|
| 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: |
914604 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2020-12-16 |
| Onset: | 2020-12-20 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2020-12-30 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EH9899 / 1 |
- / IM |
Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-20
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Spouse awoke 12/20 and found spouse dead. Client was not transferred to hospital. |
|
| 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: |
914917 (history) |
| Form: |
Version 2.0 |
| Age: |
63.0 |
| Sex: |
Male |
| Location: |
Illinois |
| Vaccinated: | 2020-12-19 |
| Onset: | 2020-12-23 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2020-12-30 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1685 / UNK |
- / - |
Administered by: Work 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: 2020-12-23
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: Atenolol, Chlorthalidone, Tamsulosin
Current Illness: None
Preexisting Conditions: hypertension
Allergies: None
Diagnostic Lab Data: Death certificate
CDC Split Type:
Write-up: Death by massive heart attack. Pfizer-BioNTech COVID-19 Vaccine EUA |
|
| 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 |
|
