|
VAERS ID: |
909095 (history) |
Form: |
Version 2.0 |
Age: |
66.0 |
Sex: |
Male |
Location: |
Colorado |
Vaccinated: |
2020-12-23 |
Onset: |
2020-12-25 |
Days after vaccination: |
2 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-25 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Foaming at mouth, Pain in extremity, Pallor, Pulse absent, Respiratory arrest, Somnolence, Unresponsive to stimuli SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad) Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-25
Days after onset: 0 Permanent Disability? No Recovered? No Office Visit? No ER Visit? No ER or Doctor Visit? No Hospitalized? No Previous Vaccinations: Other Medications: Tamsulosin 0.4mg, Lactobacillus tablet, Nephro-vite tablet 0.8mg, Allopurinol 100mg, ferrous gluconate 324mg, melatonin 6mg, lisinopril 2.5mg, colace 100mg, metamucil powder, aspirin 81mg, amidoarone 200mg, hydrooxyzine 25mg, cholestyramine Current Illness: End stage renal disease with dependence on renal dialysis, COPD, cirrhosis of the liver, hypokalemia, gout, heart failure, hyperlipidemia, atrial fibrillation. Preexisting Conditions: Refused dialysis frequently resulting in episodes of hypokalemia and hospitalization, resident dependent on supplemental oxygen. The resident refused to go to dialysis on 12/23/2020 and said he was feeling fine. Allergies: alprazolam, Lorazepam Diagnostic Lab Data: None CDC Split Type: Write-up: on 12/24/2020 the resident was sleepy and stayed in bed most of the shift. He stated he was doing okay but requested pain medication for his legs at 250PM. At 255AM on 12/25/2020 the resident was observed in bed lying still, pale, eyes half open and foam coming from mouth and unresponsive. He was not breathing and with no pulse |
|
VAERS ID: |
913143 (history) |
Form: |
Version 2.0 |
Age: |
84.0 |
Sex: |
Female |
Location: |
Texas |
Vaccinated: |
2020-12-29 |
Onset: |
2020-12-29 |
Days after vaccination: |
0 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-29 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs: Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-29
Days after onset: 0 Permanent Disability? No Recovered? No Office Visit? No ER Visit? No ER or Doctor Visit? No Hospitalized? No Previous Vaccinations: Other Medications: Gabapentin 100mg, Memantine 10mg Current Illness: Preexisting Conditions: dementia, aphasia, type 2 DM, iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, MDD Allergies: codeine, phenobarbital, penicillin Diagnostic Lab Data: CDC Split Type: Write-up: Vaccine administered with no immediate adverse reaction at 11:29am. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 1:30pm the resident passed away. |
|
VAERS ID: |
913733 (history) |
Form: |
Version 2.0 |
Age: |
85.0 |
Sex: |
Female |
Location: |
Pennsylvania |
Vaccinated: |
2020-12-29 |
Onset: |
2020-12-29 |
Days after vaccination: |
0 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-30 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / - |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs: Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-29
Days after onset: 0 Permanent Disability? No Recovered? No Office Visit? No ER Visit? No ER or Doctor Visit? No Hospitalized? No Previous Vaccinations: Other Medications: Current Illness: Preexisting Conditions: Allergies: Diagnostic Lab Data: CDC Split Type: Write-up: My grandmother died a few hours after receiving the moderna covid vaccine booster 1. While I don?t expect that the events are related, the treating hospital did not acknowledge this and I wanted to be sure a report was made. |
|
VAERS ID: |
914690 (history) |
Form: |
Version 2.0 |
Age: |
83.0 |
Sex: |
Female |
Location: |
California |
Vaccinated: |
2020-12-23 |
Onset: |
2020-12-24 |
Days after vaccination: |
1 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-30 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
- / - |
Administered by: Senior Living Purchased by: ? Symptoms: Anxiety, Death, Pyrexia, Respiratory distress, SARS-CoV-2 test negative SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad) Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-26
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: Contact facility for medical records. We think levothyroxine daily and ativan prn. Current Illness: none known Preexisting Conditions: COPD Allergies: none known Diagnostic Lab Data: We were told her last COVID test was negative CDC Split Type: Write-up: Within 24 hours of receiving the vaccine, fever and respiratory distress, and anxiety developed requiring oxygen, morphine and ativan. My Mom passed away on the evening of 12/26/2020. |
|
VAERS ID: |
914805 (history) |
Form: |
Version 2.0 |
Age: |
63.0 |
Sex: |
Male |
Location: |
Illinois |
Vaccinated: |
2020-12-28 |
Onset: |
2020-12-29 |
Days after vaccination: |
1 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-30 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EH9899 / 1 |
LA / IM |
Administered by: Other Purchased by: ? Symptoms: Death SMQs: Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-29
Days after onset: 0 Permanent Disability? No Recovered? No Office Visit? No ER Visit? No ER or Doctor Visit? No Hospitalized? No Previous Vaccinations: Other Medications: Asa-81mg, Lisinopril 10mg daily, ferrous sulfate-325, MVI with min, zyprexia-20mg, Flomax-0.4, famotidine-20mg, vit C, carbamazepine-250mg bid, Depakote-750mg bid, metformin-1000 bid, sertraline-100 bid, albuterol,buspar-10mg TID, Fibercon- Current Illness: none Preexisting Conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gerd, hyperlipidemia, dipolar, rectal bleeding, HTN Allergies: NKA Diagnostic Lab Data: CDC Split Type: Write-up: RESIDENT CODED AND EXPIRED |
|
VAERS ID: |
914895 (history) |
Form: |
Version 2.0 |
Age: |
78.0 |
Sex: |
Male |
Location: |
Nebraska |
Vaccinated: |
2020-12-28 |
Onset: |
2020-12-30 |
Days after vaccination: |
2 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-30 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1284 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs: Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-30
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: Senna Plus, Loperamide, Ondansetron, Acetaminophen, Mucus & Chest Relief cough syrup, Oystershell Calcium Plus D, Vitamin D3, Escitalopram, Bupropion, Hydrocodone/Acetaminophen, Bisacodyl Suppositories Current Illness: Alzheimer''s Disease, Encephalopathy, Hypertension,Acute Kidney failure, Urine Retention, Recent UTI Preexisting Conditions: Alzheimer''s Disease, Encephalopathy, Hypertension Allergies: No known drug allergies Diagnostic Lab Data: CDC Split Type: Write-up: Injection given on 12/28/20 - no adverse events and no issues yesterday; Death today, 12/30/20, approx.. 2am today (unknown if related - Administrator marked as natural causes) |
|
VAERS ID: |
914961 (history) |
Form: |
Version 2.0 |
Age: |
88.0 |
Sex: |
Female |
Location: |
Kentucky |
Vaccinated: |
2020-12-30 |
Onset: |
2020-12-30 |
Days after vaccination: |
0 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-30 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
LA / - |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs: Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-30
Days after onset: 0 Permanent Disability? No Recovered? No Office Visit? No ER Visit? No ER or Doctor Visit? No Hospitalized? No Previous Vaccinations: Other Medications: Current Illness: per nursing home staff over 14 days post covid Preexisting Conditions: Allergies: none listed Diagnostic Lab Data: CDC Split Type: Write-up: pt passed away with an hour to hour and 1/2 of receiving vaccine. per nursing home staff they did not expect pt to make it many more days. pt was unresponsive in room when shot was given. per nursing home staff pt was 14 + days post covid |
|
VAERS ID: |
914994 (history) |
Form: |
Version 2.0 |
Age: |
90.0 |
Sex: |
Female |
Location: |
Kentucky |
Vaccinated: |
2020-12-30 |
Onset: |
2020-12-30 |
Days after vaccination: |
0 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-30 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
AR / - |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs: Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-30
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: not known Current Illness: Preexisting Conditions: Allergies: Diagnostic Lab Data: CDC Split Type: Write-up: pt was a nursing home pt. pt received first dose of covid vaccine. pt was monitored for 15 minutes after getting shot. staff reported that pt was 15 days post covid. Pt passed away with in 90 minutes of getting vaccine |
|
VAERS ID: |
915562 (history) |
Form: |
Version 2.0 |
Age: |
88.0 |
Sex: |
Female |
Location: |
Kentucky |
Vaccinated: |
2020-12-30 |
Onset: |
2020-12-30 |
Days after vaccination: |
0 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-31 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
AR / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death, Dyspnoea, Vomiting SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad) Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-30
Days after onset: 0 Permanent Disability? No Recovered? No Office Visit? No ER Visit? No ER or Doctor Visit? No Hospitalized? No Previous Vaccinations: Other Medications: Current Illness: Preexisting Conditions: Allergies: none listed Diagnostic Lab Data: CDC Split Type: Write-up: pt received vaccine at covid clinic on 12/30 at approximately 3:30, pt vomited 4 minutes after receiving shot--dark brown vomit, staff reported pt had vomited night before. Per staff report pt became short of breath between 6 and 7 pm that night. Pt had DNR on file. pt passed away at approximately 10pm. Staff reported pt was 14 + days post covid |
|
VAERS ID: |
915682 (history) |
Form: |
Version 2.0 |
Age: |
85.0 |
Sex: |
Female |
Location: |
Kentucky |
Vaccinated: |
2020-12-30 |
Onset: |
2020-12-30 |
Days after vaccination: |
0 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-31 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Cardiac arrest, Death, Unresponsive to stimuli SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (broad) Life Threatening? No Birth Defect? No Died? Yes
Date died: 2020-12-30
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: Current Illness: Preexisting Conditions: Respiratory Disease, Essential Hypertension, Coronary Artery Disease, History of positive COVID 11/17/20 Allergies: No Known allergies Diagnostic Lab Data: CDC Split Type: Write-up: Resident received vaccine per pharmacy at the facility at 5 pm. Approximately 6:45 resident found unresponsive and EMS contacted. Upon EMS arrival at facility, resident went into cardiac arrest, code initiated by EMS and transported to hospital. Resident expired at hospital at approximately 8 pm |
|