertension, hypothyroid, rheumatoid arthritis, depression, GERD
Allergies: acetaminophen, atorvastatin, belsomra, benadryl, benzoin, cefazolin, cephalosporins, codeine, cymbalta, darvocet, dilaudid, duragesic, floxin, guaifenesin, hydrocodone, indocin, lovenox, morphine, nafcillin, oxycodone, paxil, sudafed, sulfa, vancomycin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac arrest on 1/24/21 in the early morning hours then passed away on 1/25/21 around 1:51am in the hospital


VAERS ID: 987029 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 2 RA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Pepcid Aspirin Finasteride Stress Plus Zinc Tab Seroquel Pravastatin Sodium Amlodipine besylate Flomax
Current Illness: PRESSURE ULCER OF RIGHT HEEL, STAGE 2 ATHEROSCLEROSIS OF NATIVE ARTERIES OF LEFT LEG WITH ULCERATION OF OTHER PART OF FOOT ATHEROSCLEROSIS OF NATIVE ARTERIES OF LEFT LEG WITH ULCERATION OF HEEL AND MIDFOOT
Preexisting Conditions: TRAUMATIC SUBDURAL HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS, SUBSEQUENT ENCOUNTER MUSCLE WEAKNESS (GENERALIZED) UNSPECIFIED LACK OF COORDINATION FEEDING DIFFICULTIES OTHER REDUCED MOBILITY NEED FOR ASSISTANCE WITH PERSONAL CARE DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED DYSPHAGIA, OROPHARYNGEAL PHASE OTHER SYMBOLIC DYSFUNCTIONS ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ORTHOSTATIC HYPOTENSION HYPERLIPIDEMIA, UNSPECIFIED DEMENTIA WITH LEWY BODIES CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE HYPOKALEMIA PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE CONSTIPATION, UNSPECIFIED BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS ESSENTIAL (PRIMARY) HYPERTENSION REPEATED FALLS RETENTION OF URINE, UNSPECIFIED PRESENCE OF AORTOCORONARY BYPASS GRAFT PARKINSON''S DISEASE LOCALIZED SWELLING, MASS AND LUMP, RIGHT UPPER LIMB
Allergies: Penicillins Green Food Dye Dust Mites Aricept Namenda
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident passed away at 8:15 am on 1/28/21-found to be without pulse/respirations/DNR order in place.


VAERS ID: 987126 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-01-29
Onset:2021-01-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died. Patient had been declining in health rapidly prior to receiving the vaccine


VAERS ID: 987301 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2020-12-28
Onset:2020-12-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Cerebrovascular accident, Death, Life support, SARS-CoV-2 test positive, Seizure
SMQs:, Systemic lupus erythematosus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Not Sure! Vaccine was given in a Nursing Facility
Current Illness: Previous Stroke
Preexisting Conditions: Not Sure
Allergies: Not aware
Diagnostic Lab Data: Don''t Know
CDC Split Type:

Write-up: My Mother was given the Covid Vaccine (1st Dose) on 12/28/2020. Later that night we received a call from the nursing facility that my Mother was having uncontrollable seizures and had to be transported to the nearby hospital. The ER doctor confirmed that my Mother had tested positive to Covid. She was treated for Covid and was on life support. A few days later we received a call that my Mother had a major stroke. She passed away on January 4, 2021


VAERS ID: 987469 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Atelectasis, Chest X-ray abnormal, Computerised tomogram abdomen, Computerised tomogram abnormal, Culture negative, Diarrhoea, Lung opacity, Pneumonia aspiration, Respiratory rate increased, Urine analysis normal, Vomiting
SMQs:, Acute pancreatitis (broad), Interstitial lung disease (narrow), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: was being treated with antibiotic prednisone for hand swelling day prior
Preexisting Conditions: history of bowel obstructions and diverticulosis, AFIB, Dementia, PANCYTOPENIA
Allergies:
Diagnostic Lab Data: Per hospital report CXR- aspiration pneumonia, UA C&S - all negative, CT of abdomen and pelvis showing some bibasilar airspace opacities and atelectasis. possible evidence of enterocolitis symptoms may also be secondary to immune response to second COVID 19 vaccination.
CDC Split Type:

Write-up: emesis bright yellow in color, liquid BM, increased respirations


VAERS ID: 987513 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-27
Onset:2021-01-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Oxygen saturation decreased, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: UTI And PNA
Preexisting Conditions: COPD , anxiety history of ETOH abuse ,thrombocytopenia
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Note Text: Resident oxygen was going down to 74% during change of shift 3-11, oxygen initiated 3liters via nasal canula per standing order want up to 84-86% NP notified, ordered Prednisone 20mg stat, Rocephin 1gram IM stat administered, Per NP statement if pt''s condition worsening sent him to ER, continue monitoring pt and his oxygen going to 82% increasing distress. Notified Nurses supervisor, 911 was called pt left building at 1819 to Hospital alert oriented. Vs bp. 165/60, temp. 98.3,m pulse 109, res 22, 02. 82%. Resident father notified.


VAERS ID: 987533 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-28
Onset:2021-01-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Full blood count, Lethargy, Metabolic function test
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Insulin Lispro, Propranolol 120mg, Clopidogrel 75mg, Donepezil 10mg, Memantine 10mg, QUEtiapine Fumarate 100mg, Pantoprazole 40mg, Pramipexole Dihydrochloride 1.5mg, predniSONE 20mg, Aspirin 81mg, Atorvastatin Calcium 40mg, Insulin Glarg
Current Illness: See item 12
Preexisting Conditions: COPD, CHF, DM, Asthma, HTN, Dementia, Depression, GERD, Parkinson
Allergies: Dexamethasone, Versed
Diagnostic Lab Data: Stat CBC & CMP ordered. Labs were drawn but the patient expired before the facility received the results.
CDC Split Type:

Write-up: The patient was observed to be lethargic on 1/29/21 at 1515. BP-80/50, P-75, RR-27, T-100.1. He was given a bolus of NS 150 mlx2. and Rocephin 1 gram IM.


VAERS ID: 988245 (history)  
Form: Version 1.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-16
Onset:2021-01-17
   Days after vaccination:1
Submitted: 2021-01-27
   Days after onset:10
Entered: 2021-01-29
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 93 y/o with complex medical history (severe COPD on oxygen, diastolic CHF, CKD3, myelofibrosis, marginal zone lymphoma of spleen with recent progression and no active treatment, chronic anemia, afib, CAD, pulmonary artery hypertension, h/o bladder cancer, hypertension, hypothyroidism, h/o bilateral PE, sick sinus syndrome s/p pacemaker, h/o Hodgkin''s disease). Has had multiple hospitalizations over the last 3 months for dyspnea, most recently in 12/2020. Enrolled in palliative care. Has had multiple transfusions (most recently 01/13/21) for his chronic anemia due to myelofibrosis, and recently started on darbepoetin. No documented history of anaphylaxis to medications or prior vaccinations. He received COVID19 vaccine (Moderna) on 01/16/21. He passed away suddenly at home on 01/17/21. Symptoms: & cardiac arrest Treatment:


VAERS ID: 988246 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-12-22
Onset:2021-01-26
   Days after vaccination:35
Submitted: 2021-01-27
   Days after onset:1
Entered: 2021-01-29
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 LA / -
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 3 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Alanine aminotransferase decreased, Aspartate aminotransferase decreased, Atrial fibrillation, Bilirubin conjugated increased, Blood alkaline phosphatase normal, Blood bilirubin increased, Blood creatinine increased, Blood urea decreased, Blood urea increased, Death, Pneumonia, Protein albumin ratio increased, SARS-CoV-2 antibody test negative, SARS-CoV-2 test negative, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: acetaminophen, albuterol/ipratropium, amlodipine, ascorbic acid, atorvastatin, baclofen, buspirone, calcium carbonate with vitamin D, cholecalciferol, dexmedetomidine, diltiazem, docusate, esomeprazole, famotidine, fentanyl, fluticasone, ga
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Collection DT Spec CoV19BF COVIDIg 01/21/2021 14:10 NASAL Not Detected 01/12/2021 04:00 SERUM 0.03 01/11/2021 12:35 NASAL Not Detected Collection DT Spec WBC BUN Creat Cystn-C 01/25/2021 04:00 BLOOD 15.28 H 01/25/2021 04:00 PLASM 64 H 1.3 2.46 H 01/24/2021 04:00 PLASM 56 H 1.1 01/24/2021 04:00 BLOOD 13.16 H 01/23/2021 04:40 BLOOD 14.02 H 01/23/2021 04:00 PLASM 52 H 0.9 01/23/2021 04:00 BLOOD 7.93 01/22/2021 04:00 BLOOD 10.58 H 01/22/2021 04:00 PLASM 49 H 0.9 01/21/2021 04:00 PLASM 47 H 1.0 01/21/2021 04:00 BLOOD 7.39 01/20/2021 04:00 PLASM 30 H 0.8 01/20/2021 04:00 BLOOD 9.10 01/19/2021 04:00 PLASM 17 0.7 L Collection DT Spec Protein Albumi TotBili DirBili ALT AST AlkPhos 01/25/2021 04:00 PLASM 5.6 L 3.2 L 1.1 1096 H 504 H 51 01/24/2021 04:00 PLASM 6.0 L 3.2 L 0.8 1482 H 699 H 57 01/23/2021 04:00 PLASM 5.5 L 2.9 L 0.6 1778 H 1044 H 53 01/22/2021 04:00 PLASM 5.7 L 2.6 L 0.4 2135 H 1579 H 49 01/21/2021 17:00 PLEUR 1.3 01/14/2021 04:00 PLASM 6.8 3.2 L 0.4 15 21 57 01/13/2021 04:00 PLASM 6.3 L 3.0 L 0.3 14 18 53 01/12/2021 04:00 PLASM 5.8 L 2.7 L 0.3 11 17 55
CDC Split Type:

Write-up: Narrative: See "Other Relevant History" in Section 6 above Symptoms: ElevatedLiverEnzymes & death, pneumonia, afib Treatment:


VAERS ID: 987636 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-18
Onset:2021-01-21
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure decreased, Dyspnoea, Fluid retention, Multiple organ dysfunction syndrome, Peripheral swelling, Pulmonary oedema, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant 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), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: Insulin, blood pressure medication
Current Illness: Diabetes
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Legs started swelling and shortness of breath Thursday January 21 2021 Was rushed to hospital with kidney failure and fluid build up around lungs and entire body Blood pressure dropped and had multiple organ failure


VAERS ID: 987663 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-31
Onset:2021-01-10
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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: Prescription blood pressure medication
Current Illness: None
Preexisting Conditions: For a year he had a catheter as part of treatment of a prostrate issue without surgery.
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died


VAERS ID: 987789 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-22
Onset:2021-01-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Dizziness, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: REC''D CALL FROM PT''S DAUGHTER, HER FATHER WAS VACCINATED ON 1/22/21, WOKE UP 1/23/21 WAS SHORT OF BREATH AND DIZZY. PT PRESENTED TO ED OF LOCAL HOSPITAL AND WAS ADMITTED, PT PASSED ON 1/25/21. DAUGHTER STATES THAT FAMILY AND DOCTORS AGREE THAT THE VACCINE DID NOT CONTRIBUTE TOWARDS PT''S DEATH, BUT FELT IT NEEDED TO BE REPORTED. PT''S DAUGHTER CONTACTED THIS RN AT LOCAL HEALTH DEPARTMENT TO REPORT TO VAERS.


VAERS ID: 987877 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-14
Onset:2021-01-26
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: UNKNOWN
Current Illness: PT WAS ON HOSPICE CARE AT TIME OF VACCINATION
Preexisting Conditions: UNKNOWN
Allergies: PCN
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: REC''D CALL FROM PT''S SON, PT HAS BEEN ON HOSPICE CARE AND PASSED 1/26/21. DOES NOT BELIEVE THIS IS RELATED TO VACCINE ADMINISTRATION, BUT WANTED TO REPORT TO US.


VAERS ID: 988270 (history)  
Form: Version 1.0  
Age: 90.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2020-12-28
Onset:2021-01-14
   Days after vaccination:17
Submitted: 2021-01-29
   Days after onset:15
Entered: 2021-01-30
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD039K20A / UNK RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Symptoms: & death Treatment:


VAERS ID: 988369 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-19
Onset:2021-01-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Pneumonia aspiration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Carvedilol Citalopram Phenytion Olanzapine
Current Illness:
Preexisting Conditions: diabetes gastroparesis MitraClip
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: aspiration pneumonia/death


VAERS ID: 991450 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Muscle spasms, Muscle tightness, Myalgia, Neck pain
SMQs:, Rhabdomyolysis/myopathy (broad), Dystonia (broad), Eosinophilic pneumonia (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril, furosemide, omeprazole, amlodipine, meclizine, loratadine
Current Illness:
Preexisting Conditions: Coronary artery disease (CAD); Hypertension (HTN); Renal Disease (e.g. CKD, HD, ESRF)
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient developed left sided neck and trapezoid tightness and pain after receiving the moderna covid vaccine in her left shoulder. The injection site is non tender and does not show any erythema or tenderness. The tenderness is over the left trapezius and left lateral neck area. It also feel tight like a muscle spasm.


VAERS ID: 989006 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-01-30
Onset:2021-01-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9263 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Airway secretion clearance therapy, Breath sounds abnormal, Cardiac arrest, Cardioversion, Death, Dyspnoea, Endotracheal intubation, Mobility decreased, Pulseless electrical activity, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Per reviewed on medical records: metformin, gabapentin, glipizide
Current Illness: unknown
Preexisting Conditions: diabetes obesity hypoventilation syndrome
Allergies: penicillin latex
Diagnostic Lab Data:
CDC Split Type:

Write-up: After being observed for approximately 20 minutes and patient walked to her car without assistance I was called to assess the patient in the parking lot for troubles breathing. EMS was called as I made my way outside. Upon my arrival patient was leaning out of the car and stating that she could not breath. She was able to tell me that she was allergic to penicillin. Oxygen was immediately placed on the patient with minimal relief. Lung sounds were coarse throughout. She then began to vomit about every 20-30 seconds. Epipen was administered in the right leg with no relief. Patient continued to complain of troubles breathing and vomiting. A second epipen was administered in the patients right arm again with no relief. A few minutes later patient was given racemic epinephrine through the oxygen mask. There appeared to be mild improvement in her breathing as she appeared more comfortable, but still complaining of shortness of breath and vomiting. When EMS arrived patient was unable to transport herself to the stretcher. When EMS and clinical staff transferred patient to the stretcher she became unresponsive. She appeared to still be breathing. She did not respond to verbal stimuli. Per ED report large amount of fluid was suctioned from the patients lungs following intubation in the ambulance. When patient arrived to the ED she was extubated and re-intubated without difficulty and further fluid was suctioned. At that time patient was found to be in PEA, shock was delivered. Shortly thereafter no cardiac activity was found and patient pronounced dead.


VAERS ID: 989015 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: End Stage Renal Disease, NON ST Elevation (NSTEM) Myocardial Infarction,, Type II Diabetes Mellitus, Cardiac Arrest cause unspecified, Paroxysmal atrial fibrillation, acute embolism and thrombosis of unspecified deep veins of right lower extremity, Alzheimer''s disease, Chronis systolic heart failure,
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Myocardial Infarction


VAERS ID: 990034 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-17
Onset:2021-01-31
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-01-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Rheumatoid arthritis
SMQs:, Arthritis (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Rheumatoid arthritis, diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: I helped facilitate scheduling for his COVID vaccine and received notification from his wife that he passed away unexpectedly this morning. She reported he had been experiencing a rheumatoid arthritis flare and was on steroids. His diabetes was not well controlled as a result. He did not have any reactions in the days immediately after the vaccine.


VAERS ID: 990780 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-25
Onset:2021-01-28
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Marko Cell Carcinoma Matasisized
Preexisting Conditions: was in hospice since 8/11/20 had cancer
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed


VAERS ID: 990956 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 AR / IM

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

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

Write-up: Systemic: Other- Patient passed away


VAERS ID: 991060 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Anaemia, Cardiac failure congestive, Condition aggravated, Death, Packed red blood cell transfusion, Pyrexia, Unresponsive to stimuli
SMQs:, Cardiac failure (narrow), Haematopoietic erythropenia (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Myelodysplastic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril 10mg daily, Lasix 40 mg daily, Simvastatin 40 mg daily, Senna 8.6/50mg twice daily, Namenda XR 28mg daily, Protonix 40mg daily, ASA 81 mg daily, Potassium Chloride ER 10 meq daily, Amiodarone 100mg daily, metoprolol 25 mg daily.
Current Illness: Dementia, heart failure, paroxysmal atrial fib.. BHP, HTN, thorasic aortic aneurysm, polyosteoarthritis, history of falls, anemia
Preexisting Conditions: as above Resident was transferred to hospital on 1/28/21. Returned to nursing facility on 1/30 and passed away on 1/31/21.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever 101.1, unresponsive episode. Transferred to Hospital on 1/28. Diagnosis there was anemia and CHF, aware that he had vaccine day prior. Transfused with 2 units pRBC''s. Transferred back to Nursing Home on 1/30 and passed away 0140 1/31/2021


VAERS ID: 991080 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2020-12-28
Onset:2021-01-06
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient sudden death reported by family. No further details available at this time.


VAERS ID: 991117 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-28
Onset:2021-01-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen saturation decreased
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

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

Write-up: Systemic: Other- pt had history of copd and DNR on file. approx 3 1/2hr after vaccine pt had sob and lowo2 sat, emergency services called, pt passed on their arrival.staff felt due to pt existing condition


VAERS ID: 991216 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-26
Onset:2021-01-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: History of Heart Condition
Allergies: NKDA
Diagnostic Lab Data: Unknown
CDC Split Type: 921134 WebIZ #

Write-up: Vaccine given on 01-25-2021. Wife reported on 01-29-2021 that patient had a ran a fever on 01-26-2021, Was better on 01-27-2021. She found him dead when she came home work on the evening of 01-28-2021.


VAERS ID: 991622 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-28
Onset:2021-01-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 81 mg Aspirin Prevident 5000 Pepcid 20 mg Propafenone 150 mg Biscodyl Suppository Milk of Magnesia Acetaminophen 325 mg Miralax Powder Ferrous Sulfate 325 mg
Current Illness: Cerebral Infarction due to embolism Crohn''s Disease Gastric Reflux Hyperlipidemia HTN SENILE DEGENERATION OF BRAIN, NOT ELSEWHERE CLASSIFIED PRIMARY GENERALIZED (OSTEO)ARTHRITIS
Preexisting Conditions: See Item 11
Allergies: Adhesive Tape (intolerance) Procaine (intolerance)
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Death


VAERS ID: 991677 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: diagnosed with Covid on 12/03/2020
Preexisting Conditions: hypertension, hyperlipidemia, diabetes, GERD
Allergies: Sulfa, Flexeril, trimethoprim
Diagnostic Lab Data:
CDC Split Type:

Write-up: got up in the night and stated that she couldn''t breath, ambulance was called, pt expired in route to hospital. *relayed to me by Facility staff RN.


VAERS ID: 991849 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-25
Onset:2021-01-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041620A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Dyspnoea, Hypoxia, Respiratory tract congestion, Tachycardia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: clonazepam, Flomax, Flunisolide Soln., Melatonin, Omeprazole, Miralax, Sertraline, Milk of Mag, Tylenol
Current Illness:
Preexisting Conditions: Epilepsy, HTN, BPH, ASHD, GERD, Alzheimer''s Disease, Depression, OCD
Allergies: NKA
Diagnostic Lab Data: nonne
CDC Split Type:

Write-up: Congestion, Hypoxia, SOB, Tachycardia, Weakness. Started on O2 @ 3L, HOB elevated, Tylenol supp


VAERS ID: 991859 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-29
Onset:2021-01-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Food refusal, Memory impairment, Mobility decreased, Somnolence, Urine output decreased, Visual impairment
SMQs:, Acute renal failure (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Depression (excl suicide and self injury) (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hospice patient for 1 year
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per granddaughter''s report, pt became very weak within hours of receiving the first dose of the Moderna COVID-19 vaccine and could not get out of bed the next morning without assistance, reported difficulty seeing, and did not recognize some family members. By Sunday, 1/31, pt was unable to be awakened, would not eat, and had low urinary output. Granddaughter reports that the morning of 2/1 he was awake and ate a small amount and seemed to be improving although still weak and unable to get out of bed. Granddaughter reported he died 2/1 around 10am in the morning.


VAERS ID: 991927 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-01-05
Onset:2021-01-12
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Diphenhydramine HCl, atorvastatin, furosemide, gabapentin, Healthy Eyes (vitamin A, C, & E with lutein minerals), Imodium, Isosorbide mononitrate, Jantoven, Potassium Cl, Metoprolol succinate, Nitroglycerin.
Current Illness:
Preexisting Conditions: Constipation, acute exacerbation of chronic congestive heart failure , osteoarthritis, mitral and aortic incompetence, abnormal renal function, hernia of abdominal cavity, polyp of colon, coronary arteriosclerosis, atrial fibrillation, aortic valve stenosis, aortic valve disorder, cerebrovascular disease, long term current use of anticoagulant, sick sinus syndrome, edema, gout, angina co-occurrent and due to coronary arteripolyneuropathy, essential hypertension, mixed hyperlipidemia, chronic kidney disease stage 3, chronic systolic heart failure, angina, prosthetic cardiac paravalvular leak, prosthetic heart valve in situ, aortic stenosis-non-rheumatic, macrocytic anemia, diarrhea-occasionally, heart disease, cerebrovascular accident, old MI, Squamous cells carcinoma of skin of face, long QT syndrome- 6/18/2020 PPM placed.
Allergies: No known defined allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found deceased at Nursing Home in his room 01/12/2021 at 5:25 AM.


VAERS ID: 991997 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-28
Onset:2021-01-30
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose increased, Blood potassium increased, Cardiogenic shock, Cold sweat, Death, Endotracheal intubation, Nausea, Sepsis, Troponin increased, Vomiting, White blood cell count increased
SMQs:, Cardiac failure (narrow), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, Levemir, Humalog, Trazodone, Prozac, Metoprolol, Eliquis, Plavix, Atorvastatin, Pantoprazole, Dialyvite, Renagel
Current Illness: COVID + diagnosis (12/17/2020) ASYMPTOMATIC Multiple oral extractions completed by dentist on 1/26/2020 ESRD (on 3x week dialysis-last date of dialysis 1/29/2020)
Preexisting Conditions: ESRD, Diabetic, Heart Disease, Vascular Disease, HTN,
Allergies: Bactrim/Sulfa, Cyclobenzaprine, Fentanyl, Gabapentin, Lisinopril, Metoprolol, Primidone
Diagnostic Lab Data: Multiple test completed during course of ER and hospital stay WBC 16.8, K+ 6.1, Serial Troponins 363, 444, 578
CDC Split Type:

Write-up: Resident c/o nausea evening of 1/29 (nausea common for her post dialysis), had a large emesis at approx 2220, 0030 (unusual for resident to vomit)- received Zofran per order. Skin cool and damp, Blood sugar 147 (checked due to h/o diabetes and poor intake). At approx 230am Blood pressured checked and noted to be 52/29. Resident transferred to ER, intubated and transferred to higher level of care where she passed away on 1/30 at 736pm. Resident''s medical notes indicated likely shock, cardiogenic in nature, sepsis (source unknown) along with a multitude of other co-morbidities that resident has.


VAERS ID: 992063 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-19
Onset:2021-01-29
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypoxia, Respiratory depression, SARS-CoV-2 test positive, Skin discolouration
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tums, folic acid, hydroxychloroquine (pre-existing prescription to pandemic), pain pump, symbicort inhaler, multi-vitamin, albuterol inhaler, duloxetine, nystatin powder, senna-docusate, tofacitinib citrate, probiotic, polyethylene glycol,
Current Illness:
Preexisting Conditions: Vascular dementia, swelling of left lower extremity (chronic), subclinical hypothyroidism, STEMI (2014), rheumatoid arthritis, postinflammatory pulmonary fibrosis, posterior tibial tendon dysfunction, paroxsymal atrial fibrillation, osteoporosis, OSA on CPAP, microscopic colitis, interstitial lung disease, hypertension, hx of squamous cell carcinoma of skin, hx of basal cell carcinoma, hearing loss, gout, GERD, dyspnea on exertion, dyslipidemia, diverticulitis, HX of CVA, COPD, chronic heart failure w. preserved ejection fraction, chronic back pain, carotid artery stenosis, CAD, BPH, Barrett''s esophagus, asthma, anxiety, allergic rhinitis, actinic keratosis.
Allergies: Amoxicillin (N&V), "poison ivy/treatments"
Diagnostic Lab Data: Positive COVID-19 per PCR, 1/29/2021
CDC Split Type:

Write-up: Patient received first dose of the COVID-19 Moderna vaccine on 1/19/2021 at an outside facility (no lot #, route, or site available to me in electronic charting). Pt began having hypoxia, SOB, and a dusky appearance of extremities on 1/29/2021 and was brought by EMS to our hospital. PT is a DNR and family had been looking into a hospice sign up due to dementia and general decline in the weeks prior to hospitalization. Pt tested positive on admission for COVID-19 via PCR test on 1/29/2021. Pt continued to have respiratory decline, was put on comfort care per wishes of family/advanced directives, and he passed away the evening of 1/30.


VAERS ID: 992082 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-24
Onset:2021-01-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EI3249 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Culture urine negative, Death, Full blood count normal, General physical health deterioration, Hemiparesis, Metabolic function test, Metabolic function test normal, Mobility decreased
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Noninfectious encephalitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Rocephin, depakote sprinkles, metoprolol, trazodone, famotidine, certevite, mylanta, vit D, zocor, keppra, aspirin, tylenol, tricor.
Current Illness: None
Preexisting Conditions: Supraventricular Tachycardia, cerebral palsey, epilepsy,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident was noted on 1/25 with an increased functional decline as she would not feed herself with utensils, but would eat finger foods if placed in her hand. She was started on Rocephin IM for possible infections. Labs had been obtained on 1/21/21, unremarkable for CBC and CMP. 75,000 colony count on urine. On 1/26/21 she was noted with right sided weakness and further decline. She was sent to Hospital for further evaluation. We were notified that she expired on 1/28/2021. Resident had been noted with a decline in function about 2 weeks earlier when she would not stand or transfer any longer. She was still responsive, taking meds, and feeding herself until 1/26/21. Further information on admitting diagnoses and progress notes from hospital have not been available to date.


VAERS ID: 992137 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-01-19
Onset:2021-01-25
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, Cardio-respiratory arrest, Death, Diarrhoea haemorrhagic, Hyporesponsive to stimuli, Hypotension, Mechanical ventilation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ischaemic colitis (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 6
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: oxymorphone ,mertazapine,medical marijuana , duloxetine , lisinopril , monolucast, hydocortisone, simvastatin amlodipine famotidine
Current Illness:
Preexisting Conditions: pan-hypo pituitarism, hypertension, hyperlipidemia chronic pain sleep apnea
Allergies:
Diagnostic Lab Data: See hospital record
CDC Split Type:

Write-up: 6 days after vaccine developed bloody diarrhea. Thought to have ischemic colitis but negative evaluation. became hypotensive bradycardic placed on ventilator. Subsequently was poorly responsive and eventually coded once more and succumbed


VAERS ID: 992154 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-11
Onset:2021-01-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: duo neb, lasix, protonix, prednisone, apap , dulcolax, cough syryp, levsin, MOM, morphine, tums, ativan, flomax, aquaiphor oint, senna, muscle rub
Current Illness: None
Preexisting Conditions: Alzheimers Dementia late onset without behavioral disturbance, Hypotension, benign prostatic hyperplasia, Left inguinal hernia found 2016, Left shoulder lesions, Hypothyroidism, GERD (gastroesophageal reflux disease), Mixed hyperlipidemia, Basal Cell Carcinoma, Kyphosis, Hx of shingles, dysphagia, Legally blind LEFT eye, cataracts both eyes, frality, hard of hearing Hospice- general decline in the past year.
Allergies: NKA
Diagnostic Lab Data: none, pt on hospice, comfort cares
CDC Split Type:

Write-up: No adverse events reported post vaccine. 1 st dose on 1/11/21 by public health. Death 1/31/21 Patient was on hospice for gradual decline.


VAERS ID: 992209 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Alaska  
Vaccinated:2021-01-08
Onset:2021-01-30
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lorazepam, Haloperidol, Morphine
Current Illness: Hyperlipidemia
Preexisting Conditions: Hyperlipidemia
Allergies: NKDA, NKFA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death


VAERS ID: 992237 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-25
Onset:2021-01-29
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Chest discomfort, Death, Dyspepsia, Electrocardiogram, Endotracheal intubation, Mechanical ventilation, Palpitations, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific dysfunction (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Nebivolol 5mg; Pantoprazole 40 mg; Levocetirizine dehydrochloride 10 mg
Current Illness:
Preexisting Conditions: Hypertension; Hyperlipidemia; decreased GFR. Family history of CAD
Allergies: None
Diagnostic Lab Data: Bag valve mask and intubation prior to arrival to ED. Epi x3 and defibrillation x2.
CDC Split Type:

Write-up: 1/28/2021- Seen by FNP for indigestion, chest pressure and palpitations. EKG reviewed and referral made to Cardiology. 1/29/2021-1800 Presented to ED in cardiac arrest-onset PTA. Patient was found unresponsive by his wife at their home. The last known well was at 1530 when she called him on the phone. The patient was pronounced at ~1850.


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