VAERS 2021 Database www.vaers.hhs.gov

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VAERS Updated: 11/12/2021
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Died: Y

Date Died: 10/18/2020

ID: 0916803
Sex: M
Age: 78
State: LA

Vax Date: 10/06/2020
Onset Date: 10/10/2020
Rec V Date: 01/01/2021

Lab Data: Hospitalized 10/11/2020 and died 11/18/2020

Allergies: N?A

Symptoms: respitory colase

Other Meds: Lisinopril, Novolog,, Lantus Solostar, Gabapentin, Glusosamine-chondrotin, Lanaoprost, Alphagan, Metoprol Tartrate, Colocrys. . as needed, Chlorthlidone.

Current Illness: none

Died: Y

Date Died: 01/01/2021

ID: 0917117
Sex: M
Age: 82
State: AR

Vax Date: 12/22/2020
Onset Date: 12/28/2020
Rec V Date: 01/01/2021

Lab Data: COVID-19 positive test approximately one week after vaccination. There is no evidence to support that the vaccine caused his death in any way.

Allergies: None

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

Other Meds: Quietapine, Mertazipine, Hydrocodone, Fentanyl

Current Illness: Yes

Died: Y

Date Died: 01/03/2021

ID: 0917790
Sex: F
Age: 90
State: AR

Vax Date: 12/22/2020
Onset Date: 12/29/2020
Rec V Date: 01/03/2021

Lab Data: Unknown

Allergies: None

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

Other Meds: Torsemide, Trazadone, Amitizide, Morphine Sulfate, Fentanyl, Carbidoba-Levodopa, Prednisone, Potassium Chloride, Escalitapram, Incruse Ellipta, Mirtazipane, Clonazepam, Levothyroxine

Current Illness: Patient was a resident of a long term care facility and had numerous chronic conditions prior to vaccination.

Died: Y

Date Died: 01/02/2021

ID: 0917793
Sex: F
Age: 78
State: AR

Vax Date: 12/22/2020
Onset Date: 12/29/2020
Rec V Date: 01/03/2021

Lab Data: Unknown

Allergies: None

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

Other Meds: Metoprolol-Tartrate, Latanoprost, Glipizide, Pravastatin, Metformin, Benaprezil, Potassium-Chloride, Levothyroxine

Current Illness: Diabetes, Thyroid disease

Died: Y

Date Died: 01/01/2021

ID: 0918065
Sex: M
Age: 64
State: CA

Vax Date: 12/30/2020
Onset Date: 01/01/2021
Rec V Date: 01/04/2021

Lab Data: N/A

Allergies: - Clozaril - Tegretol

Symptoms: 1/1/2020: Residents was found unresponsive. Pronounced deceased at 6:02pm

Other Meds: - Invega Trenza 546mg Q3months - Lithium 300mg BID - Oxybutynin 5mg QID - lipitor 20mg QHS - cogentin 2mg BID - Norvasc 5mg QD - Dyazide Capsule 37.5-25 MG (Triamterene-HCTZ) QD

Current Illness: - covid-19

Died: Y

Date Died: 01/01/2021

ID: 0918388
Sex: F
Age: 65
State: FL

Vax Date: 12/30/2020
Onset Date: 01/01/2021
Rec V Date: 01/04/2021

Lab Data:

Allergies: NKA

Symptoms: Resident found unresponsive without pulse, respirations at 04:30 CPR performed, expired at 04:52 by Rescue

Other Meds: Albuteral Sulfate Amlodipine Carvedilol Ipratropium Levetiracetam Olanzapine Sodium Chloride Symbicort Valproic Acid

Current Illness: No acute illness at time of vaccination. History of: CVA SCPT Dementia Seizure Disorder HTN COPD

Died: Y

Date Died: 01/03/2021

ID: 0918418
Sex: M
Age: 65
State: FL

Vax Date: 12/30/2020
Onset Date: 01/01/2021
Rec V Date: 01/04/2021

Lab Data: low oxygen saturation

Allergies: NKA

Symptoms: Resident became SOB, congested and hypoxic requiring oxygen, respiratory treatments and suctioning. Stabilized after treatment and for the next 72 hours with oxygen saturations in the 90s. On 1/3/2021 was found without pulse and respirations. Resident was a DNR on Hospice.

Other Meds: Mucomyst ASA Benadryl Periactin Colace Ferrous Sulfate Folic Acid Gabapentin Sennosides Albuterol Ipratropium Melatonin MVI Oxycodone Polyethylene Glycol Seroquel Rosuvastatin Valproic Acid Venlafaxine Vitamin C

Current Illness: Hypoxia started on 1/1/2021. History of: Osteomyelitis CVA Pain Pressure Ulcers PVD Hepatitis C COPD HTN HLD Constipation SCPT Anemia Seizure disorder Depression AKA

Died: Y

Date Died: 01/04/2021

ID: 0918487
Sex: M
Age: 93
State: MI

Vax Date: 01/02/2020
Onset Date: 01/04/2021
Rec V Date: 01/04/2021

Lab Data: None

Allergies: Beta Adrenergic Blockers

Symptoms: Two days post vaccine patient went into cardiac arrest and passed away.

Other Meds: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.

Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD

Died: Y

Date Died: 12/31/2020

ID: 0918518
Sex: F
Age: 50
State: NE

Vax Date: 12/31/2020
Onset Date: 12/31/2020
Rec V Date: 01/04/2021

Lab Data: Autopsy being performed

Allergies: To be determined

Symptoms: syncopal episode - arrested - CPR - death

Other Meds: To be determined

Current Illness: To be determined

Died: Y

Date Died: 01/03/2021

ID: 0919108
Sex: F
Age: 100
State: NY

Vax Date: 12/22/2020
Onset Date: 12/23/2020
Rec V Date: 01/04/2021

Lab Data: UA. C&S, CBC/Blood culture 1/2/2021

Allergies:

Symptoms: Fever, Malaise

Other Meds:

Current Illness:

Died: Y

Date Died: 01/03/2021

ID: 0919537
Sex: F
Age: 96
State: MN

Vax Date: 01/03/2021
Onset Date: 01/03/2021
Rec V Date: 01/04/2021

Lab Data: N/A.

Allergies: Celebrex and Tramadol

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

Other Meds: Robitussin Cough+Chest Cong DM Liquid 5-100 MG/5ML (Dextromethorphan-guaiFENesin) Tylenol Extra Strength Tablet (Acetaminophen) amLODIPine Besylate Tablet 5 MG Morphine Solu Tab 2.5MG Capsaicin Cream 0.025 % Leflunomide Tablet 10 MG Levothy

Current Illness: Resident had suspected vasovagal episode with drop in O2 saturation.

Died: Y

Date Died: 07/28/2018

ID: 0919902
Sex: M
Age:
State: CA

Vax Date:
Onset Date: 07/28/2018
Rec V Date: 01/05/2021

Lab Data:

Allergies:

Symptoms: shingles; death; Information has been received from a lawyer refers to an erderly male patient. The patient's medical history and concurrent conditions were not reported. In 2014, the patient was vaccinated with zoster vaccine live (ZOSTAVAX) (dose, unit, route of administration, lot # and expiration date were not reported) for the long-term prevention of shingles and zoster-related conditions, in medical office. Subsequently, the patient was treated by various healthcare providers at medical offices for the following injuries resulting from the patient's zoster vaccine live (ZOSTAVAX) use: shingles. The outcome of shingles was not reported. On 28-JUL-2018, the patient died (the cause of death and autopsy information were not reported). The reporter considered death and shingles to be related to zoster vaccine live (ZOSTAVAX).

Other Meds:

Current Illness:

Died: Y

Date Died: 01/01/2021

ID: 0920326
Sex: F
Age: 89
State: IN

Vax Date: 12/29/2020
Onset Date: 12/30/2020
Rec V Date: 01/05/2021

Lab Data: NA

Allergies: Lactose

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

Other Meds: Cetirizine, Lactaid

Current Illness: G30.1 Alzheimer's disease with late onset (Primary) M19.90 Unspecified osteoarthritis, unspecified site J44.9 Chronic obstructive pulmonary disease, unspecified I95.1 Orthostatic hypotension J45.909 Unspecified asthma, uncomplicated R13.12 Dysphagia, oropharyngeal phase M15.0 Primary generalized (osteo)arthritis M85.80 Other specified disorders of bone density and structure, unspecified site Note: Osteopenia J30.9 Allergic rhinitis, unspecified F41.1 Generalized anxiety disorder M24.511 Contracture, right shoulder M24.512 Contracture, left shoulder M24.521 Contracture, right elbow R29.3 Abnormal posture M17.4 Other bilateral secondary osteoarthritis of knee M25.561 Pain in right knee R26.89 Other abnormalities of gait and mobility Z74.1 Need for assistance with personal care Z91.81 History of falling M62.81 Muscle weakness (generalized) R29.6 Repeated falls R27.8 Other lack of coordination R63.3 Feeding difficulties E73.8 Other lactose intolerance R53.1 Weakness I95.89 Other hypotension

Died: Y

Date Died: 01/01/2021

ID: 0920368
Sex: F
Age: 92
State: IN

Vax Date: 12/29/2020
Onset Date: 12/30/2020
Rec V Date: 01/05/2021

Lab Data: Influenza Swab: 12/30/20-Negative Results CBC: 12/30/20 showed WBC of 14.1 (H) CMP: 12/30/20 showed BUN: 113 (H); Creatinine 2.7 (H) CXR: 12/30/20 showed: Conclusion: A mild left lower lung infiltrate

Allergies: quinine sulfate

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

Other Meds: Acetaminophen, Atenolol, Colace, Lisinopril, Mirtazapine, Omeprazole, Simvastatin, Vitamin D3

Current Illness: F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified

Died: Y

Date Died: 01/04/2021

ID: 0920545
Sex: M
Age: 93
State: SD

Vax Date: 01/04/2021
Onset Date: 01/04/2021
Rec V Date: 01/05/2021

Lab Data:

Allergies: NKA

Symptoms: The resident received is vaccine around 11:00 am and tolerated it without any difficulty or immediate adverse effects. He was at therapy from 12:36 pm until 1:22 pm when he stated he was too tired and could not do anymore. The therapist took him back to his room at that time and he got into bed himself but stated his legs felt heavy. At 1:50 pm the CNA answered his call light and found he had taken himself to the bathroom. She stated that when he went to get back into the bed it was "abnormal" how he was getting into it so she assisted him. At that time he quit breathing and she called a RN into the room immediately. He was found without a pulse, respirations, or blood pressure at 1:54 pm. He was a DNR.

Other Meds: Ferrex 150 mg, Folic Acid 1 mg, Furosemide 20 mg, Isosorbide Mononoitrate ER 30 mg, Lactulose 15 mL, Omeprazole 40 mg, Potassium Chloride ER 20 MEQ, Metoprolol 12.5 mg, PreserVision AREDS 2 one capsule, Ranolazine ER 1,000 mg, and Sucralf

Current Illness:

Died: Y

Date Died: 01/04/2021

ID: 0920815
Sex: F
Age: 58
State: KY

Vax Date: 12/30/2020
Onset Date: 01/04/2021
Rec V Date: 01/05/2021

Lab Data:

Allergies: Lisinpril, Codeine, Latex , environmental (hay fever)

Symptoms: Found deceased in her home, unknown cause, 6 days after vaccine.

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/04/2021

ID: 0920832
Sex: F
Age: 104
State: NY

Vax Date: 12/30/2020
Onset Date: 01/01/2021
Rec V Date: 01/05/2021

Lab Data:

Allergies:

Symptoms: Vaccine 12/30/2020 Screening PCR done 12/31/2020 Symptoms 1/1/2021 COVID test result came back positive 1/2/2021 Deceased 1/4/2021

Other Meds:

Current Illness:

Died: Y

Date Died: 01/05/2021

ID: 0921175
Sex: F
Age: 77
State: NJ

Vax Date: 01/03/2021
Onset Date: 01/03/2021
Rec V Date: 01/05/2021

Lab Data: Epi pen 0.3mg given, sent to ER

Allergies: NKA

Symptoms: Resident received Covid Vaccine, noted after 30 mins with labored breathing BP 161/77, HR 116, R 38, T 101.4,

Other Meds:

Current Illness: CHF, COPD, DM, heart failure, anemia, sleep apnea

Died: Y

Date Died: 01/04/2021

ID: 0921481
Sex: M
Age: 88
State: OH

Vax Date: 12/29/2020
Onset Date: 01/01/2021
Rec V Date: 01/05/2021

Lab Data: n/a

Allergies: No known allergies

Symptoms: Vaccine given on 12/29/20 by Pharmacy. On 1/1/21, resident became lethargic and sluggish and developed a rash on forearms. He was a Hospice recipient and doctor and Hospice ordered no treatment, just to continue to monitor. When no improvement of codition reported, doctor and Hospice ordered comfort meds (Morphine, Ativan, Levsin). Resident expired on 1/4/2021

Other Meds: Vitamin D3 5000 units qd Furosemide 20mg qd Olanzapine 2.5mg bid

Current Illness: Dementia Chronic PVD

Died: Y

Date Died: 01/04/2021

ID: 0921547
Sex: M
Age: 65
State: AR

Vax Date: 01/02/2021
Onset Date: 01/04/2021
Rec V Date: 01/05/2021

Lab Data: N/A

Allergies: NKDA

Symptoms: DEATH ON 1/4/2021, RESIDENT RECIEVED VACCINE ON 1/2/20

Other Meds: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Pain. elevated Temp. Phone Active 05/08/2020 05/08/2020 AmLODIPine Besylate Tablet 10 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYP

Current Illness: CEREBRAL INFARCTION, UNSPECIFIED(I63.9), LONG TERM (CURRENT) USE OF ASPIRIN(Z79.82), VITAMIN DEFICIENCY, UNSPECIFIED(E56.9), ACUTE KIDNEY FAILURE, UNSPECIFIED(N17.9), HYPERKALEMIA(E87.5), ACUTE RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA(J96.00), PURE HYPERCHOLESTEROLEMIA, UNSPECIFIED(E78.00), PAIN IN RIGHT FOOT(M79.671), ESSENTIAL (PRIMARY) HYPERTENSION(I10), ACIDOSIS(E87.2), ABNORMAL LEVELS OF OTHER SERUM ENZYMES(R74.8), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), DISORDER OF THYROID, UNSPECIFIED(E07.9), GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS(K21.9), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES(M62.59), COGNITIVE COMMUNICATION DEFICIT(R41.841), UNSPECIFIED LACK OF COORDINATION(R27.9), OTHER DYSPHAGIA (R13.19), OTHER CHRONIC PAIN(G89.29), HYPOTHYROIDISM, UNSPECIFIED(E03.9), DRY EYE SYNDROME OF UNSPECIFIED LACRIMAL GLAND (H04.129), METABOLIC ENCEPHALOPATHY(G93.41), UNSPECIFIED CONVULSIONS(R56.9), POLYNEUROPATHY, UNSPECIFIED(G62.9), TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA(E10.319), NASAL CONGESTION(R09.81), BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC(J40), HYPOKALEMIA(E87.6), ELEVATED WHITE BLOOD CELL COUNT, UNSPECIFIED(D72. 829), OTHER MALAISE(R53.81), CELLULITIS OF RIGHT LOWER LIMB(L03.115), CELLULITIS OF LEFT LOWER LIMB(L03.116), EDEMA, UNSPECIFIED (R60.9), IRON DEFICIENCY ANEMIA, UNSPECIFIED(D50.9), CUTANEOUS ABSCESS, UNSPECIFIED(L02.91), COVID-19(U07.1)

Died: Y

Date Died: 01/02/2021

ID: 0921572
Sex: M
Age: 87
State: WI

Vax Date: 12/29/2020
Onset Date: 12/30/2020
Rec V Date: 01/05/2021

Lab Data:

Allergies: Lisinopril, Losartan

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

Other Meds: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl

Current Illness: Heart Failure

Died: Y

Date Died: 01/03/2021

ID: 0921667
Sex: F
Age: 39
State: OH

Vax Date: 12/29/2020
Onset Date: 01/03/2021
Rec V Date: 01/05/2021

Lab Data:

Allergies:

Symptoms: LTCF Pfizer Vaccine clinic conducted 12/29/2020 Vaccine lead received a call indicating that a staff member deceased somewhere between 1/3/2021 and 1/4/2021. Cause of death is unknown, and an autopsy is being performed.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/04/2021

ID: 0921768
Sex: F
Age: 58
State: WA

Vax Date: 01/04/2021
Onset Date: 01/04/2021
Rec V Date: 01/05/2021

Lab Data: Autopsy scheduled for 01/07/2021

Allergies: None Known

Symptoms: Vaccine received at about 0900 on 01/04/2021 at her place of work, Medical Center, where she was employed as a housekeeper. About one hour after receiving the vaccine she experienced a hot flash, nausea, and feeling like she was going to pass out after she had bent down. Later at about 1500 hours she appeared tired and lethargic, then a short time later, at about 1600 hours, upon arrival to a friends home she complained of feeling hot and having difficulty breathing. She then collapsed, then when medics arrived, she was still breathing slowly then went into cardiac arrest and was unable to be revived.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/02/2021

ID: 0921880
Sex: M
Age: 96
State: VA

Vax Date: 01/02/2021
Onset Date: 01/02/2021
Rec V Date: 01/05/2021

Lab Data:

Allergies: oxycodone

Symptoms: The resident was found deceased a little less than 12 hours following COVID vaccination, and he had had some changes over the last 2 days. He was 96 and had been on hospice care for a little while. Noone noticed any side effects from vaccine after it was given

Other Meds: Olanzapine, polyethylene glycol, ativan, morphine, senna

Current Illness: was under hospice care

Died: Y

Date Died: 12/28/2020

ID: 0922977
Sex: M
Age: 71
State: NY

Vax Date: 12/21/2020
Onset Date: 12/27/2020
Rec V Date: 01/05/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/02/2021

ID: 0923993
Sex: M
Age: 62
State: NC

Vax Date: 12/30/2020
Onset Date: 01/02/2021
Rec V Date: 01/06/2021

Lab Data:

Allergies: Hay fever

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

Other Meds: Unknown

Current Illness: No

Died: Y

Date Died: 01/01/2021

ID: 0924126
Sex: F
Age: 84
State: MI

Vax Date: 12/30/2020
Onset Date: 01/01/2021
Rec V Date: 01/06/2021

Lab Data: N/A

Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin

Symptoms: resident expired 1/1/2021

Other Meds: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium

Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.

Died: Y

Date Died: 01/03/2021

ID: 0924186
Sex: F
Age: 91
State: MI

Vax Date: 12/30/2020
Onset Date: 01/03/2021
Rec V Date: 01/06/2021

Lab Data:

Allergies: Codeine, Penicillin, Sulfa

Symptoms: Resident expired 1/3/21

Other Meds: aldactone, lasix, aspirin, tylenol, potassium, spiriva

Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg

Died: Y

Date Died: 01/05/2021

ID: 0924456
Sex: F
Age: 85
State: CA

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/06/2021

Lab Data: OVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19

Allergies: No known allergies

Symptoms: Patient did not display any obvious signs or symptoms; the vaccination was administered at approximately 10:00 AM and the patient continued throughout her day without any complaints or signs of adverse reaction. Patient was helped to bed by the nursing assistant estimated at around 9:00 PM. The facility received notification from the lab around 11:00 PM that the patient's COVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19. When the nursing staff went to the room to check on the resident and prepare her to move to a COVID-19 care area the patient was found unresponsive, no movement, no chest rises, noted regurgitated small amount of food to mouth left side, lying on left side. Pupils non reactive.

Other Meds: Lexapro, famotidine, Namenda, Seroquel, simvastatin, Trazodone; Tamsulosin; Docusate sodium; Polyethylene glycol; Celebrex; Acetaminophen

Current Illness: COVID-19 detected after vaccination; asymptomatic

Died: Y

Date Died: 01/06/2021

ID: 0924464
Sex: F
Age: 61
State: IA

Vax Date: 01/05/2021
Onset Date: 01/06/2021
Rec V Date: 01/06/2021

Lab Data:

Allergies:

Symptoms: coughing up blood, significant hemoptysis -- > cardiac arrest. started day after vaccine but likely related to ongoing progression of lung cancer

Other Meds:

Current Illness: COPD, lung cancer

Died: Y

Date Died: 01/06/2021

ID: 0924664
Sex: F
Age: 92
State: HI

Vax Date: 01/02/2021
Onset Date: 01/05/2021
Rec V Date: 01/06/2021

Lab Data: CT scan, X ray 1/5/2021

Allergies: Hydrochlorothiazide

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

Other Meds: Metoprolol succ ER 50mg 1 tab PO daily Omeprazole DR 20mg 1 cap PO daily Amlodipine besylate 5mg 1 tab PO daily Aspirin 81mg 1 tab PO daily Carbamazepine ER 100mg 1 tab PO TID Docusate 100mg 1 cap PO daily Multivitamin 1 tab PO daily Olmesa

Current Illness: none

Died: Y

Date Died:

ID: 0924934
Sex: M
Age:
State:

Vax Date:
Onset Date:
Rec V Date: 01/07/2021

Lab Data:

Allergies:

Symptoms: green bret syndrome and he died from it; Initial information was received on 05-Jan-2021 regarding an unsolicited valid serious social media case from a consumer. This case is linked to case 2021SA003660 (same reporter). This case involves male patient (of an unknown age) who had green bret syndrome and he died from it (Guillain-Barre Syndrome) after receiving NFLUENZA VACCINE. Medical history, medical treatment(s), concomitant medications, vaccination(s) and family history were not provided. On an unknown date, the patient received a dose of suspect INFLUENZA VACCINE produced by unknown manufacturer (lot number and expiry date not reported) via an unknown route at an unknown administration site for prophylactic vaccination. On an unknown date, the patient developed serious green bret syndrome and he died from it (Guillain-Barre Syndrome) (unknown latency) following the administration of INFLUENZA VACCINE. This event was assessed as medically significant and was leading to death. Details of laboratory data were not reported. It was not reported if the patient received any corrective treatment. On an unknown date, the outcome was reported as fatal for the event Guillain-Barre syndrome. It is unknown if an autopsy was done. The cause of death was reported as Guillain-Barre syndrome. Information on the lot number was requested.; Sender's Comments: This was a poorly documented social media case involves male patient (of an unknown age) who had Guillain-Barre Syndrome and died from it, after receiving INFLUENZA VACCINE. Time to onset is unknown. Additional information regarding patient's relevant medical history, health condition at the time of vaccination, laboratory tests ruling out other alternate etiologies and autopsy results is needed for complete assessment of the case. Based upon the reported information, the role of the vaccine cannot be assessed.; Reported Cause(s) of Death: green bret syndrome

Other Meds:

Current Illness:

Died: Y

Date Died: 01/04/2021

ID: 0925154
Sex: F
Age: 84
State: FL

Vax Date: 01/03/2021
Onset Date: 01/04/2021
Rec V Date: 01/07/2021

Lab Data: Hospital

Allergies: None

Symptoms: Deceased

Other Meds: Avorstatin Aspirin Oxycodone

Current Illness: NONE

Died: Y

Date Died: 01/07/2021

ID: 0925264
Sex: M
Age:
State: OK

Vax Date: 12/31/2020
Onset Date:
Rec V Date: 01/07/2021

Lab Data: None

Allergies: NKDA

Symptoms: PT was found deceased in his home on 1/5/2021

Other Meds: Norco 5/325 1 tablet every 6 hours as needed. Warfarin 4mg , 2 tablets orally Monday and Friday Torsemide 100mg, 1/2 tablet orally once a day Sabcubitril-Valsartan 24/26mg 1/4 tablet orally twice a day Gabapentin 300mg, tablet once daily Ca

Current Illness: CHF HTN DM 2 CKD Obesity DDD

Died: Y

Date Died: 01/06/2021

ID: 0925556
Sex: M
Age: 81
State:

Vax Date: 12/30/2020
Onset Date: 01/06/2021
Rec V Date: 01/07/2021

Lab Data:

Allergies:

Symptoms: Expired 1/05/2021

Other Meds:

Current Illness: Acute on chronic heart failure, sepsis

Died: Y

Date Died: 01/05/2021

ID: 0926269
Sex: M
Age: 74
State: MD

Vax Date: 01/04/2021
Onset Date: 01/05/2021
Rec V Date: 01/07/2021

Lab Data:

Allergies: No Known Allergies

Symptoms: Pt last seen at 1200 by nurse for ID band check. No visible signs of distress noted. Pt states "I just want to be left alone". 1230 nurse was called to pt room. Pt was noted unresponsive, no pulse and respiration noted. CPR started immediately, at 1239 first shock given. 1245 EMT took over, at 1319 EMT called time of death

Other Meds: Acetaminophen Tablet 325 MG, Enulose Solution 10 GM/15ML (Lactulose Encephalopathy), HYDROcodone-Acetaminophen Tablet 5-325 MG, Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide, Potassium Chloride ER Tablet Extended Release 20 ME

Current Illness: Fracture of right superior and inferior pubic rami, fracture of the right sacral alla, and fracture of the L3 vertebral body. UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

Died: Y

Date Died: 01/05/2021

ID: 0926462
Sex: M
Age: 91
State:

Vax Date: 12/28/2020
Onset Date: 01/04/2021
Rec V Date: 01/07/2021

Lab Data:

Allergies: no known food or medication allergies

Symptoms: Patient developed hypoxia on 1/4/2021 and did not respond to maximal treatment and passed way on 1/5/2021

Other Meds: Lorazepam, pantoprazole, miralax, senna plus, carbodopa-levodopa, metoprolol, mirtazipine, quetiapine

Current Illness: dementia, Upper gastrointestinal bleed

Died: Y

Date Died: 01/04/2021

ID: 0926568
Sex: M
Age: 77
State:

Vax Date: 12/28/2020
Onset Date: 12/30/2020
Rec V Date: 01/07/2021

Lab Data:

Allergies: clopidigrel, sulfa, vicodin

Symptoms: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020

Other Meds: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin

Current Illness: chronic medical problems as noted below

Died: Y

Date Died: 01/06/2021

ID: 0926600
Sex: M
Age: 65
State: MO

Vax Date: 01/04/2021
Onset Date: 01/06/2021
Rec V Date: 01/07/2021

Lab Data:

Allergies: Penicillin, ibuprofen

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

Other Meds: Unknown

Current Illness: Diabetes, renal insufficiency

Died: Y

Date Died: 01/01/2021

ID: 0926797
Sex: M
Age: 93
State: SD

Vax Date: 12/31/2020
Onset Date: 01/01/2021
Rec V Date: 01/07/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness: This is a 93 year old with significant heart issues?EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine

Died: Y

Date Died: 01/07/2021

ID: 0927189
Sex: M
Age: 74
State: CA

Vax Date: 01/07/2021
Onset Date: 01/07/2021
Rec V Date: 01/07/2021

Lab Data:

Allergies: none

Symptoms: Patient was vaccinated at 11am and was found at the facility in his room deceased at approximately 3:00pm. Nurse did not have cause of death

Other Meds: unknown

Current Illness: stroke

Died: Y

Date Died: 01/06/2021

ID: 0927260
Sex: F
Age: 87
State: WI

Vax Date: 12/28/2020
Onset Date: 01/06/2021
Rec V Date: 01/07/2021

Lab Data: Brain CT negative WBC and lactic acid increased. COVID 19 on 1/4/21 negative

Allergies: Codeine, Meperidine, Morphine, Estrogens, Penicillins, Tetanus Toxoids

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

Other Meds: Vit D3, Miralax, Spironolactone, Tramadol, Metoprolol Succinate, MOM, Ferrous Gluconate, Ondansetron, Nitroglycerin Sublingual PRN, PreserVision AREDS, Fluticasone Propionate Suspension, Lisinopril, Clopidogrel Bisulfate, Campor-Methol-Met

Current Illness: Digestive Surgery for bowel obstruction

Died: Y

Date Died: 06/07/2016

ID: 0927454
Sex: M
Age:
State: NC

Vax Date:
Onset Date: 06/07/2016
Rec V Date: 01/08/2021

Lab Data:

Allergies:

Symptoms: shingles; death; This spontaneous report was received from a lawyer concerning a case in litigation and refers to a 80 year old male patient. The patient's concurrent conditions, medical history, historical drugs and concomitant therapies were not reported. On or about 2014, the patient was vaccinated with zoster vaccine live (ZOSTAVAX) (dose, route, lot number and expiration date were not reported) for long-term prevention of shingles and zoster-related conditions. On an unknown date (reported as "subsequent to vaccination"), the patient experienced shingles and was treated with unspecified medications. On 07-JUN-2016, the patient died. The caused of death and if an autopsy was performed were not reported. The outcome of shingles was unknown. The reporter considered death and herpes zoster to be related to Zoster Vaccine Live (ZOSTAVAX).

Other Meds:

Current Illness:

Died: Y

Date Died: 01/07/2021

ID: 0928062
Sex: M
Age: 85
State: MA

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/08/2021

Lab Data: Pancytopenia, elevated lactate, troponin, LFTs. Left mid lung infiltrate and pulmonary vascular congestion.

Allergies: angioedema due to ACE and ARB meds

Symptoms: vomiting later on 01/05/21. Lethargy and hypoxia in pm of 01/06/21. Hypotension am of 01/07/21. Hospitalized, intubated, cardiac arrest, died 01/07/21.

Other Meds: ACETAMINOPHEN CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA ER CITALOPRAM HBR DONEPEZIL HCL EUCERIN FINASTERIDE FLOMAX LATANOPROST OMEPRAZOLE QUETIAPINE FUMARATE QUETIAPINE FUMARATE SENNA LAX

Current Illness: Parkinson's Disease with advanced dementia, dysphagia. Alcoholism in remission. HTN. BPH. GERD

Died: Y

Date Died: 01/06/2021

ID: 0928513
Sex: F
Age: 72
State: MI

Vax Date: 01/05/2021
Onset Date: 01/06/2021
Rec V Date: 01/08/2021

Lab Data: N/A

Allergies: Aldactone, contrast dye

Symptoms: Resident passed away in her sleep

Other Meds: Amiodarone Hcl, Carvedilol, Ferrous sulfate, Eliquis (cont)

Current Illness: Atrial fibrillation, Anemia, 1st degree AV block, CDK stage 4,

Died: Y

Date Died: 01/08/2021

ID: 0928933
Sex: F
Age: 56
State: IA

Vax Date: 12/23/2020
Onset Date: 01/08/2021
Rec V Date: 01/08/2021

Lab Data:

Allergies:

Symptoms: Patient had been diagnosed with COVID-19 on Dec. 11th, 2020. Symptoms were thought to have started on 12/5/2020. Received Moderna vaccine on 12/23. Unexpected death on 1/8/2021. Resuscitation attempts unsuccessful

Other Meds:

Current Illness:

Died: Y

Date Died: 01/08/2021

ID: 0929359
Sex: M
Age: 76
State: FL

Vax Date: 01/06/2021
Onset Date: 01/06/2021
Rec V Date: 01/08/2021

Lab Data: none

Allergies: none

Symptoms: 3:07 pm lung sounds diminished oxygen sats 68%, oxygen applied Oxygen sats remained low for next 36 hours ( patient on Hospice care ) expired 6:22 am 1-8-21

Other Meds: none

Current Illness: Cerebral Atherosclerosis, malnutrition, thrombocytopenia, cva, hypothyroidism

Died: Y

Date Died: 12/29/2020

ID: 0929764
Sex: M
Age: 45
State: WA

Vax Date: 12/28/2020
Onset Date: 12/29/2020
Rec V Date: 01/08/2021

Lab Data:

Allergies: no known allergies recorded in medical record

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

Other Meds: Hydrochlorthiazide (by record, not confirmed)

Current Illness:

Died: Y

Date Died: 01/07/2021

ID: 0929997
Sex: M
Age: 86
State: WI

Vax Date: 01/04/2021
Onset Date: 01/05/2021
Rec V Date: 01/08/2021

Lab Data: He did not have testing at that point because he was on Hospice.

Allergies: Losartan, lisinopril, metoprolol

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

Other Meds: Amlodipine 5 mg daily, Dexamethasone 4 mg daily (for itching related to renal failure), Isosorbide dinitrate 30 mg daily, Levothyroxine 0.075 mg daily, Bisoprolol 5 mg BID, Furosemide 80 mg BID, saline nasal spray, Tylenol 1000 mg PO TID

Current Illness: none acute

Died: Y

Date Died: 01/08/2021

ID: 0930154
Sex: M
Age: 60
State: OH

Vax Date: 01/05/2021
Onset Date: 01/08/2021
Rec V Date: 01/08/2021

Lab Data:

Allergies: Sulfa

Symptoms: Notified today that he passed away. No other details known at this time.

Other Meds: unknown

Current Illness: unkown

Died: Y

Date Died: 01/08/2021

ID: 0930431
Sex: F
Age: 89
State: CT

Vax Date: 01/06/2021
Onset Date: 01/08/2021
Rec V Date: 01/08/2021

Lab Data: Unknown

Allergies: None

Symptoms: Cardiac event, 2 days after vaccination, patient expired.

Other Meds: Enteric Coded Aspirin, Atenolol, Centrum Silver, Citrical, Levothyroxin, Lisinipril, Phillips Colon Health Caps, Vitamin D

Current Illness: none

Died: Y

Date Died: 01/05/2021

ID: 0930466
Sex: F
Age: 82
State: LA

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/08/2021

Lab Data:

Allergies: None

Symptoms: Fever, shortness of breath and chest pain that resulted in a heart attack a few hours after vaccination

Other Meds:

Current Illness:

Died: Y

Date Died: 01/08/2021

ID: 0930487
Sex: M
Age: 86
State: NC

Vax Date: 01/08/2021
Onset Date: 01/08/2021
Rec V Date: 01/08/2021

Lab Data: na

Allergies: cephalexin

Symptoms: Medical docter state patient has a acute cardiac attack

Other Meds: calcium-D tablet, cholecalciferol, fish oil, melatonin, tylenol,

Current Illness: na

Died: Y

Date Died: 01/08/2021

ID: 0930876
Sex: M
Age: 88
State: TX

Vax Date: 01/07/2021
Onset Date: 01/08/2021
Rec V Date: 01/08/2021

Lab Data: Had IV dye imaging procedure after he received the COVID-19 vaccine (the same day in the afternoon) and passed away overnight.

Allergies:

Symptoms: Death

Other Meds:

Current Illness:

Died: Y

Date Died: 12/26/2020

ID: 0958443
Sex: F
Age:
State:

Vax Date: 12/24/2020
Onset Date: 12/26/2020
Rec V Date: 01/08/2021

Lab Data:

Allergies:

Symptoms: death by suicide Narrative: death by suicide; 12/26/20, self inflicted gun shot wound; found deceased by family member

Other Meds:

Current Illness:

Died: Y

Date Died: 01/08/2021

ID: 0930910
Sex: F
Age: 52
State: HI

Vax Date: 01/08/2021
Onset Date: 01/08/2021
Rec V Date: 01/09/2021

Lab Data:

Allergies: Metformin, morphine, statins, latex

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

Other Meds: Patient was refusing to take all medications for over a year

Current Illness: None

Died: Y

Date Died: 01/08/2001

ID: 0930912
Sex: M
Age: 73
State: NY

Vax Date: 01/07/2021
Onset Date: 01/08/2021
Rec V Date: 01/09/2021

Lab Data:

Allergies: None

Symptoms: Diarrhea followed by death 24 hrs after vaccination

Other Meds: None

Current Illness: None

Died: Y

Date Died: 01/04/2021

ID: 0951518
Sex: M
Age: 77
State: WY

Vax Date: 12/28/2020
Onset Date: 01/04/2021
Rec V Date: 01/09/2021

Lab Data: Specimen: NASOPHARYNX. Specimen Collection Date: Dec 29, 2020@09:45 Test name Result units Ref. range Site Code COVID-19 (M2000) Not Detected

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/05/2021

ID: 0951519
Sex: M
Age: 78
State: MN

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/09/2021

Lab Data:

Allergies:

Symptoms: Narrative: Symptoms: Palpitations & Syncope Treatment: EPINEPHRINE 1 MG ONCE ,EPINEPHRINE 1 MG ONCE ,SODIUM BICARBONATE 50 ML ONCE

Other Meds:

Current Illness:

Died: Y

Date Died: 12/27/2020

ID: 0956903
Sex: M
Age: 85
State:

Vax Date: 12/22/2020
Onset Date: 12/27/2020
Rec V Date: 01/09/2021

Lab Data:

Allergies:

Symptoms: mi Narrative: patient with asymptomatic covid 19, covid positive 12/10/2020.

Other Meds:

Current Illness:

Died: Y

Date Died: 12/25/2020

ID: 0956966
Sex: M
Age: 85
State:

Vax Date: 12/25/2020
Onset Date: 12/25/2020
Rec V Date: 01/09/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 12/27/2020

ID: 0964629
Sex: M
Age: 63
State:

Vax Date: 12/17/2020
Onset Date: 12/27/2020
Rec V Date: 01/09/2021

Lab Data:

Allergies:

Symptoms: Death - Hospice patient with metastatic CA admitted to facility and received vaccine during stay. No adverse sequelae noted from vaccine administration, but reporting as required because pt died 7 days later. Narrative: Reporting this event because patient died 7 days after receiving vaccine in the facility where he was in hospice care for metastatic cancer. Vaccine was administered by protocol without complications. The patient had been asked and denied any prior severe reaction to this vaccine or its components and gave permission to receive it. No vaccine adverse sequelae were documented after the immunization as monitored for 15 minutes nor in facility notes for 7 days after the immunization. The patient's death was felt to be due to underlying terminal illness.

Other Meds:

Current Illness:

Died: Y

Date Died: 12/22/2020

ID: 0964636
Sex: M
Age: 80
State:

Vax Date: 12/17/2020
Onset Date: 12/22/2020
Rec V Date: 01/09/2021

Lab Data:

Allergies:

Symptoms: Pt on hospice in facility for severe cardiomyopathy unable to perform interventions received vaccine without adverse sequelae died 5 days later. Reporting as required. Narrative: Reporting as required patient death 5 days after immunization with Pfizer vaccine. However, no adverse sequelae were noted to the vaccine in the 15minute observation period, nor in the days following the immunization related to the vaccine. The patient denied any prior severe reaction to this vaccine or its components, and the patient gave verbal consent to receive the vaccine. Patient had been in the facility on hospice since 11/18/20 for severe decompensated HF and newly diagnosed cardiomyopathy, unable to perform interventions, also LE ischemic wounds with very poor potential to heal due to advanced PVD.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/10/2021

ID: 0932346
Sex: M
Age: 66
State: NC

Vax Date: 01/07/2021
Onset Date: 01/08/2021
Rec V Date: 01/10/2021

Lab Data: autopsy pending

Allergies: Statin - muscle aches

Symptoms: 1/7-21 - Received second dose of pfizer covid-19 vaccine 1/8/21 - Fever, dizziness, headache 1/10/21 0250 was found not breathing. EMS performed CPR and patient deceased

Other Meds: Unknown

Current Illness: none known

Died: Y

Date Died: 01/10/2021

ID: 0932787
Sex: F
Age: 70
State: GA

Vax Date: 01/08/2021
Onset Date: 01/10/2021
Rec V Date: 01/10/2021

Lab Data: NONE AT TIME OF REPORTING, TALK OF AN AUTOPSY

Allergies: TRAMADOL, methocarbamol

Symptoms: RECIEVED VACCINE 1/8/21 EXPIRED UNEXPECTED 1/10/21, NO ADVERSE REACTIONS NOTED

Other Meds: CRANBERRY, PROZAC, NEUROTIN PERCOCET, IMMODIUM, SYNTHROID, LINZESS, LIPITOR, MELATONIN METFORMIN, PROTONIX PLAVIX, PROAIR, ropinirole, PROAIR SYMBICORT, THIAMINE TYLENOL VIT C VOLTAREN. ZANAX, ZOFRAN

Current Illness: PNEUMONIA

Died: Y

Date Died: 12/30/2020

ID: 0932898
Sex: M
Age: 61
State: PA

Vax Date: 12/17/2020
Onset Date: 12/23/2020
Rec V Date: 01/10/2021

Lab Data: Unknown.

Allergies: None known.

Symptoms: The patient had an apparent cardiac arrest on 12/23/20 and was admitted to the ICU. He was taken off of life support on 12/30/20. He had known cardiac disease.

Other Meds: Amlodipine, Atorvastatin, Xarelto, Aspirin (These were medications listed with our office in 2019. Unknown if this patient was still taking at time of vaccination).

Current Illness:

Died: Y

Date Died: 01/09/2021

ID: 0933090
Sex: M
Age: 60
State: CA

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/10/2021

Lab Data: Unknown

Allergies: Unknown

Symptoms: Patient died, I have a copy of his vaccination card

Other Meds: Unknown

Current Illness: Unknown

Died: Y

Date Died: 01/07/2021

ID: 0964653
Sex: M
Age: 78
State:

Vax Date: 01/06/2021
Onset Date: 01/07/2021
Rec V Date: 01/10/2021

Lab Data: Patient's temperature log: 12-15-20 08:38:00 97.6 O 12-15-20 16:38:00 97.8 O 12-16-20 08:43:00 97.9 O 12-16-20 11:25:00 98.3 O 12-16-20 16:50:18 98.2 12-17-20 06:22:47 98.1 12-17-20 08:27:00 98.1 O 12-17-20 14:20:00 98.4 O 12-17-20 16:34:00 97.5 O 12-18-20 06:14:00 97.3 Ax 12-18-20 08:05:00 97.5 O 12-18-20 17:30:00 97.5 O 12-19-20 05:35:00 98.1 O 12-19-20 08:21:00 98.4 O 12-19-20 16:32:00 98.4 O 12-20-20 08:27:00 98 O 12-20-20 16:58:39 97.6 12-21-20 08:20:00 98 O 12-21-20 16:34:00 98.8 O 12-22-20 05:44:00 98.2 O 12-22-20 08:58:00 97.7 O 12-22-20 16:39:00 97.5 O 12-23-20 08:12:00 97.5 O 12-23-20 16:56:26 98.1 12-24-20 08:18:00 98.2 O 12-24-20 16:37:00 98.4 O 12-25-20 05:35:00 98 O 12-25-20 08:17:00 97.6 O 12-26-20 05:54:00 98.2 O 12-26-20 08:30:01 97.7 12-26-20 16:16:00 97.5 O 12-27-20 06:23:34 97.9 12-27-20 08:40:37 97.6 O 12-27-20 16:23:00 97.4 O 12-28-20 07:52:00 98.3 O 12-28-20 17:57:31 97.7 12-29-20 05:23:14 98.3 12-29-20 08:43:00 98.4 O 12-29-20 16:44:00 98.6 O 12-30-20 05:54:15 97.4 12-30-20 08:24:00 97.6 O 12-30-20 21:16:00 98.3 O 12-31-20 06:04:02 97.9 12-31-20 08:26:00 97.5 Ax 12-31-20 19:00:00 97.9 O 01-01-21 06:22:09 98.3 01-01-21 08:04:00 98.7 O 01-01-21 16:15:00 99.1 O 01-01-21 17:01:00 97.1 O 01-02-21 06:19:09 98 01-02-21 08:22:00 98.3 O 01-02-21 16:05:00 98 O 01-03-21 06:11:00 97.2 O 01-03-21 08:20:00 98.2 O 01-03-21 16:03:00 97.7 O 01-04-21 05:42:00 97.8 O 01-04-21 08:25:00 98.1 O 01-04-21 18:04:00 97.9 O 01-05-21 05:27:21 98 01-05-21 08:50:00 98.4 O 01-05-21 08:53:22 98.4 01-05-21 16:53:01 98.6 01-06-21 06:03:04 98.1 01-06-21 08:13:00 97.8 O 01-06-21 16:59:00 98 O ***01-07-21 05:35:15 102.9*** 01-07-21 08:15:00 98.5

Allergies:

Symptoms: loss of consciousness; respiratory distress Narrative: Patient tolerated his 1st dose of the COVID-19 vaccine well, on 12/16/2020, and received his 2nd dose on 1/6/2021. Patient had some mild clinical decline the past few days prior to 2nd vaccination, with a decreased appetite and some increased fatigue per nursing report, but no significant changes. He experienced nausea on the evening of 1/6/21, which was effectively managed, but by early morning he spiked a fever of 102.9 with a sat of 86.1%. He continued to deteriorate from that point on and died 1/7/21 @13:20. Clinically, the presentation was most consistent with an aspiration pneumonia.

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0933578
Sex: M
Age: 43
State: NY

Vax Date: 01/08/2021
Onset Date:
Rec V Date: 01/11/2021

Lab Data:

Allergies: NKA

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

Other Meds: metform, atorvastin

Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese

Died: Y

Date Died: 01/10/2021

ID: 0933739
Sex: F
Age: 54
State: OH

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/11/2021

Lab Data: COVID-19 test administered - 1/9/2021 - Negative 2 EEGs were performed on 1/9/2021 and both indicated she had not brain activity

Allergies: Penicillin

Symptoms: Staff member checked on her at 3am and patient stated that she felt like she couldn't breathe. 911 was called and taken to the hospital. While in the ambulance, patient coded. Patient was given CPR and "brought back". Once at the hospital, patient was placed on a ventilator and efforts were made to contact the guardian for end of life decisions. Two EEGs were given to determine that patient had no brain activity. Guardian, made the decision to end all life saving measures. Patient was taken off the ventilator on 1/9/2021 and passed away at 1:30am on 1/10/2021. The initial indication from the ICU doctor was the patient had a mucus plug that she couldn't clear.

Other Meds: Aspirin, Diazepam, Doxepin HCL, Duloxetine, Juven POW, Lamotri Levothyroxin, Loratadine, Melatonin, Mucus Relief, Olanzapine, Prazosin HCL, Pregabalin,

Current Illness: Recent g-tube placement, Several hospitalizations over the pas few months due to low Oxygen Levels.

Died: Y

Date Died: 01/04/2021

ID: 0933846
Sex: F
Age: 91
State: WV

Vax Date: 01/02/2021
Onset Date: 01/02/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies: NKDA

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

Other Meds: NONE

Current Illness: MACULAR DEGENERATION 10 YEARS OR MORE

Died: Y

Date Died: 01/08/2021

ID: 0934050
Sex: M
Age: 68
State: KS

Vax Date: 01/07/2021
Onset Date: 01/08/2021
Rec V Date: 01/11/2021

Lab Data: None

Allergies: Allergies: NKDA

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

Other Meds: Patient was a resident in Group Home Current Medications Treatments/PRN Medications: Start Date: 04/02/14: Benztropine 2mg tab BID (8-8) 02/27/15: Midodrine (Proamatine) 5mg tab TID (8-12-8) 12/30/15: Cetirizine 10mg tab daily @8am 1

Current Illness: No Acute Illnesses

Died: Y

Date Died: 01/10/2021

ID: 0934059
Sex: F
Age:
State: IA

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies: anastrozole

Symptoms: Acute anterior MI with death

Other Meds: tramadol, calcium, Tylenol, lisinopril, Mucinex, MVI, namenda

Current Illness: Had Covid 19 infection in November recovered, had spinal stenosis with leg weakness chronic

Died: Y

Date Died: 01/02/2021

ID: 0934263
Sex: M
Age: 92
State: NM

Vax Date: 12/30/2020
Onset Date: 01/01/2021
Rec V Date: 01/11/2021

Lab Data: Again, I cannot confirm the results of any test, i.e., COVID or other, because the patient is independent and sought care independent of the center.

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/10/2021

ID: 0934373
Sex: F
Age: 82
State: WV

Vax Date: 01/09/2021
Onset Date: 01/10/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies: PCN & Sulfa drugs

Symptoms: Patient went to bed around 11pm on Saturday PM and sometime between then and 1:30am on Sunday morning got up and went into the living room without waking up her husband (which is normal). At 1:30am, the husband got up to use the restroom and she was out of bed then, but the husband did not know if she was having any problems at this time. When he got up at 7:45am, she was in the recliner and did not move or anything, which is normal for her. At 8:45am, the husband went back into the living room and tried to wake his wife and that is when he noticed there was no pulse and he called 9-1-1 at this time. EMS got on scene and did CPR for 30 mins and she was pronounced dead at 9:21am.

Other Meds: Husband only knew that she took several medications.

Current Illness: Newly diagnosed heart murmur the week prior by PCP. Was referred to her cardiologist.

Died: Y

Date Died: 01/05/2021

ID: 0934507
Sex: F
Age: 89
State: MA

Vax Date: 01/03/2021
Onset Date: 01/05/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies: KNDA KNFA

Symptoms: Resident died suddenly and expectantly on 01/05/2021

Other Meds: Coumadin 2mg po Sat-Mon-Tues-Thurs Coumadin 1mg po Fri Sun APAP 650 mg po PRN pain or temp above 101 Amiodarone 200mg po daily Ativan 0.5mg po PRN anxiety Claritin 10mg po daily Gabapentin 100mg po BID PRN phantom pain Miralax 17Gm po with

Current Illness: No other illness prior to vaccination or within the month prior

Died: Y

Date Died: 01/09/2021

ID: 0934539
Sex: F
Age: 68
State: KY

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/11/2021

Lab Data: Postmortem examination was performed at the State Medical Examiner Office on January 10, 2021 (MEC21-0019). Tissue samples were obtained for histology and red top/tiger top/purple top tubes of blood were obtained for potential further studies. Samples of blood and vitreous humor were also obtained and submitted to AXIS Laboratories for toxicologic analysis.

Allergies: No known allergies

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

Other Meds: Singulair, Oxybutynin, Fosamax, Prednisone, Meloxicam, Eliquis, Bumetanide, Triamcinolone cream, Klor-Con, Lisinopril, Promethazine,

Current Illness: Cellulitis of left lower limb (12/2020)

Died: Y

Date Died: 01/12/2021

ID: 0934745
Sex: F
Age: 79
State: IA

Vax Date: 01/09/2021
Onset Date: 01/10/2021
Rec V Date: 01/11/2021

Lab Data: Family requested comfort cares. No tests provided.

Allergies: NKA

Symptoms: Resident had seizure like activity followed by a vagel response with large bowel movement. Resident then began to show signs of blood clot to left lower extremity. No pedal pulse, area on leg warm to touch. Left lower leg now cold to touch, stiff, purple and white in color. No other signs of modeling, body warm to touch, no fever noted. Respirations and pulse increased with low oxygen levels. Resident not responding to stimuli.

Other Meds: Exelon 13.3 mg daily, APAP 500 mg three times a day, Namenda 10 mg two times a day, Senna 8.6 mg two tablets daily, Mirilax 27 grams two times a day, 2 cal 4oz three times a day, Amlodipine 5 mg daily

Current Illness: NA

Died: Y

Date Died: 01/04/2021

ID: 0934966
Sex: F
Age:
State: CA

Vax Date: 01/02/2021
Onset Date: 01/04/2021
Rec V Date: 01/11/2021

Lab Data: Test Date: 20201225; Test Name: COVID-19; Test Result: Negative ; Test Date: 20210104; Test Name: COVID-19; Test Result: Positive

Allergies:

Symptoms: COVID-19; COVID-19; Pneumonia; respiratory failure; This is a spontaneous report from a contactable consumer. An 80-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on 02Jan2021 for COVID-19 immunization. Medical history included Alzheimer's and others. No known allergies. Concomitant medications included unspecified medications. The reporter's mother in law was tested for COVID-19 at a nursing facility on 25Dec2020 and she was negative. On 02Jan2021, she received the first dose of Pfizer vaccine. On 04Jan2020, she developed a high fever, needed oxygen and was positive for COVID-19. Date of death was 04Jan2021. The cause of her death was listed as pneumonia, respiratory failure and COVID-19. No autopsy performed. No treatment received. No one knew if the vaccination contributed to her death. It was hard to know if her death was due to the administration of the vaccine or it exacerbated the COVID19 symptoms which led to her death. Since this was unknown, it could have been a possibility. The reporter wanted to give us this information because we might want to consider having high risk population, patients with underlying conditions, older population tested for COVID-19 prior to the vaccination, as this is not currently a recommendation or a requirement. All is very new and they are all learning so the reporter wanted to share this information with us. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. There are medications the patient received within 2 weeks of vaccination. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient has been tested for COVID-19. The outcome of the events was fatal. Information about Lot/Batch has been requested.; Sender's Comments: The association between the fatal event lack of effect (pneumonia, respiratory failure and COVID-19) with BNT162b2 can not be fully excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.; Reported Cause(s) of Death: Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19

Other Meds:

Current Illness:

Died: Y

Date Died: 01/06/2021

ID: 0934968
Sex: M
Age:
State: CA

Vax Date: 01/04/2021
Onset Date: 01/04/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies:

Symptoms: he passed away; not responsive; mind just seemed like it was racing; body was hyper dried; Restless; not feeling well; ate a bit but not much; kind of pale; Agitated; Vomiting; trouble in breathing; This is a spontaneous report from a contactable consumer (brother of the patient). A 54-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration, on 04Jan2021 (at the age of 54-years-old) as a single dose for COVID-19 immunization. Medical history included diabetes and high blood pressure. Concomitant medications included metformin (MANUFACTURER UNKNOWN) taken for diabetes, glimepiride (MANUFACTURER UNKNOWN) taken for diabetes, lisinopril (MANUFACTURER UNKNOWN), and amlodipine (MANUFACTURER UNKNOWN). The patient experienced not feeling well, ate a bit but not much, kind of pale, vomiting, trouble in breathing, and agitated on 04Jan2021; body was hyper dried and restless on 05Jan2021; mind just seemed like it was racing on 06Jan2021; and not responsive and he passed away on 06Jan2021 at 10:15 (reported as: around 10:15 AM). The clinical course was reported as follows: The patient received the vaccine on 04Jan2021, after which he started not feeling well. He went right home and went to bed. He woke up and ate a bit but not much and then was kind of pale. The patient then started to vomit, which continued throughout the night. He was having trouble in breathing. Emergency services were called, and they took his vitals and said that everything was okay, but he was very agitated; reported as not like this prior to the vaccine. The patient was taken to urgent care where they gave him an unspecified steroid shot and unspecified medication for vomiting. The patient was told he was probably having a reaction to the vaccine, but he was just dried up. The patient continued to vomit throughout the day and then he was very agitated again and would fall asleep for may be 15-20 minutes. When the patient woke up, he was very restless (reported as: his body was just amped up and could not calm down). The patient calmed down just a little bit in the evening. When the patient was awoken at 6:00 AM in the morning, he was still agitated. The patient stated that he couldn't breathe, and his mind was racing. The patient's other brother went to him and he was not responsive, and he passed away on 06Jan2021 around 10:15 AM. It was reported that none of the symptoms occurred until the patient received the vaccine. Therapeutic measures were taken as a result of vomiting as aforementioned. The clinical outcome of all of the events was unknown; not responsive was not recovered, the patient died on 06Jan2021. The cause of death was unknown (reported as: not known by reporter). An autopsy was not performed. The batch/lot number for the vaccine, BNT162B2, was not provided and has been requested during follow up.; Reported Cause(s) of Death: not responsive and he passed away

Other Meds: ; ; ;

Current Illness:

Died: Y

Date Died: 01/07/2021

ID: 0935222
Sex: M
Age: 73
State: FL

Vax Date: 12/30/2020
Onset Date: 01/07/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies: NKA

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

Other Meds: Oxybutynin Chloride, Lasix 80mg, hydyralazine 50mg, amlodipine 10mg, amitriptyline 10mg, ASA, Klor-Con 20meq, Tylenol, allopurinol 100mg, Vit D3, turmeric 400mg, Lipitor 80mg, gabapentin 100mg, baclofen 5mg, candesartan 32mg, insulin lispro

Current Illness: No acute illnesses

Died: Y

Date Died: 01/11/2021

ID: 0935343
Sex: F
Age: 89
State: KS

Vax Date: 01/08/2021
Onset Date: 01/11/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies:

Symptoms: There were no adverse reactions. Resident Died, she had a history of issues with her health prior to the vaccine.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/06/2021

ID: 0935350
Sex: M
Age: 81
State: TX

Vax Date: 12/31/2020
Onset Date: 01/02/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies: No known allergies

Symptoms: Patient was found unresponsive at home with SpO2 20% 1/2/2021

Other Meds: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me

Current Illness: Dyspnea, Shortness of breath

Died: Y

Date Died: 01/09/2021

ID: 0935511
Sex: F
Age: 56
State: SD

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/11/2021

Lab Data: unknown

Allergies: latex (skin reaction)

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

Other Meds: unknown

Current Illness: none known of

Died: Y

Date Died: 01/10/2021

ID: 0935767
Sex: F
Age: 85
State: CA

Vax Date: 01/07/2021
Onset Date: 01/10/2021
Rec V Date: 01/11/2021

Lab Data: She had tested NEGATIVE for Covid per Doc Win he told us on Sunday.

Allergies: IDK

Symptoms: My mother was given Pfizer vaccine on Thursday and she died 3 days later yesterday on Sunday!!!

Other Meds: IDK

Current Illness: Pneumomia

Died: Y

Date Died: 01/05/2021

ID: 0935815
Sex: M
Age: 63
State: CA

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies:

Symptoms: Difficulty breathing, death.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/05/2021

ID: 0936043
Sex: F
Age: 98
State: CA

Vax Date: 01/04/2021
Onset Date: 01/05/2021
Rec V Date: 01/11/2021

Lab Data:

Allergies: PENICILLINS

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

Other Meds: atorvastatin,senna,MultiVitamin,Metamucil,metformin,Levothyroxine

Current Illness: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia

Died: Y

Date Died: 01/09/2021

ID: 0936738
Sex: M
Age: 88
State:

Vax Date: 01/06/2021
Onset Date: 01/09/2021
Rec V Date: 01/12/2021

Lab Data: RSV, Bordetella Parapertussis, Bordetella Pertussis, Chlamydia pneumoniae, mycoplasma pneumoniae, Coronavirus, Adenovirus, Human metapneumovirus, human rhino/entero virus, influenza A/B, parainfluenza PCRs negative (NOT DETECTED) per 12/27/20 results COVID-19 PCR, Influenza A/B, and RSV PCRs negative (NOT DETECTED) per 1/4/21 results MRSA SURVL NARES DNA negative (NOT DETECTED) per 12/27/20, 12/28/20, & 1/5/21 results

Allergies:

Symptoms: loss of consciousness Narrative: Patient received COVID-19 vaccine dose #1 on 1/6/21 w/o complications. Per 1/6/21- 1/9/21 nursing notes, patient did not experience any injection site reactions, denied pain or tenderness at injection site, no dizziness, no n/v, remained afebrile. Around 1/9/21 @1810, patient became acutely nonresponsive after being helped to the edge of bed. Per nurses, he was previously awake/alert, talking and asymptomatic. Patient is DNR/DNI but facility rapid response emergency team called d/t patient's sudden change of condition. Emergency team helped patient into lying position. Per 1/9/21 ICU emergency team note, patient appeared comfortable w/ no palpable radial pulse and had minimal shallow agonal breathing. Pulse ox 94%, HR in 60s per machine. BP unmeasurably low by BP cuffx3. Resident passed at 18:20 pm.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/11/2021

ID: 0936805
Sex: M
Age: 25
State: KY

Vax Date: 12/22/2020
Onset Date: 01/11/2021
Rec V Date: 01/12/2021

Lab Data: None associated.

Allergies: Ceftriaxone

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

Other Meds: See Continuation Field

Current Illness: Whiplash injury to neck. Sprain of ligaments of cervical spine

Died: Y

Date Died: 01/04/2021

ID: 0937127
Sex: M
Age: 91
State: AR

Vax Date: 12/22/2020
Onset Date: 12/28/2020
Rec V Date: 01/12/2021

Lab Data:

Allergies: None

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

Other Meds: Mirtazapine, Fentanyl Patch,

Current Illness: Chronic pain

Died: Y

Date Died: 01/11/2021

ID: 0937152
Sex: F
Age: 91
State: AR

Vax Date: 12/22/2020
Onset Date: 12/24/2020
Rec V Date: 01/12/2021

Lab Data:

Allergies: None

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

Other Meds: Metoprolol, Cephalexin, Brimonidine, Donepezil, Losartan, Latanoprost, Timolol

Current Illness: High blood pressure, pain, eye issues

Died: Y

Date Died: 01/10/2021

ID: 0937186
Sex: F
Age: 87
State: AR

Vax Date: 12/22/2020
Onset Date: 12/24/2020
Rec V Date: 01/12/2021

Lab Data:

Allergies: None

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

Other Meds: Hydrocodone-Acetamenaphin, Lidocaine, Cefritriaxone, Citalopram

Current Illness: Chronic pain

Died: Y

Date Died: 01/12/2021

ID: 0937434
Sex: M
Age: 70
State: MT

Vax Date: 01/07/2021
Onset Date: 01/11/2021
Rec V Date: 01/12/2021

Lab Data:

Allergies:

Symptoms: Pt expired due to possible cardiac arrest. Unsure if this was vaccine related.

Other Meds:

Current Illness: None known

Died: Y

Date Died: 01/11/2021

ID: 0937444
Sex: F
Age: 86
State: IL

Vax Date: 01/11/2021
Onset Date: 01/11/2021
Rec V Date: 01/12/2021

Lab Data: The county coroner declared her death was related to a heart attack

Allergies:

Symptoms: Resident was found deceased at approximately 6pm in her apartment

Other Meds:

Current Illness: Brain bleed, sleep apnea, htn

Died: Y

Date Died: 01/04/2021

ID: 0937527
Sex: F
Age: 44
State: NH

Vax Date: 12/23/2020
Onset Date: 01/04/2021
Rec V Date: 01/12/2021

Lab Data: unknown, not reported

Allergies: unknown

Symptoms: unsure if related to vaccine, but was notified by her next of kin that she died on 1/4/2021. No reports of side effects or hospitalization were reported to the facility prior to the notification of death.

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/07/2021

ID: 0937569
Sex: M
Age: 62
State: RI

Vax Date: 01/02/2021
Onset Date: 01/07/2021
Rec V Date: 01/12/2021

Lab Data:

Allergies: unknown

Symptoms: patient reported expired 1/7/2021

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/03/2021

ID: 0937773
Sex: M
Age: 85
State: KS

Vax Date: 01/02/2021
Onset Date: 01/02/2021
Rec V Date: 01/12/2021

Lab Data:

Allergies: Baclofen, PCN, Ambien, Singulair

Symptoms: Patient was sent to the ED due to significant hematuria. He was afebrile.

Other Meds:

Current Illness: COVID-19 positive on 11/30/2020

Died: Y

Date Died: 01/09/2021

ID: 0937818
Sex: M
Age: 63
State: OH

Vax Date: 01/07/2021
Onset Date: 01/09/2021
Rec V Date: 01/12/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0938097
Sex: U
Age:
State:

Vax Date:
Onset Date:
Rec V Date: 01/12/2021

Lab Data:

Allergies:

Symptoms: died; This is a spontaneous report from a non-contactable consumer via a Pfizer-sponsored program. A patient of unspecified age and gender received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, via an unspecified route of administration on an unspecified date at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. It was reported the patient was a doctor, died after the vaccine with no apparent disease. It was not reported if an autopsy was performed. No follow-up attempts are possible. Information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Unknown cause of death

Other Meds:

Current Illness:

Died: Y

Date Died: 01/10/2021

ID: 0938118
Sex: F
Age: 51
State: MI

Vax Date: 01/05/2021
Onset Date: 01/08/2021
Rec V Date: 01/12/2021

Lab Data: CT brain head; CT cervical spine; chest xray; CT chest, abdomen, pelvis; abdominal xray; CT angiogram neck & brain

Allergies: latex

Symptoms: on 1/8/2021 17:30 patient taken to ER, cerebellar hemorrhage, stroke, aneurysm

Other Meds: multivitamin; vitamin D

Current Illness: none mentioned

Died: Y

Date Died: 01/11/2021

ID: 0938974
Sex: M
Age: 88
State: OH

Vax Date: 01/06/2021
Onset Date: 01/11/2021
Rec V Date: 01/12/2021

Lab Data: Labs contacted facility with critical lab, Hemoglobin 4.8, at 9:45am after resident passed

Allergies: NKDA

Symptoms: Hospice Resident received first Covid 19 vaccine dose on 1/6/21. 1/7/21 resident had decreased appetite noted in am but ate 100% of meal at dinner. 1/9/21 resident had decreased appetite with emesis x 2, loose BM x 2. Call placed to hospice. 1/10/21 5:44 am resident able to take HS meds, ingest 2 cups of shake. No emesis or loose stool noted. 12PM nurse noted resident not eating meals but ingesting milkshake and medications without any problems. Hospice contacted for change in condition. 1:00 pm hospice ordered Phenergan 12.5 mg Q 6 hrs PRN. Labs to be drawn 1/11/21. Hospice notified POA. 1/11/21 12:24am Resident had blood in stool. Resident denies any pain, on 2L of O2 for comfort.

Other Meds:

Current Illness: Hospice

Died: Y

Date Died: 01/04/2021

ID: 0939050
Sex: F
Age: 32
State: NY

Vax Date: 12/28/2020
Onset Date: 12/29/2020
Rec V Date: 01/12/2021

Lab Data:

Allergies: Unknown

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

Other Meds: Unknown

Current Illness: Unknown

Died: Y

Date Died: 12/31/2020

ID: 0939270
Sex: M
Age: 48
State: HI

Vax Date: 12/22/2020
Onset Date: 12/31/2020
Rec V Date: 01/12/2021

Lab Data:

Allergies:

Symptoms: Sudden cardiac death

Other Meds:

Current Illness:

Died: Y

Date Died: 01/08/2021

ID: 0963163
Sex: M
Age: 87
State:

Vax Date: 01/06/2021
Onset Date: 01/08/2021
Rec V Date: 01/12/2021

Lab Data:

Allergies:

Symptoms: Narrative:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/11/2021

ID: 0939845
Sex: M
Age: 88
State: IL

Vax Date: 01/11/2021
Onset Date: 01/11/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies:

Symptoms: Three hours after receiving COVID 19 vaccination, Patient oxygen level decreased to a critical level and went into cardiac arrest. Staff performed full code but was unable to bring back patient from cardiac arrest.

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0940602
Sex: M
Age: 83
State: TX

Vax Date: 01/08/2021
Onset Date: 01/10/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies: None

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

Other Meds: see attached

Current Illness: None reported

Died: Y

Date Died: 01/08/2021

ID: 0940822
Sex: M
Age:
State: GA

Vax Date: 01/07/2021
Onset Date: 01/08/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies:

Symptoms: patient passed away after receiving the Covid vaccine; This is a spontaneous report from a contactable nurse. An 81-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE), intramuscular into the right arm on 07Jan2021 at 0.3 mL, single for covid-19 immunization. There was no medical history and no concomitant medications. On 08Jan2021, the patient passed away after receiving the COVID vaccine. The patient died on 08Jan2021. An autopsy was not performed. Investigations indicate that unspecified labs were done, but nothing two weeks prior; no further details were provided. The patient received the first dose the day prior. The reporting nurse discussed it with the medical director, and he thought that he potentially passed away from the COVID vaccine. The relatedness of the event to the suspect vaccine was reported as related by the reporting nurse per The Agency. The batch/lot number for the vaccine, BNT162B2, was not provided and will be requested during follow-up .; Sender's Comments: Based on the limited information available, it is medically not possible to make meaningful causality assessment, it is unlikely the vaccine could have contributed to the death of the patient based on the known safety profile. However case will be reevaluated when additional information is received during the follow-up The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Stated that the patient passed away after receiving the Covid vaccine

Other Meds:

Current Illness:

Died: Y

Date Died: 01/12/2021

ID: 0940855
Sex: F
Age: 79
State: AR

Vax Date: 01/12/2021
Onset Date: 01/12/2021
Rec V Date: 01/13/2021

Lab Data: N/A

Allergies: None

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

Other Meds: LORazepam Solution 2 MG/ML

Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.

Died: Y

Date Died: 01/09/2021

ID: 0940866
Sex: M
Age: 75
State: SC

Vax Date: 01/07/2021
Onset Date: 01/09/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies: Loxapine, Thioridazine

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

Other Meds: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr

Current Illness: None

Died: Y

Date Died: 01/11/2021

ID: 0940955
Sex: F
Age:
State: NY

Vax Date: 01/11/2021
Onset Date: 01/11/2021
Rec V Date: 01/13/2021

Lab Data: Test Date: 20210111; Test Name: pulseless; Result Unstructured Data: Test Result:pulseless; Test Date: 20210111; Test Name: breathless; Result Unstructured Data: Test Result:breathless; Test Date: 20210106; Test Name: Covid-19 PCR; Result Unstructured Data: Test Result:Negative (Nasal Swab)

Allergies:

Symptoms: Cardiac Arrest; Patient was found pulseless and breathless 20 minutes following the vaccine administration.; Patient was found pulseless and breathless 20 minutes following the vaccine administration.; This is a spontaneous report from a contactable other healthcare professional (HCP). A 66-year-old female patient (pregnant at the time of vaccination: no) received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL1284) via intramuscular at left arm on 11Jan2021 12:15 PM at single dose for COVID-19 immunization. Medical history included diastolic CHF, spinal stenosis, morbid obesity, epilepsy, pulmonary hypertension and COVID-19 (Prior to vaccination, the patient was diagnosed with COVID-19). The patient received medication within 2 weeks of vaccination included amiodarone, melatonin, venlafaxine hydrochloride (EFFEXOR), ibuprofen, aripiprazole (ABILIFY), lisinopril, cranberry capsules, diltiazem, paracetamol (TYLENOL), famotidine, furosemide (LASIX [FUROSEMIDE]), ipratropium bromide, salbutamol sulfate (IPRATROPIUM/ALBUTEROL), buspirone, senna alexandrina leaf (SENNA [SENNA ALEXANDRINA LEAF]), polyethylene glycol 3350 and morphine. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. Patient used took Penicillin, propranolol, quetiapine, topiramate, Lamictal and had allergy to them. Patient used took the first dose of BNT162B2 (lot number: EJ1685) via intramuscular at right arm on 21Dec2020 12:00 PM at single dose for COVID-19 immunization. Since the vaccination, the patient been tested for COVID-19 (Sars-cov-2 PCR) via nasal swab on 06Jan2021, covid test result was negative. Patient was found pulseless and breathless 20 minutes following the vaccine administration (11Jan2021 12:30 AM). MD found no signs of anaphylaxis. Patient died on 11Jan2021 12:30 AM because of cardiac arrest. No treatment received for the events. Outcome of pulseless and breathless was unknown. the autopsy was performed, and autopsy remarks was unknown. Autopsy-determined cause of death was unknown. It was reported as non-serious, not results in death, Life threatening, caused/prolonged hospitalization, disabling/Incapacitating nor congenital anomaly/birth defect.; Sender's Comments: Based on the available information this patient had multiple underlying medical conditions including morbid obesity, diastolic CHF, epilepsy, pulmonary hypertension and COVID-19 diagnosed prior to vaccination. All these conditions more likely contributed to patients cardiac arrest resulting in death. However, based on a close temporal association ("Patient was found pulseless and breathless 20 minutes following the second dose of BNT162B2 vaccine administration, contributory role of BNT162B2 vaccine to the onset of reported events cannot be completely excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Cardiac arrest; Autopsy-determined Cause(s) of Death: autopsy remarks was unknown. Autopsy-determined cause of death was unknown

Other Meds: ; ; EFFEXOR; ; ABILIFY; ; CRANBERRY; ; TYLENOL; ; LASIX [FUROSEMIDE]; IPRATROPIUM/ALBUTEROL; ; SENNA [SENNA ALEXANDRINA LEAF]; POLYETHYLENE GLYCOL 3350;

Current Illness:

Died: Y

Date Died: 01/08/2021

ID: 0941215
Sex: F
Age:
State:

Vax Date: 01/06/2021
Onset Date: 01/08/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies:

Symptoms: Actual event and cause of death were unknown; This is a spontaneous report from a non-contactable consumer. A 90-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 06Jan2021 at single dose for COVID Prevention. The relevant medical history included aortic valve replacement from Nov2019. Concomitant medications were not reported. The consumer stated that she was taking the reporting responsibilities to report that a friend of hers, informed that the patient passed away on Friday, and had received the COVID vaccine on Wednesday. The consumer stated that it was unknown to her at this time, if the friend had called to complete a report herself, regarding the incident. Their conversation was very brief. The patient was 90 years old, and it was her friend's mother that was the patient. Actual event and cause of death were unknown. The patient had her vaccine on Wednesday 06Jan2021, and then the patient collapsed in front of the reporter at Friday night on 08Jan2021 and passed away that same day. The autopsy was unknown. The outcome of the event was fatal. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Actual event and cause of death were unknown

Other Meds:

Current Illness:

Died: Y

Date Died: 01/11/2021

ID: 0941561
Sex: M
Age: 91
State: MN

Vax Date: 01/07/2021
Onset Date: 01/08/2021
Rec V Date: 01/13/2021

Lab Data: Resident was declining for some time. He normally had a high heart rate. Appetite was poor with a significant weight loss noted.

Allergies: No known Allergies

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

Other Meds: Escitalopram Oxalate, Metformin ER, Systane balance, Colace, Refresh tears, Milk of Magnesia, Diltiazem

Current Illness: Resident was on hospice for Alzheimer's disease.

Died: Y

Date Died: 01/13/2021

ID: 0941607
Sex: F
Age: 83
State: IN

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/13/2021

Lab Data: N/A

Allergies: NKA

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

Other Meds: Tylenol 325mg, Lasix 20mg, Senna 8.6mg, Aspirin 81mg, Levothyroxine 75mcg

Current Illness: N/A

Died: Y

Date Died: 01/13/2021

ID: 0941743
Sex: F
Age: 60
State: NY

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/13/2021

Lab Data: None

Allergies: No known drug or food allergies

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

Other Meds: Amitiza, Anastrozole, Calcium Carbonate, Levemir, Novolog, Docusate, Fiber Lax, Fluvoxamine Maleate, Gavilax, Glucerna, Ketoconazole, levetiracetam, loratadine, Selenium sulfide lotion, vimpat, vitamin D3, Prolia AS needed medications: fle

Current Illness: None

Died: Y

Date Died:

ID: 0941811
Sex: F
Age: 56
State: LA

Vax Date: 01/04/2021
Onset Date: 01/11/2021
Rec V Date: 01/13/2021

Lab Data: CXR on 1/11/21: Suspicion of minimal infrahilar infiltrates bilaterally. U/A on 1/11/21: Leuk Esterase 3+, Albumin 2+, Few Bacteria, White cells 10 CBC on 1/11/21: WBC 8.9

Allergies: NKDA & NO FOOD ALLERGIES

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

Other Meds: Haldol 2mg TWICE DAILY, DEPAKENE 750MG THREE TIMES

Current Illness: NONE

Died: Y

Date Died: 01/13/2021

ID: 0942040
Sex: M
Age: 78
State: IA

Vax Date: 01/13/2021
Onset Date: 01/13/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies: unknown

Symptoms: little bit of a reaction light headed after 5 minutes. vitals were low, so observed for 30 minutes after being light headed. Patient was found unresponsive and pronounced dead later that day.

Other Meds: unknown

Current Illness: none

Died: Y

Date Died: 01/05/2021

ID: 0942072
Sex: F
Age: 87
State: VT

Vax Date: 01/02/2021
Onset Date: 01/05/2021
Rec V Date: 01/13/2021

Lab Data: COVID-19 PCR neg on 12/31/20 and 1/3/21

Allergies: No known allergies

Symptoms: Death occurred 3 days after vaccine receipt; attributed to complications of her chronic advanced dementia with aspiration at age 87. No evidence of acute vaccine reaction.

Other Meds: Tramadol, risperidone, fluoxetine, cyanocobalamin, colchicine, torsemide, levothyroxine

Current Illness: aspiration pneumonia- completed treatment prior to vaccination.

Died: Y

Date Died: 01/08/2021

ID: 0942085
Sex: F
Age: 62
State: KS

Vax Date: 01/02/2021
Onset Date: 01/08/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies: Amoxicillin, Clavulanic Acid, Codeine, Morphine, Pencillin

Symptoms: No adverse effects from vaccination seen on 1/2/21. On 1/6/21 resident was seen by Dr and her baclofen pump was refilled with 20 ml Baclofen 4,000mcg/ml. ITB Rate increased by 6% to 455.5 mcg/day simple continuous rate over 3 days. On 1/8/21 at 0615 resident was shaking, lower extremities mottled, Sa02 70%, pulse 45. Oxygen started at 2 L/m per NC. At 0715 her primary physician was notified as well as her daughter. Oxygen increased to 4 L/min, sats at 83%. SOA noted, reported all over pain. At 0850 when they attempted to reposition the resident, she was not responsive. Licensed nurse assessed her and no heartbeat heard or pulse found.

Other Meds: Ativen, Butrans Patch, Tylenol, Potassium Citrate-Citric Acid

Current Illness: Medical diagnosis: quadriplegia, Atherosclerotic heart disease

Died: Y

Date Died: 01/09/2021

ID: 0942106
Sex: M
Age: 54
State: CA

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/13/2021

Lab Data:

Allergies:

Symptoms: 54 y/o M with PMH of HTN, HLD, Alcoholic Cirrhosis, Aortic Valve Stenosis, and angina BIBA as a Medical Alert for cardiac arrest noted PTA. Per EMS, the patient called because he was having constant, diffuse abdominal pain x 1 day that radiated to his chest. On scene, the patient had a witnessed arrest with EMS starting CPR. He was given 3 rounds of epi without ROSC. Pt had no associated shockable rhythm. Of note, pt's wife, had noted pt had received covid vaccine the prior day.

Other Meds:

Current Illness:

Died: Y

Date Died: 12/21/2020

ID: 0942246
Sex: M
Age: 1
State: OR

Vax Date: 12/11/2020
Onset Date: 12/20/2020
Rec V Date: 01/13/2021

Lab Data: Initial cap glucose- Undetectable 12/21/2020 12/21/2020 16:29(pm) Glucose- 37 mg/dL 12/21/2020 16:36(pm) Glucose- 46 mg/dL 12/21/2021 16:50(pm) Glucose- 244 mg/dL

Allergies: NKMA

Symptoms: On 12/20/2020, dad of patient called our office after hours. Nurse triage line took the call. Dad's reported that pt had a fever of 100.6 F (max temp) and hard stools. Pt was given a dose of Tylenol and 10-15 minutes later, pt vomited. Triage nurse advised that dad follow up with PCP office when open in the AM. Dad called our office at 10:25am on 12/21/2020 stating that pt fever had lifted, but pt vomited a total of 5 times since the night before, with the last episode at 7:45 am on 12/21/2020. Pt had adequate fluid intake and urine output and stool had softened. MA advised continued home care. Appropriate triage advice was given and documented. At 16:43(pm) on 12/21/20, dad called back to clinic stating patient symptoms had worsened and they were at the emergency department. Dad disconnected call before speaking with the MA. The MA attempted to call dad back, but there was no answer. A message was left for dad to return call. On 12/22/20 at 12:44(pm), dad called in to clinic to report that pt had died- cause unknown. Our clinic obtained records from Hospital. The ED report stated that pt presented to the emergency department via EMS Code 3 in cardiac arrest. Unknown downtime prior to the initiation of chest compressions. Pt was staying with grandparents. When grandma went to wake pt from his nap, he was not responsive. When grandma tried to pick him up, there was possibly some brief, generalized seizure activity as well as coughing and gagging. Child remained unresponsive and was taken by private vehicle to outside Urgent Care where pt was found to be apneic and in asystole. An AED was applied, no shock advised. EMS was called and CPR was started. EMS placed an endotracheal tube and established IO access. 4 rounds of epinephrine were administered during the course of the prehospital resuscitation which was approximately 15-20 minutes. Presenting rhythm was asystole. No change in rhythm upon transport and arrival. Immediately upon arrival the pediatric transport team was activated and the pediatric intensivist was paged. Chest compressions were resumed according to protocol. Additional inter osseous access was established in the left proximal tibia. Fluid bolus was initiated. Serial doses of epinephrine were administered every 4 minutes throughout the resuscitation. The child also received several boluses of IV bicarb. Online consultation by ED physician with PICU attending was established early in the resuscitation course. It was agreed by ED physician and PICU attending that the peds transport team would be dispatched urgently to the ED location in anticipation of possible ROSC and need for emergent transport to PICU. It was agreed by ED physician and PICU attending that transportation would not be initiated with the child still undergoing resuscitation requiring chest compressions prior to ROSC. Initially, endotracheal tube position felt to be acceptable based on the clinical evaluation, however chest x-ray did demonstrate some degree of right mainstem intubation, after which the tube was pulled back approx 2cm and subsequent x-ray showed the ETT tip in good position approx 1 cm above the carina. Initial end-tidal CO2 was 14 on arrival, this continued to trend downward until undetectable throughout the course of the resuscitation. At no point were there palpable pulses or other evidence of return of circulation throughout the resuscitation. Capillary blood glucose was initially undetectable. The child received serial boluses of D 25 via IO line for a tital of 30 g dextrose after which CBG ultimately came up to 244. Multiple efforts were made throughout the resuscitation to achieve IV access and to obtain blood for laboratory studies. All efforts were unsuccessful, making it impossible to obtain any labs throughout the course of the resuscitation. Attempts to obtain even capillary blood samples via heel stick for CBG measurements were extremely difficult. Resuscitation continued for 49 minutes after ED arrival. A total of at least 65 minutes of CPR time. Bedside ultrasound was used to look for cardiac activity during the last 5 pulse checks of the resuscitation, demonstrating cardiac standstill. Despite the efforts and interventions mentioned, ROSC was never obtained and the code was discontinued at 17:03(pm). The child's parents were informed of his death upon their arrival to the ED at approximately 17:40(pm). Family was given time with the pt. The medical examiner arrived and discussed case at 19:11(pm). At 19:49(pm) Medical Examiner was interviewing grandparents along with 2 County Detectives. The medical examiner took custody of the pt at 21:52(pm). Evidence bag was sent with the medical examiner. Pt received vaccinations 10 days prior to death. We are still waiting for M.E. report, as we do not have any further information as to why pt passed.

Other Meds: Enfamil Gentlease Formula

Current Illness: No known illness.

Died: Y

Date Died: 01/11/2021

ID: 0942290
Sex: F
Age: 89
State: CA

Vax Date: 01/04/2021
Onset Date: 01/06/2021
Rec V Date: 01/13/2021

Lab Data: Resident has allergy to Influenza Virus Vaccines, pharmacists were informed of this prior to resident receiving the vaccine and both pharmacists stated that was not a risk factor.

Allergies: Dilaudid; Morphine Sulfate; Sulfonamides; Influenza Virus Vaccines

Symptoms: Resident received 1st dose on 1/4/2021. On 1/6/2021 resident having SOB, increased weakness with O2 sats at 91% RA. On 8th resident sustained a fall, O2 sats 88-92, dizzy, weakness. Rapid COVID test performed with negative results. Evening of 8th resident was lethargic and diaphoretic with fever of 99.9. Resident transferred to ER, on 5lt of oxygen. Resident returned from the ER on 1/9/2021 with new diagnosis of Leukemia and orders for hospice. Continued with fever, crackles and N/V and loss of appetite from the 9th and 10th of January. Resident expired at 820am on 1/11/2021.

Other Meds: Tylenol, tylenol with codeine, Artificial Tears, ASA, Cal-Mag-Zinc, Claritin, Sertraline, Melatonin, MOM, Latuda, Estradiol, Gabapentin, Alendronate, Atorvastatin, Multi-Vit

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0943266
Sex: F
Age: 88
State: AZ

Vax Date: 01/12/2021
Onset Date: 01/12/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies: Penicillin, Sulfa, Gluten

Symptoms: Initial pain in back of head and extreme headache. Some vomiting. At emergency, went into coma and was intubated. Hole drilled in skull to relieve pressure. MRI taken. Lot of bleeding in brain - anuerism lead to death approximately 14 hours after initial symptoms.

Other Meds: Losartan, Levothyroxine, Carvedilol

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0943362
Sex: F
Age: 73
State: MI

Vax Date: 01/13/2021
Onset Date: 01/13/2021
Rec V Date: 01/14/2021

Lab Data: currently undergoing preliminary autopsy

Allergies: none reported

Symptoms: Pt collapsed at home approx 5:30 pm and died

Other Meds: unknown none reported

Current Illness: none known

Died: Y

Date Died: 01/11/2021

ID: 0943397
Sex: M
Age: 28
State: NJ

Vax Date: 12/23/2020
Onset Date: 01/11/2021
Rec V Date: 01/14/2021

Lab Data: No labs or tests.

Allergies: Ceclor, Penicillin, Sulfa

Symptoms: On day due for 2nd dose, Patient was found unresponsive at work in the hospital. Patient pupils were fixed and dilated. Full ACLS was initiated for 55 minutes with multiple rounds of bicarb, calcium chloride, magnesium, and epinephrine. Patient was intubated. Patient continued into V. Fib arrest and was shocked multiple times.

Other Meds: None

Current Illness: None

Died: Y

Date Died:

ID: 0943442
Sex: M
Age: 68
State: GA

Vax Date: 12/30/2020
Onset Date: 12/31/2020
Rec V Date: 01/14/2021

Lab Data:

Allergies: nka

Symptoms: Systemic: reported by staff patient expired under suspicious circumstnces after receiving vaccine. Patient was on hospice, reported not expected to pass this soon; symptoms lasted 0 days

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0943889
Sex: M
Age: 75
State: VA

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies: No known allergies

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

Other Meds: Alvesco, Amiodarone, Lipitor, Atrovent, Coreg, Cymbalta, Guaifenesin, Keppra, Levothroid, Megace, Protonix, Potassium, Prednisone, Rifampin, Carafate, Bactrim, Flomax

Current Illness: Rigth femur fracture, GI bleed

Died: Y

Date Died: 01/09/2021

ID: 0944282
Sex: M
Age:
State: NY

Vax Date: 01/05/2021
Onset Date: 01/09/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies:

Symptoms: resident coded on 09Jan at 8am and expired; This is a spontaneous report from a contactable Other Health Professional. A 70-year-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Batch/lot number: EL0140), intramuscularly in left arm on 05Jan2021 15:15 at single dose for COVID-19 immunization. Medical history included DM2(Type two diabetes mellitus), CHF(congestive heart failure), open wound, wound infection, heart failure. Allergies to medications, food, or other products: none. Concomitant medications included unspecified products (List of any other medications the patient received within 2 weeks of vaccination: yes). If the patient received any other vaccines within 4 weeks prior to the COVID vaccine: Unknown. Facility where the most recent COVID-19 vaccine was administered: Nursing Home/Senior Living Facility. The resident coded on 09Jan2021 at 8 AM and expired. The patient died on 09Jan2021. An autopsy was not performed. AE resulted in: patient died. Death cause: unknown at this time. Was treatment received for the adverse event: Unknown. Prior to vaccination, was the patient diagnosed with COVID-19: No. Since the vaccination, has the patient been tested for COVID-19: No. Serious: Yes. Seriousness criteria-Results in death: Yes. Seriousness criteria-Life threatening: No. Seriousness criteria-Caused/prolonged hospitalization: No. Seriousness criteria-Disabling/Incapacitating: No. Seriousness criteria-Congenital anomaly/birth defect: No.; Sender's Comments: The old patient had diabetes mellitus, congestive heart failure, open wound complicated by infection, all these pre-existing medical conditions contribute to the patient death. More information including complete medical history, concomitant medications and event term details especially death cause and autopsy results are needed for a full assessment of the case. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate; Reported Cause(s) of Death: resident coded on 09Jan at 8am and expired

Other Meds:

Current Illness:

Died: Y

Date Died: 12/30/2020

ID: 0944365
Sex: M
Age: 76
State: KY

Vax Date: 12/26/2020
Onset Date: 12/30/2020
Rec V Date: 01/14/2021

Lab Data: N/A

Allergies: N/A

Symptoms: Resident expired on 12/30/20, dx cardiac arrest.

Other Meds: Diazepam, Levothyroxine, Magnesium Oxide, Olanzapine, Omeprazole, Sertraline, and Vitamin D3

Current Illness: None

Died: Y

Date Died: 01/03/2021

ID: 0944439
Sex: F
Age: 62
State: KY

Vax Date: 12/26/2020
Onset Date: 01/03/2021
Rec V Date: 01/14/2021

Lab Data: N/A

Allergies: N/A

Symptoms: Resident expired on 1/2/21.

Other Meds: Keppra, Levothyroxine, Miralax, Olanzapine, Trazadone, Risperidone, and Lorazepam

Current Illness: Receiving hospice services

Died: Y

Date Died: 01/14/2021

ID: 0944595
Sex: M
Age: 56
State: FL

Vax Date: 01/12/2021
Onset Date: 01/12/2021
Rec V Date: 01/14/2021

Lab Data: mulitple Full ER code and then ICU support for 2 days

Allergies: nkda

Symptoms: Cardiac arrest within 1 hour Patient had the second vaccine approximately 2 pm on Tuesday Jan 12th He works at the extended care community and was in good health that morning with no complaints. He waited 10-15 minutes at the vaccine admin site and then told them he felt fine and was ready to get back to work. He then was found unresponsive at 3 pm within an hour of the 2nd vaccine. EMS called immediately worked on him 30 minutes in field then 30 minutes at ER was able to put him on life support yet deemed Brain dead 1-14-21 and pronounced dead an hour or so later

Other Meds: losartan, spironolactone, carvedilol

Current Illness: No known new illnesses,

Died: Y

Date Died: 01/13/2021

ID: 0944641
Sex: F
Age: 83
State: FL

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/14/2021

Lab Data: NA

Allergies: Sulfa

Symptoms: Patient died on 1/21-2021

Other Meds: Atorvastatin 80mg daily, biotin 2500mg daily, Calcium-Mag-Zinc tab daily, Restasis eye drop q12hr, ezetimibe 10mg qhs, gabapentin 100mg bid, lysine 1000mg daily, metoprolol tart 50mg bid, fish oil 1000mg daily, prilosec 20mg daily, ranola

Current Illness: CAD, angina, coronary bypass in 1990's, Cardiac Cath on 12/28/2020

Died: Y

Date Died: 01/14/2021

ID: 0944732
Sex: M
Age: 92
State: WI

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/14/2021

Lab Data: None.

Allergies: hydrocodone

Symptoms: Resident found unresponsive and without pulse at 05:45am.

Other Meds: Cholecalciferol, furosemide, metoprolol tartrate, tamsulosin, amlodipine, finasteride

Current Illness: Covid-19 infection from 12/31-01/10/2021

Died: Y

Date Died: 01/12/2021

ID: 0944998
Sex: F
Age: 88
State: KY

Vax Date: 01/04/2021
Onset Date: 01/12/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies: Phenazopyridine, Demerol, Pyridium, Penicillins

Symptoms: On 1/11/21 noted with headache, nausea/vomiting, severe melaise. On 1/12/21 resident expired.

Other Meds: Resident in skilled nursing facility. Please contact facility if needing all medications.

Current Illness:

Died: Y

Date Died: 01/14/2021

ID: 0945241
Sex: F
Age: 71
State: MD

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies: UNK

Symptoms: 71yo female resident who died after receiving Pfizer BioNTech vaccine. On 1/14/2021, VS taken at 10am, B/P 99/60, O2 sats, 95% (trach w/O2). At 11:30am, Patient showed no s/sx of distress, A&Ox3. At 11:50am, a nurse went to perform a COVID test and assessment (the facility is experiencing an outbreak), and found the patient unresponsive on the bathroom floor. CPR was immediately started; no shock advised per AED; 12:15pm EMS arrived and took over. At 12:38pm, EMT called time of death.

Other Meds: UNK

Current Illness: UNK

Died: Y

Date Died: 01/13/2021

ID: 0945247
Sex: F
Age: 96
State: PA

Vax Date: 12/29/2020
Onset Date: 01/05/2021
Rec V Date: 01/14/2021

Lab Data: Urinalysis did show a UTI and CXR was negative for aspiration pneumonia. Family did not want her sent to the hospital. She died on 1/13/21

Allergies: aricept, namenda, penicillin, actonel, erythromycin, niacin

Symptoms: Has underlying dementia and often with difficulty eating. 1 week after immunization she developed a stroke with left sided weakness and difficulty swallowing. Comfort measures instituted. Not sure if this is related to the vaccine, but thought I should report

Other Meds: depakote, lexapro, lisinopril, multiple vitamin, senna, seroquel, tylenol

Current Illness: Nothing acute prior

Died: Y

Date Died: 01/14/2021

ID: 0945253
Sex: F
Age: 83
State: MD

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/14/2021

Lab Data: UNK

Allergies: UNK

Symptoms: 83yo female resident who died after receiving Pfizer BioNTech vaccine. On 1/14/2021, the patient reportedly got up in the middle of the night with c/o feeling "blah", restlessness, and nausea. VS normal, no other s/sx. At 4:15am, the patient was asked to go back to bed, assisted by a nurse and GNA. At 6am, GNA was going to do morning VS and found the patient unresponsive, no pulse, no respirations. GNA notified the nurse. At 6:03am, CPR started and EMS called. At 6:15am, EMS arrived and took over. At or around 6:30am, EMT called time of death

Other Meds: UNK

Current Illness: UNK

Died: Y

Date Died: 01/11/2021

ID: 0945578
Sex: F
Age: 72
State: KS

Vax Date: 01/02/2021
Onset Date: 01/10/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies: NKA

Symptoms: No reactions immediately after vaccine was given. Resident has dementia, has had multiple hospitalizations related to a renal stone recently. Had a tooth that was bothering her, went to see her dentist and it was extracted on 1/6/21. On 1/10 they noted feet and ankles are dark purple with white splotches appears to be mottling. Minimally responsive to voice and touch. Not eating. Compassionate visit with family. Family did not want hospice, did not feel it was needed, said, what more could they do for her than you're already doing? On 1/11 at 1950 was determined to be deceased.

Other Meds: Aspirin 81 mg, metformin, namenda, effexor XR, donepezil, potassium chloride, Vitamin B12, Brillinta, clonzepam, flomax, ultram, oxybutynin chloride, sucralfate, ferrous sulfate, protonix, percocent, metoprolol succinate ER, senna Colace, n

Current Illness: Had a tooth extraction done on 1/6/21. Was on amoxicillin for 7 days and it caused diarrhea. Changed to Keflex.

Died: Y

Date Died: 01/08/2021

ID: 0945603
Sex: M
Age: 94
State: KS

Vax Date: 01/02/2021
Onset Date: 01/08/2021
Rec V Date: 01/14/2021

Lab Data: 1/5/21 BMP drawn

Allergies: NKA

Symptoms: Had no immediate issues with the vaccine. He had returned from the hospital on 12/21 and had some concerns about his weight which were shared with his physician on 1/4/21. On 1/5/21 had a visit with his cardiologist for a pacemaker check. On 1/8/21 staff were called to his room, he was on the floor, bluish skin color. No vital signs found, no heart rhythm heard at 2200.

Other Meds: Verapamil ER, Pepcid, Norco, Vit D3, synthroid, flecainide Ace acetate, mucinex, lisinpril, amitriptyline, eliquis, atorvastatin, furosemide, acetaminophen, Coenzyme Q-10, metoprolol succinate ER

Current Illness: Hospitalized for abnormal heart rhythm 12/18/20.

Died: Y

Date Died: 01/14/2021

ID: 0945642
Sex: M
Age: 43
State: CA

Vax Date: 12/20/2020
Onset Date: 01/14/2021
Rec V Date: 01/14/2021

Lab Data: n/a

Allergies: n/a

Symptoms: COVID-19 mRNA/Pfizer-BioNTech vaccine After 1st dose- arm soreness, nausea, sleepiness and headache for 24 hours After 2nd does- fever 101.0 oral, chills, headache for hours

Other Meds: vitamin c 1000mg, tylenol 1000mg, motrin 400 mg

Current Illness: n/a

Died: Y

Date Died: 01/04/2021

ID: 0963167
Sex: M
Age: 88
State: DE

Vax Date: 01/02/2021
Onset Date: 01/04/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies:

Symptoms: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE

Other Meds:

Current Illness:

Died: Y

Date Died: 01/05/2021

ID: 0967754
Sex: F
Age: 66
State:

Vax Date: 12/21/2020
Onset Date: 01/05/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies:

Symptoms: Death - unknown cause, no reported side effects Narrative: Unknown cause of death

Other Meds:

Current Illness:

Died: Y

Date Died: 01/07/2021

ID: 1349711
Sex: M
Age: 77
State: TN

Vax Date: 12/22/2020
Onset Date: 01/07/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies:

Symptoms: Symptoms: & cardiopulmonary arrest Treatment: EPINEPHRINE 8 MG Unknown during code

Other Meds:

Current Illness:

Died: Y

Date Died: 01/08/2021

ID: 1349910
Sex: M
Age: 85
State: KS

Vax Date: 01/07/2021
Onset Date: 01/07/2021
Rec V Date: 01/14/2021

Lab Data:

Allergies:

Symptoms: Symptoms: & Death

Other Meds:

Current Illness:

Died: Y

Date Died: 01/15/2021

ID: 0946225
Sex: F
Age: 70
State: PA

Vax Date: 01/14/2021
Onset Date: 01/14/2021
Rec V Date: 01/15/2021

Lab Data: No testes were done at the facility. Unsure what was performed in the ER.

Allergies: Lithium

Symptoms: At approximately 10:30pm on 1/14/2021, resident was noted to have a rash on her face, hands, arms, and chest. VS:100.2, 113, 20,108/59, 84% room air. applied nasal cannula at 4-L, telephoned Physician orders 6mg Decadron one time order, a second set of Vitals , reads 99.3, 110, 20, 106/60, 90% on 4-L N/C. On coming shift advised. At approximately 2:00am on 1/15/2021, resident congested and coughing. BP 151/70, pulse 124, temp 98.1 forehead, resp 20 and pulse oc 79% on 3L. At approximately 2:30am PRN cough syrup and breathing tx. Resident's condition began to worsen with breathing tx. This LPN updated at 0248 doctor on resident's condition. Doctor gave permission for resident to go to hospital. At 4:19am the Er called to say resident passed away.

Other Meds: CloZAPine 550 mg QD, Clozaril 150 mg QD, Ergocalciferol Capsule 1.25 MG (50000 UT) QD, MiraLax Powder 17 gram QD, Multivitamin QD, Remeron 45 MG QD, Sertraline HCl 200 mg QD, Simvastatin 20 MG QD, Synthroid Tablet 75 MCG QD, Tricor 14

Current Illness:

Died: Y

Date Died: 01/12/2021

ID: 0946293
Sex: M
Age: 51
State: VA

Vax Date: 01/07/2021
Onset Date: 01/07/2021
Rec V Date: 01/15/2021

Lab Data:

Allergies: none

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

Other Meds: Alvesco inh, Mepron susp, Coreg, Zetia, Tricor, Umeclidinum, Cellcept, Zyprexa, Prilosec, paxil, Miralax, prednisone, trazodone, xopenex inh

Current Illness: Pulmonary fibrosis on O2

Died: Y

Date Died: 01/15/2021

ID: 0946959
Sex: M
Age: 83
State: NC

Vax Date: 01/14/2021
Onset Date: 01/15/2021
Rec V Date: 01/15/2021

Lab Data: Unsure, autopsy pending

Allergies: None

Symptoms: Sudden death 18 hours post vaccine .

Other Meds:

Current Illness: Post COVID-19 complications, A-fib, CHF

Died: Y

Date Died: 10/10/2020

ID: 0946972
Sex: M
Age: 93
State: MI

Vax Date: 10/08/2020
Onset Date: 10/09/2020
Rec V Date: 01/15/2021

Lab Data: none

Allergies: Mirtazapine, Myrbetriq, Penicillin

Symptoms: Patient received first dose of Shingrix and annual flu vaccine on 10/8/20. Patient's home care therapist called on 10/9/20 that patient developed nausea, vomiting, sweating, and cough after receiving the vaccines. Called patient later that day for follow-up and his wife reported he was feeling better, but was not planning to get the second dose of Shingrix in the future. Did not receive further communication regarding the patient, until on 12/24/20 spoke to patient's wife who reports the patient expired on 10/10/20. He went to bed the evening of 10/9/20, she woke up at 1:30AM on 10/10/20 and heard the patient take two deep breaths and then he stopped breathing. She called the funeral home who had her call the police and the medical examiner was notified.

Other Meds: Fluoxetine, Allopurinol, Omeprazole, Nadolol, Furosemide, Finasteride, Ramipril, Atorvastatin, Hydralazine, Metformin, Tamsulosin

Current Illness: None

Died: Y

Date Died: 01/01/2021

ID: 0947129
Sex: F
Age: 101
State: GA

Vax Date: 12/23/2020
Onset Date: 12/25/2020
Rec V Date: 01/15/2021

Lab Data:

Allergies: None known

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

Other Meds: Aspirin, Digoxin, Diltiazem CR, Namenda CR, Toprol XL, Acetaminophen, Vitamin D, Zyrtec

Current Illness: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis

Died: Y

Date Died: 01/09/2021

ID: 0947642
Sex: M
Age:
State: PA

Vax Date: 01/07/2021
Onset Date: 01/08/2021
Rec V Date: 01/15/2021

Lab Data:

Allergies:

Symptoms: died two days after receiving the vaccine; Fever; This is a spontaneous report from a contactable consumer (patient's stepchild). A 66-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, on 07Jan2021 (at the age of 66-years-old) as a single dose for COVID-19 immunization. The patient's medical history was not reported. Concomitant medications included an unspecified statin. The patient experienced fever on 08Jan2021. The patient died two days after receiving the vaccine on 09Jan2021, which was reported as fatal. The clinical course was reported as follows: The patient had a fever the day after getting the vaccine and then he just died in the middle of night. It was reported that it was not clear what exactly happened, but they are looking into this. The clinical outcome of fever was unknown and of died two days after receiving the vaccine was fatal. The patient died on 09Jan2021. The cause of death was not reported. An autopsy was not performed (was reported to be taking place soon). The batch/lot number for the vaccine, BNT162B2, was not provided and has been requested during follow up.; Reported Cause(s) of Death: died two days after receiving the vaccine

Other Meds:

Current Illness:

Died: Y

Date Died: 01/06/2021

ID: 0947662
Sex: M
Age: 84
State: MN

Vax Date: 12/30/2020
Onset Date: 01/01/2021
Rec V Date: 01/15/2021

Lab Data: None completed- Resident was determined to be at end of life

Allergies: Lisinopril

Symptoms: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death

Other Meds: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am

Current Illness: no acute illnesses

Died: Y

Date Died: 01/14/2021

ID: 0947841
Sex: M
Age: 83
State: MI

Vax Date: 01/14/2021
Onset Date: 01/14/2021
Rec V Date: 01/15/2021

Lab Data: unknown.

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0947891
Sex: M
Age: 93
State: WI

Vax Date: 12/29/2020
Onset Date: 01/08/2021
Rec V Date: 01/15/2021

Lab Data:

Allergies: None

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

Other Meds: Lantus, Benzapril, Metoprolol, Fluticasone, Aspirin, Tylenol, Miralax, Multiple Vitamin, Glipizide, Gabapentin, Vitamin D

Current Illness: Diabetes, Dementia, Hypercholesterolemia, Malignant Neoplasm of Pancreas, Hypertensive Chronic Kidney Disease, Athlerosclerotic Heart Disease

Died: Y

Date Died: 01/12/2021

ID: 0948150
Sex: M
Age: 85
State: OH

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/15/2021

Lab Data:

Allergies: ibuprofen,sulfa antibiotics

Symptoms: increase weakness and fatigue, weakness in extremities, incontinent, jerky arm movements, within first 24 hours, continue to decline sent to hospital returned weaker, within 24 hrs hours BP dropped, low pulse oximeter reading, diaphoretic, lung sounds diminished, loss consciousness and passed away. 01-12-2021

Other Meds: MANTOUX; ACIDOPHILUS; ALPHA LIPOIC ACID; ASPIRIN EC; BUMETANIDE; C-GEL; ESCITALOPRAM; PROSCAR; KRILL OIL; LEVOTHYROXINE; MAGOX; K-DUR; FLOMAX; VITAMIN B-12; VITAMIN D3; LIORESAL; CALCIUM CITRATE; COCONUT OIL; CURCUMIN; PROAMATINE; PRESERVIS

Current Illness: pneumonia,

Died: Y

Date Died: 01/15/2021

ID: 0948164
Sex: M
Age: 77
State: MI

Vax Date: 01/06/2021
Onset Date: 01/08/2021
Rec V Date: 01/15/2021

Lab Data: CT- 1/14/21, chest x-ray 1/14/21 & 1/15/21, abdomen CT 1/14/21; CBC, CMP, Liver panel 1/14/21

Allergies:

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

Other Meds: Multivitamin, Zinc, Doxycycline, Ultram, Xanax, Pepcid, Nitroglycerin, Tylenol, Simethicone, Metoprolol Succinate ER, Loperamide, Levothyroxine,

Current Illness: UTI and Sinus infection

Died: Y

Date Died:

ID: 0948181
Sex: M
Age:
State: MI

Vax Date:
Onset Date:
Rec V Date: 01/15/2021

Lab Data:

Allergies: 0

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

Other Meds: ANORA, Albuterol, Flovent, Bumex, Carvediol; omeprazole

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0948228
Sex: M
Age: 78
State: FL

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/15/2021

Lab Data:

Allergies:

Symptoms: Patient reportedly expired the day following receipt of the vaccine.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/12/2021

ID: 0948418
Sex: F
Age: 37
State: CO

Vax Date: 01/07/2021
Onset Date: 01/12/2021
Rec V Date: 01/15/2021

Lab Data: Autopsy pending;

Allergies: No known

Symptoms: Expired on 1/12/2021; unknown cause of death

Other Meds: Unknown

Current Illness: Received 1st Covid vaccine 12/18/2020; 2nd 1/7/2021. This patient is now deceased 1/12/2021.

Died: Y

Date Died:

ID: 0948428
Sex: F
Age: 82
State: LA

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/15/2021

Lab Data:

Allergies: unknown

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

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/14/2021

ID: 0949474
Sex: M
Age: 79
State: CA

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/15/2021

Lab Data: None

Allergies: NKA

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

Other Meds: Melatonin 3mg PO QHS Amlopidine Besylate 5mg PO QD Atorvastin Calcium 20mg PO QHS Carbidopa-Levodopa 25-100mg PO TID Multiple Vitamin 1 PO QD Senna 8.6mg PO BID Calcium-Vitamin D 600mg PO BID Metformin HCl 500mg PO BID Rivastigmine patch 9

Current Illness: None but he has History of COVID-19 previously when initially admitted to the facility.

Died: Y

Date Died: 01/15/2021

ID: 0949523
Sex: F
Age: 61
State: CA

Vax Date: 01/13/2021
Onset Date: 01/15/2021
Rec V Date: 01/15/2021

Lab Data: N/A

Allergies: NKA

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

Other Meds: Ascorbic Acid Tablet 500 MG GT QD Multi-Vite Liquid (Multiple Vitamins-Minerals) 15 ml GT QD Famotidine Tablet 20 MG GT BID Memantine HCl Tablet 10 MG GT BID Polyethylene Glycol 3350 Kit 7gm GT QD Senna Tablet 8.6 MG (Sennosides) 2 tablets

Current Illness: None

Died: Y

Date Died: 01/08/2021

ID: 0949630
Sex: F
Age: 98
State: HI

Vax Date: 01/02/2021
Onset Date: 01/03/2021
Rec V Date: 01/15/2021

Lab Data: None as she was under hospice care

Allergies: Simvastatin

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

Other Meds: Senna-S, cranberry pills

Current Illness: Redness to left foot about 1 week prior to vaccination that resolved a few days prior

Died: Y

Date Died: 01/13/2021

ID: 0949657
Sex: M
Age: 89
State: DC

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/15/2021

Lab Data:

Allergies: none

Symptoms: Veteran was found by family slumped over and unresponsive at the breakfast table on 1/13/21, had expired

Other Meds: Xarelto ,topical lidocaine patch

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0949965
Sex: F
Age: 101
State:

Vax Date: 01/11/2021
Onset Date: 01/13/2021
Rec V Date: 01/16/2021

Lab Data: No cause of death found on labs/cxr including cultures (blood and urine) that are now growth to date and viral respiratory pcr that was negative.

Allergies:

Symptoms: Patient 101 years old, nursing home resident, received vaccine 1/11, on 1/13 found on floor without obvious trauma, unresponsive. Brought to ED and was bradycardic, hypotensive, hypothermic and refractory to aggressive medical management. No obvious cause of death found on exam or labs, cxr. Unknown if event could be related to vaccine or not. Medical Examiner accepted case although initially unknown that patient had recently received vaccine. ME updated with that information today as soon as discovered.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/15/2021

ID: 0950057
Sex: F
Age: 49
State: AL

Vax Date: 01/15/2021
Onset Date: 01/15/2021
Rec V Date: 01/16/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0950073
Sex: M
Age: 63
State: WI

Vax Date: 01/15/2021
Onset Date: 01/15/2021
Rec V Date: 01/16/2021

Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21

Allergies: Lisinopril, Losartan

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

Other Meds: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril

Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity

Died: Y

Date Died: 01/15/2021

ID: 0950108
Sex: F
Age: 53
State: KY

Vax Date: 01/05/2021
Onset Date: 01/12/2021
Rec V Date: 01/16/2021

Lab Data: Unknown

Allergies: Unknown

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

Other Meds: Unknown

Current Illness: Pt. stated she was not ill at the time of vaccination.

Died: Y

Date Died: 01/15/2021

ID: 0950441
Sex: M
Age: 66
State: CA

Vax Date: 01/15/2021
Onset Date: 01/15/2021
Rec V Date: 01/16/2021

Lab Data: 1/15/2021 CBC WITH AUTO DIFF - Abnormal Result Value WBC 8.8 RBC 5.1 Hgb 15.7 Hematocrit 49.5 MCV 97.1 (*) MCH 30.8 MCHC 31.7 (*) Red Cell Distribution Width 14.3 Platelets 173 Mean Platelet Volume 11.4 COMPREHENSIVE METABOLIC PANEL - Abnormal Glucose 167 (*) Blood Urea Nitrogen 14 Creat, Serum 1.2 Sodium 134 (*) Potassium 3.1 (*) Chloride 93 (*) CO2 25 Anion Gap 16 (*) Calcium 9.9 Total Bilirubin 1.0 Alkaline Phosphatase 126 AST 62 ALT (SGPT) 41 Total Protein 6.7 Albumin 3.6 Globulin, Total 3.1 A/G Ratio 1.16 BUN/Creatinine Ratio 11.67 Corrected Calcium 10.2 eGFR >60.00 Narrative: Specimen slightly hemolyzed, K, AST & ALK may be affected. MAGNESIUM - Abnormal Magnesium 2.4 (*) Narrative: Specimen slightly hemolyzed, Mg may be affected. DIFFERENTIAL, MANUAL - Abnormal Total Counted 100 Nucleated Red Blood Cell 1.0 Neutrophils Relative 45 Band Neutrophils Relative 0 Lymphocytes Relative 46 Monocytes Relative 5 Eosinophils Relative 1 Basophils Relative 1 Immature Granulocytes Relative 2 Neutrophils Absolute 4.0 Lymphocytes Absolute 4.0 (*) Monocytes Absolute 0.4 Eosinophils Absolute 0.1 Basophils Absolute 0.1 Toxic Granulation Present Platelet Estimate Normal

Allergies: Walnuts

Symptoms: Pt had witnessed arrest by wife. Pt wife started CPR and called EMS. CPR started at 15:12. Continued by EMS. Pt arrived to medical center asystole with CRP in progress and ventilated via igel device. He was in refractory ventricular fibrillation and continued CPR for a total of 1 hour. At that point, we checked a bedside ultrasound which showed his heart at a standstill. He was unresponsive to verbal and tactile stimulus and had fixed unreactive pupils. He was pronounced at 16:13.

Other Meds: Hydrochlorothiazide Toprol XL spironolactone prasugrel furosemide Vit D3 albuterol inhaler sildenafil aspirin 81mg Crestor nitroglycerin SL singulair testosterone gel levothyroxine

Current Illness: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris

Died: Y

Date Died: 01/07/2021

ID: 0950893
Sex: F
Age: 90
State: PA

Vax Date: 01/03/2021
Onset Date: 01/07/2021
Rec V Date: 01/16/2021

Lab Data: None

Allergies: Shellfish, other

Symptoms: Death

Other Meds: Ask the nursing home,

Current Illness: Diabetes dementia, cll, trigeminal neuralgia

Died: Y

Date Died: 01/13/2021

ID: 0967747
Sex: M
Age: 72
State:

Vax Date: 01/13/2021
Onset Date: 01/13/2021
Rec V Date: 01/16/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0967749
Sex: M
Age: 82
State:

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/16/2021

Lab Data: Jan 11, 2021@15:111 NASOPHARYNX COVID-19 MONT (VELA): DETECTED Jan 11, 2021@10:51 PLASMA BNP: 403 H pg/mL 0 - 100

Allergies:

Symptoms: Cardiac Arrest Narrative:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/15/2021

ID: 0950935
Sex: F
Age: 97
State: CA

Vax Date: 01/12/2021
Onset Date: 01/15/2021
Rec V Date: 01/17/2021

Lab Data:

Allergies:

Symptoms: Resident expired

Other Meds:

Current Illness:

Died: Y

Date Died: 01/14/2021

ID: 0950979
Sex: M
Age: 81
State: MI

Vax Date: 01/14/2021
Onset Date: 01/14/2021
Rec V Date: 01/17/2021

Lab Data:

Allergies: Lisinopril

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

Other Meds: allopurinol -Zyoprim 3000 mg amlodipine Norvasc 5 mg Lispro 100/unit /ml ups us to 150 unit daily per insulin scale Levemir U-100 - 100/unit/ml - (3ML) 55 units nightly Levothryoxine -Synthroid - 137 mcg - daily Simvastatin 25 mg - d

Current Illness:

Died: Y

Date Died: 01/05/2021

ID: 0951101
Sex: M
Age: 90
State: CO

Vax Date: 12/31/2020
Onset Date: 01/03/2021
Rec V Date: 01/17/2021

Lab Data: CREATININE = 4.73 AST= 410 ALT= 579 WBC= 25.95 TROPONIN = 0.174 CT SCAN OF HEAD PER THE RADIOLOGIST = ACUTE LEFT PCA DISTRIBUTION INFARCT. NO HEMORRHAGICE CONVERSION. NO MIDLINE SHIFT. BASILAR CISTERNS ARE PATENT. CT OF CHEST= NEGATIVE

Allergies: tramadol

Symptoms: PATIENT GOT HER FIRST COVID PFIZER VACCINE AT 12/31 IN THE AM. HAD GOTTEN FLU LIKE SYMPTOMS AND HAD BEEN SICK FOR A COUPLE OF DAYS. HAD NAUSEA AND VOMITTING DURING THIS TIME AS WELL. ON 1/3 THE CARE GIVER WENT TO CHECK ON HER PT AT HER LTC FACILITY WHERE SHE LIVES AND SHE WASN'T ACTING RIGHT. SHE WAS UNABLE TO DO A STROKE EXAM. PT HAD NO MOVEMNET IN ARMS OR LEGS AND WAS UNABLE TO SPEAK. PT WAS VITALLY STABLE AT THE TIME. EMS RECORDED THAT THEY THOUGHT DIAGNOSIS WOULD BE STROKE, PNEUMONIA OR SEPSIS. AFTER ARRIVAL AT THE HOSPITIAL DETERMED THAT SHE HAD A STORKE, ACUTE KIDNEY INJURY, ABNORMAL LFTS.

Other Meds: metoprolol tartrate, furosemide

Current Illness:

Died: Y

Date Died: 01/17/2021

ID: 0951678
Sex: M
Age: 75
State: CA

Vax Date: 01/13/2021
Onset Date: 01/17/1921
Rec V Date: 01/17/2021

Lab Data: Heart attack death medical test

Allergies: None

Symptoms: Heart attack death medical test

Other Meds: Crestor 20 mg, Claritin-D 24 hour, Zaria 10 mg, baby aspirin, replatha,valsart hits 160-12.5mg Fish oil, wheat germ oil, D3 1000 mg, testosterone 8% gel, CO Q 10, weirder prime , eye drops

Current Illness: None

Died: Y

Date Died: 01/17/2021

ID: 0951688
Sex: M
Age: 63
State: AR

Vax Date: 01/02/2021
Onset Date: 01/17/2021
Rec V Date: 01/17/2021

Lab Data: na

Allergies: No Known Allergies

Symptoms: Resident expired 1/17/21

Other Meds: Diclofenac Sodium Gel 1 %, Atorvastatin Calcium Tablet 40 MG, Acetaminophen Tablet 325 MG, Melatonin Tablet 3 MG, Vitamin D3 Tablet 25 MCG, Iron Tablet 325, Multivital-M Tablet, Eliquis Tablet 5 MG, metFORMIN HCl Tablet 500 MG, NIFEdipine

Current Illness: 11/25/20 Lower mid back abscess 11/4/20 toenail removal

Died: Y

Date Died:

ID: 0955091
Sex: M
Age: 65
State: NV

Vax Date: 11/16/2020
Onset Date: 11/16/2020
Rec V Date: 01/17/2021

Lab Data:

Allergies:

Symptoms: Pt rec'd flu vaccine (lot # 2202: UJ535AB) at a pharmacy on 11/16/2020. The next day he developed right hemifacial spasm and palatal myoclonus. 11/17/2020 BRAIN MRI showed a small left frontal non-enhancing lesion, initially thought to possibly be a subacute stroke. However, he worsened and developed anarthria, aphagia, right arm wkns, and aspiration pneumonia necessitating intubation. Repeat BRAIN MRI 11/24/2020 was worse. He had the 1st of 2 brain biopsies 11/28/2020, which pathology was resulted as "reactive changes" but was non-diagnostic. He had add'l BRAIN MRIs that showed continued worsening of the left hemisphere lesion and subsequent involvement of the right hemisphere. A 2nd brain brain biopsy was done 12/16/2020, which pathology was also resulted as "reactive changes" but was also non-diagnostic. The pt has a h/o "low-grade" T-cell lymphoma, but neither biopsy samples had evidence of lymphoma in CNS or of obvious features to suggest other neoplasm, vasculitis, granulomatous disease, infection, or demyelination. This is a very odd / challenging case. Initially despite the timing I did not consider the flu vaccine to be relevant / causative. However, there is no other obvious possible etiology. Hence I would consider the flu vaccine probably related to his CNS problem and a serious adverse reaction. He eventually started having seizures. He remains in a coma on life support. His family is going to withdraw care 1/8/2020.

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0955256
Sex: M
Age: 88
State: FL

Vax Date: 01/16/2021
Onset Date: 01/16/2021
Rec V Date: 01/17/2021

Lab Data:

Allergies: None Listed

Symptoms: Patient was vaccinated in right arm. Within 5 to 10 seconds after vaccination, patient started clinching his hands tightly and became unresponsive. Patient was lowered to the floor and did not exhibit a pulse. CPR was initiated and 911 was called. An AED was used and healthcare professionals onsite continued compressions until the paramedics arrived.

Other Meds: None listed

Current Illness: None Listed

Died: Y

Date Died: 12/01/2020

ID: 0952204
Sex: M
Age: 75
State: FL

Vax Date: 12/30/2020
Onset Date: 12/30/2020
Rec V Date: 01/18/2021

Lab Data: A full autopsy was done but results are pending.

Allergies: None

Symptoms: Patient became sick 3 hours after the vaccine and was found deceased 1 day after his vaccination. He passed away in his sleep.

Other Meds: Amoxicillin 500mg

Current Illness: None: Clean bill of health and a full cardiac exam was performed 2 months prior.

Died: Y

Date Died: 01/17/2021

ID: 0952228
Sex: F
Age: 87
State: KS

Vax Date: 01/06/2021
Onset Date: 01/17/2021
Rec V Date: 01/18/2021

Lab Data:

Allergies: Unknown

Symptoms: No known symptoms

Other Meds: Omeprazole, Levothyroxine, Amlodipine, Ezetimibe, Dicyclomine, triamcinolone

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0952704
Sex: M
Age: 79
State: OK

Vax Date: 01/14/2021
Onset Date: 01/14/2021
Rec V Date: 01/18/2021

Lab Data: Covid 19 : negative and pt lungs clear, all else unknown to reporter -- Daughter

Allergies: N/A

Symptoms: Daughter call in for VAERS report to file for father whom committed suicide 1/16/2021 in the AM after reportable ae of COVID 19 vaccine administered 1/14/2021. Patient sought care twice at ER; first visit by ambulance around 5PM and Friday 1/15/2021 Medical Center: Emergency Room. 1st Discharge summary diagnosis: adverse reaction to COVID shot; 2nd Discharge summary diagnosis: adverse reaction to COVID shot, fever, Panic Disorder-- ER. Medical Center Discharge summary diagnosis: Adverse reaction to the vaccine, acute anxiety. Reportable patient symptoms at, 1st visit : fever, shaking stomach cramps, breathing issues. Medical Center -- No fever, confusion and dementia type, patient would not stay in patient bed; patient would get up and sit down again repeatedly, agitated and anxious. Attempted to urinated hospital bed. Patient committed suicide in home.

Other Meds: Daughter does not know all medications to list at time of reporting

Current Illness: Pneumonia 12/20 not Covid19 related

Died: Y

Date Died: 01/16/2021

ID: 0952713
Sex: M
Age: 64
State: MO

Vax Date: 12/30/2020
Onset Date: 01/12/2021
Rec V Date: 01/18/2021

Lab Data: PCR and antigen test

Allergies: PCN, Zithromax, Flomax

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/17/2021

ID: 0952799
Sex: M
Age: 79
State: PA

Vax Date: 01/05/2021
Onset Date: 01/17/2021
Rec V Date: 01/18/2021

Lab Data:

Allergies:

Symptoms: On 1/17/2021 at 4:35 am resident found apneic and pulseless, at 4:40am death confirmed

Other Meds:

Current Illness:

Died: Y

Date Died: 01/15/2021

ID: 0952881
Sex: M
Age: 89
State: MO

Vax Date: 01/10/2021
Onset Date: 01/11/2021
Rec V Date: 01/18/2021

Lab Data: RBC 3.72; HGB 9.8; HCT 32.7; MCH 26.3; MCHC 30; RDW 15.2; Neut # 7.18; Lymph # 0.97; NA 135; K 5.0; CL 97; CO2 34; BUN 11; CRT 0.76; ALB 1.9; ALT/SGPT 6; GFR >60; BNP 415

Allergies: No known allergies

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

Other Meds: Lasix, Timolol Maleate, Benefiber, Pravastatin, Multivitamin, Carbidopa ER 50-Levodopa 200 daily; Carbidopa ER 50-Levodopa 200 2 tabs daily, I-vite, Lactobacillus; Metoprolol Succinate; Tamsulosin, Finasteride, Oxubytynin

Current Illness: Edema, Hypokalemia, Hypertensive heart with heart failure

Died: Y

Date Died: 01/18/2021

ID: 0953129
Sex: F
Age: 74
State: KY

Vax Date: 01/09/2021
Onset Date: 01/18/2021
Rec V Date: 01/18/2021

Lab Data: none

Allergies: none

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

Other Meds: unknown

Current Illness: none known

Died: Y

Date Died: 01/14/2021

ID: 0953183
Sex: M
Age: 83
State: PA

Vax Date: 01/05/2021
Onset Date: 01/11/2021
Rec V Date: 01/18/2021

Lab Data:

Allergies:

Symptoms: 1/11/21 at 8:57 Resident with fever and at 11 am saturation down to 83 O2 to 10 liters. Resident continued to decline until CTB on 1/14/2021 at 1325

Other Meds:

Current Illness:

Died: Y

Date Died: 01/14/2021

ID: 0953348
Sex: M
Age: 81
State: AR

Vax Date: 12/22/2020
Onset Date: 12/24/2020
Rec V Date: 01/18/2021

Lab Data:

Allergies: None

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

Other Meds: Atorvastatin, Ibuprofen, Oxybutinin, Morphine Sulfate

Current Illness:

Died: Y

Date Died: 01/11/2021

ID: 0953590
Sex: M
Age:
State: NY

Vax Date: 01/05/2021
Onset Date: 01/11/2021
Rec V Date: 01/18/2021

Lab Data: Test Date: 20210109; Test Name: Nasal Swab; Test Result: Negative

Allergies:

Symptoms: resident expired; This is a spontaneous report from a contactable healthcare professional. An 82-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE; Lot number: EL0140), intramuscular in the left arm on 05Jan2021 15:00 at a single dose for COVID-19 immunization. Medical history included metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia. Known allergies was none. The patient took unspecified concomitant medication. On 11Jan2021, the resident expired. The patient underwent lab tests and procedures which included nasal swab: negative on 09Jan2021. There was no treatment given for the event. The patient died on 11Jan2021. An autopsy was not performed.; Sender's Comments: Lacking information on the cause of patient's demise, the Company cannot completely exclude a causal relationship between COVID 19 vaccine, BNT162B2, and patient's death of unknown cause, as a cautionary measure and for reporting purposes. The patient's pre-existing medical condition of metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia may have provided the contribution to the event in this 82-year-old male patient. The impacts of this report on the benefit/risk profile of the product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: resident expired

Other Meds:

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0953754
Sex: F
Age: 74
State: NJ

Vax Date: 01/06/2021
Onset Date: 01/13/2021
Rec V Date: 01/18/2021

Lab Data:

Allergies: no known allergies

Symptoms: patient suddenly developed pneumonia 7 days after vaccination and died the evening of developing pneumonia

Other Meds: not provided by facility

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0953785
Sex: F
Age: 73
State: FL

Vax Date: 01/07/2021
Onset Date: 01/16/2021
Rec V Date: 01/18/2021

Lab Data: Autopsy pending

Allergies: Egg (anaphylaxis) Chicken

Symptoms: Death

Other Meds: No scheduled medications Tylenol and Zyrtec as needed

Current Illness: None

Died: Y

Date Died: 01/13/2021

ID: 0953858
Sex: F
Age: 76
State: TN

Vax Date: 01/08/2021
Onset Date: 01/13/2021
Rec V Date: 01/18/2021

Lab Data: general decline starting 1/10/2021 - patient deceased 1/13/2021

Allergies: nka

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

Other Meds: Seroquel, ibandronate, atenolol, Lexapro, simvastatin, acetaminophen, estradiol, famotidine, calcium citrate, antacid, donepezil, ferrous sulfate, Probiotic Pearls Complete, memantine, Antifungal cream, potassium chloride, Creon, bisacodyl

Current Illness: COVID-19, ARDS, enterocolitis, Sepsis, UTI, Acute renal failure

Died: Y

Date Died: 01/17/2021

ID: 0953865
Sex: M
Age: 99
State: RI

Vax Date: 01/14/2021
Onset Date: 01/17/2021
Rec V Date: 01/18/2021

Lab Data: RAPID COVID-19 TEST ON 1/17 NEGATIVE NO OTHER TESTS

Allergies: NKA

Symptoms: REPORTING ONLY AS RESIDENT EXPIRED ON 1/17/2021 3 DAYS AFTER. S/S HYPOXIA/CONGESTED LUNG SOUNDS

Other Meds: FINASTERIDE 5MG QD, FAMOTIDINE 20 MG DAILY, FOLIC ACID 400 MCG QD, SENNA 8.6 DAILY

Current Illness: NONE

Died: Y

Date Died: 12/31/2020

ID: 0953922
Sex: M
Age: 72
State: MA

Vax Date: 12/26/2020
Onset Date: 12/27/2020
Rec V Date: 01/18/2021

Lab Data:

Allergies: NKDA

Symptoms: The day following the vaccine, the patient complained of throat issues and anxiety. This was not new... however . That evening he reported difficulty breathing and was placed on oxygen; a COVID test was performed and was negative. On 12/30/2020, patient complained of sternal pressure and was transferred to the hospital. The patient died 12/31/2020 and records obtained from the hospital indicated the patient died from a massive myocardial infarction.

Other Meds:

Current Illness: Diabetes, COPD, Chrone's Disease, DJD, OSA, PTSD, GERD, HLD, Depression, HTN, lobectomy 3/4/2019, cancer

Died: Y

Date Died: 01/17/2021

ID: 0954251
Sex: F
Age: 71
State:

Vax Date: 01/08/2021
Onset Date: 01/12/2021
Rec V Date: 01/18/2021

Lab Data:

Allergies:

Symptoms: 71 year old woman at rehabilitation center for physical therapy with history of cirrhosis of the liver, asthma, and heart condition was tested for COVID-19 on 01/07/21, received 1st dose of Pfizer COVID-19 vaccine on 01/08/21, positive test result for COVID-19 received on 01/09/21. She was sent to the hospital and admitted on 01/12/21 after O2 was 70% and was in a confused state. Patient passed away on 01/17/21.

Other Meds:

Current Illness: Cirrhosis of the liver, asthma, heart condition

Died: Y

Date Died: 01/13/2021

ID: 0954780
Sex: M
Age: 82
State: MI

Vax Date: 01/05/2021
Onset Date: 01/13/2021
Rec V Date: 01/19/2021

Lab Data: None.

Allergies: Shellfish/Seafood

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

Other Meds: Norvasc 10mg daily Multivitamin daily Vitamin C 500mg twice daily Folic Acid 1mg daily Aspirin 81mg daily Thiamine 100mg daily Coreg 6.25mg twice daily Ativan 0.5mg three time daily Cymbalta 30mg daily ProStat 30ml three time daily D

Current Illness: None

Died: Y

Date Died: 01/16/2021

ID: 0954812
Sex: F
Age: 86
State: NY

Vax Date: 01/15/2021
Onset Date: 01/16/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies: NKDA

Symptoms: She had the first dose of Pfizer vaccine at the Campus on Friday 1/15 at 4:30 pm. After the vaccine, she had no new symptoms or signs of vaccine reaction and MD friend reports that he checked her pulse which was not elevated from baseline. On 1/16, she awakened and continued to feel at her recent baseline. However, in the early afternoon, she complained of headache, nausea/epigastric pain, and chest heaviness. These apparently were not unusual symptoms for her to feel intermittently. Per her niece, who has a home O2 sat device, her 02 sat that morning was 97 with a HR of 87 irregularly irregular. She was afebrile. (continue on page 2)

Other Meds: apixaban, levothyroxine, prednisone, diltiazem, (cont page 2)

Current Illness: Unknown

Died: Y

Date Died: 01/19/2021

ID: 0955261
Sex: F
Age: 85
State: MD

Vax Date: 01/18/2021
Onset Date: 01/19/2021
Rec V Date: 01/19/2021

Lab Data: None

Allergies: darvocet, toradol

Symptoms: Death

Other Meds: Nystatin, vitamin C, Klor Con, Vit B12, Coreg, Lactulose, simethicone, colace, trazodone, multi vitamin, torsemide, miralax, calcium, pantoprazole, breo ellipta,

Current Illness: Hip fracture,

Died: Y

Date Died: 01/16/2021

ID: 0955390
Sex: F
Age: 95
State: AL

Vax Date: 01/15/2021
Onset Date: 01/16/2021
Rec V Date: 01/19/2021

Lab Data: unknown

Allergies: unknown

Symptoms: Resident received vaccination on January 15, 2021. She was found unresponsive with shallow respirations on the morning of January 16, 2021 and was sent to ER via ambulance. The resident was admitted to medical center ICU where she passed away later that day.

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/16/2021

ID: 0955425
Sex: M
Age: 90
State: MN

Vax Date: 01/05/2021
Onset Date: 01/15/2021
Rec V Date: 01/19/2021

Lab Data: none

Allergies: PCN

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

Other Meds: amlodipine, aricept, bactrim, namenda, remeron

Current Illness: pressure ulcer

Died: Y

Date Died: 01/17/2021

ID: 0955426
Sex: U
Age: 96
State: IL

Vax Date: 01/16/2021
Onset Date: 01/17/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies: NItrofuratin, HCTZ

Symptoms: 1120: Drooling, Rt side facial drooping, BP: 60/30; 911 contacted; became unresponsive on toliet; shallow deep breathing; transferred to Wheelchair; EMS arrived and transferred to ED; In hospital cause of death listed Cardiac Pulmonary Arrest; Date of death 1/17/21

Other Meds: n/a

Current Illness: no

Died: Y

Date Died: 01/05/2021

ID: 0955436
Sex: M
Age: 84
State:

Vax Date: 12/29/2020
Onset Date: 01/05/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies: none

Symptoms: patient received vaccine 12/29. Unexpected death 1/5.

Other Meds: aspirin atorvastatin bumetanide carvedilol vit d 3 miralax tamsulosin tylenol keppra lisinopril mirtazapine pantoprazole senna

Current Illness: CAD s/p CABG, prior ischemic HFpEF (EF 45% > 50%), mild-mod Mitral Stenosis, bradycardia s/p PPM, HTN, HLD, DMII (A1C 6.5), CKD (baseline Cr 2-2.5), GERD, BPH, seizure disorder (on keppra)

Died: Y

Date Died: 01/13/2021

ID: 0955532
Sex: F
Age: 51
State: NJ

Vax Date: 01/12/2021
Onset Date:
Rec V Date: 01/19/2021

Lab Data: N/A

Allergies: NKA

Symptoms: COVID 19 Vaccination administered by pharmacy staff. No adverse effect at the present time. Staff will continue to observe adverse reaction. Will continue to monitor. Patient at start of shift awake in the bed. Pt at 3am was on the commode leaned to the side. Patient body still warm to touch no pulse. Called for assistance Asap. Cpr started promptly. Cpr given patient on floor 911 arrived at the scene at 3:10am Cpr rotated Between Nursing and EMT on Scene. Cpr was given to patient for over 45 minutes. Patient was pronounced at the scene at 3:50am. Call placed to Pt family by supervisor on shift. MD to be notified. AT 3:00am, I was notified by the nurse that resident is unresponsive. Upon entering room, resident was sitting on the commode unresponsive with absent respiration and pulse. Resident lowered down on the floor with 4 person assist. CPR initiated, AED pads placed on chest with no shock indicated. 911 called and EMT and paramedics arrived around 3:10am. ACLS performed until code stopped and pronounced death at 3:48am. I called and notified family member of his demise and awaiting for family to call us back for funeral arrangements.

Other Meds: Lantus SoloStar; Atorvastatin Calcium; Gabapentin; Potassium Chloride ER; Levothyroxine Sodium; Alogliptin Benzoate; Acetaminophen; Milk of Magnesia; Enema Rectal; Bisacodyl Rectal Suppository; Tramadol HCl; Ceftriaxone Sodium; Santyl Exter

Current Illness: Cellulitis of RLE, S/P wound debridement

Died: Y

Date Died: 01/15/2021

ID: 0955597
Sex: M
Age: 50
State: NE

Vax Date: 01/13/2021
Onset Date: 01/15/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies: Contrast media

Symptoms: Death

Other Meds: Levothyroxine Calcium Acetate Albuterol Clonidine Hydralazine Ropinirole Aspirin Ergocalciferol Metoprolol Ondansetron Rifaximin Hydroxyzine Mutlivitamins Buspirone Pantoprazole Oxycodone Atorvastatin

Current Illness:

Died: Y

Date Died:

ID: 0955879
Sex: U
Age:
State: OH

Vax Date: 12/22/2020
Onset Date:
Rec V Date: 01/19/2021

Lab Data:

Allergies:

Symptoms: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar death events for 8 patients. This report is for 5th of 8 patients. A patient of unspecified age and gender received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on 22Dec2020 at single dose for COVID-19 immunisation. The patient medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. The patient died on an unspecified date. It was unknown if an autopsy was performed. Information on the lot/batch number has been requested.; Sender's Comments: The limited information provided in this report does not allow a full assessment of the case. The event death with unknown cause is assessed as related to the suspect drug per company guidance. This case will be reassessed when additional information, particularly the clinical course before death, complete medical history and concomitant medication and autopsy report, becomes available.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: expired before receiving the second dose

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0955880
Sex: U
Age:
State: OH

Vax Date: 12/22/2020
Onset Date:
Rec V Date: 01/19/2021

Lab Data:

Allergies:

Symptoms: passed unexpectedly; This is a spontaneous report from a contactable nurse communicated to a Pfizer colleague. This nurse reported similar death events for 8 patients. This report is for 8th of 8 patients. A patient of unspecified age and gender received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on 22Dec2020 at single dose for COVID-19 immunisation. The patient medical history and concomitant medications were not reported. The patient passed unexpectedly on an unspecified date. The patient died on an unspecified date. It was unknown if an autopsy was performed. Information on the lot/batch number has been requested.; Sender's Comments: The limited information provided in this report does not allow a full assessment of the case. The event death with unknown cause is assessed as related to the suspect drug per company guidance. This case will be reassessed when additional information, particularly the clinical course before death, complete medical history and concomitant medication and autopsy report, becomes available. The case will be reassessed if additional information becomes available. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: passed unexpectedly

Other Meds:

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0955959
Sex: M
Age: 82
State: NM

Vax Date: 01/11/2021
Onset Date: 01/18/2021
Rec V Date: 01/19/2021

Lab Data: None

Allergies: none

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

Other Meds: alfuzosin, allopurinol. amlodipine, aspirin, Sinemet, vitamin D, multivitamin, Lexapro, finasteride, mirtazipine, ropinirole, trospium

Current Illness: recently diagnosed with progressive supranuclear palsy

Died: Y

Date Died: 01/12/2021

ID: 0956211
Sex: M
Age: 91
State: KY

Vax Date: 01/09/2021
Onset Date: 01/10/2021
Rec V Date: 01/19/2021

Lab Data: Ct scan of abdomen, was COVID negative

Allergies: NKDA

Symptoms: patient passed away on 1/12 at 1800 from a ruptured colonic mass.

Other Meds: amiodarone (PACERONE) 100 mg Tablet ferrous gluconate (FERGON) 324 mg (38 mg iron) Tablet furosemide (LASIX) 20 mg tablet lidocaine (XYLOCAINE) 2 % Solution Melatonin 1 mg Tablet nystatin (MYCOSTATIN) 100,000 unit/mL suspension

Current Illness: known colonic mass, presumed malignant but no biopsy diagnosis.

Died: Y

Date Died:

ID: 0956225
Sex: M
Age: 82
State: CA

Vax Date: 01/16/2021
Onset Date: 01/16/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies: No known allergies

Symptoms: Systemic: Pt monitored by nursing for 30min after inj,pt was stable/no reaction.At ~1hr post inj pt was unresponsive.Pt was a hospice/dnr per director

Other Meds:

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0956365
Sex: F
Age: 81
State: CA

Vax Date: 12/21/2020
Onset Date: 01/04/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies:

Symptoms: 12/28/2020: generalized weakness and fell twice at home, cough, nausea,1/04/2021: cough, nausea, fever and chronic pain when she fell from being weak. admitted to hospital with Covid pneumonia, shortness of breath, covid postive, 1/09/2021: pt on bipap, 1/15/2021: pt was intubated, on TPN, pt DNR, 1/18/2021: was extubated and put on comfort measures and passed away

Other Meds:

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0956458
Sex: M
Age: 60
State: MA

Vax Date: 01/06/2021
Onset Date: 01/14/2021
Rec V Date: 01/19/2021

Lab Data: Tests of 1/15/2021 included CBC, BMP and LFTs - abnormal results noted in narrative of question 18.

Allergies: Nnone

Symptoms: Patient was vaccinated for SARS-CoV-2 on 6-Jan-21 at his site of employment, a Nursing Home. Patient presented to Urgent Care on 15-Jan-21 complaining of left sided chest pain that started the evening before with an associated slight cough. Pt was afebrile with a heart rate of 88 and an O2 sat on room air of 98% in triage. His EKG showed a sinus tachycardia of 114 with a slightly prolonged QTc of 463 ms. Physical exam was significant for bibasilar crackles and X-ray showed bibasilar infiltrates consistent with COVID pneumonia but bacterial pneumonia could not be excluded. The patients BP was documented as 97/64. He was treated with Zofran for nausea and tylenol. He was prescribed a five day course of Azithromycin, an Albuterol inhaler, guaifenessin with codeine cough syrup, and Zofran. Labs were drawn and he was discharged. His lab results were reported after his departure and were significant for a white blood cell count of 1.33, platelet count of 73, 2% myelocytes, 1% metamyelocytes, an absolute neutrophil count of 0.75 K/ul, a creatinine of 1.83, total bilirubin of 1.3, with direct bilirubin of 0.8, alkaline phosphatase of 294 and AST of 112 with ALT noted to be within normal limit. His COVID nasopharyngeal swab from the visit was reported as negative and a swab performed at his employment on 13-Jan-21 was also reported to be negative. Patient could not be reached by phone after discharge from Urgent Care about these labs. On the evening of 16-Jan-21, Police Department received a 911 call about an adult at the patient's address who was found unresponsive. Upon arrival on scene, the patient was found to be deceased and a decision was made not to attempt to resuscitate. The death was deemed to be non-suspicious and the patient's body was transported to a funeral home. On 19-Jan-21, I contacted the State Medical Examiner's Office. They have decided to perform an autopsy and have recovered the CBC and chemistry specimens obtained for further testing.

Other Meds: Amlodipine, Lipitor, Lisinopril

Current Illness: None

Died: Y

Date Died: 01/15/2021

ID: 0956761
Sex: M
Age: 94
State: NJ

Vax Date: 01/13/2021
Onset Date: 01/15/2021
Rec V Date: 01/19/2021

Lab Data: none

Allergies: none

Symptoms: Family was told that Patient expired in his sleep during the early morning hours of 1/15. I spoke with him the evening before (on 1/14), which was a day after he had received the Covid vaccine. He was not having any symptoms of allergy or reaction then. He did say that he felt tired, but he often complained of feeling tired over time.

Other Meds: Eliquis, losartan, torsemide, metolazone, carvedilol, docusate

Current Illness: episode of congestive heart failure two months ago requiring hospitalization

Died: Y

Date Died: 01/18/2021

ID: 0956811
Sex: M
Age: 75
State: NJ

Vax Date: 01/18/2021
Onset Date: 01/18/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies:

Symptoms: Resident was noted unresponsive, no respiration, no blood pressure, no pulse, code blue called according to facility protocol, resident is full code, CPR started, 911 called, arrived and took over from staff. Resident was pronounced dead at 1:16pm 1/18/21

Other Meds:

Current Illness:

Died: Y

Date Died: 01/19/2021

ID: 0956843
Sex: M
Age: 71
State: IA

Vax Date: 01/17/2021
Onset Date: 01/19/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies: NKA

Symptoms: Resident was found deceased in his bed at 7:15 am.

Other Meds: Tylenol 500 Mg 2 tabs Bid; Allopurinol 100 Mg Daily; Atorvastatin 40 Mg Hs; Bumetanide 4 Mg Bid; Bupropn 150 Mg Daily; Carvedilol 3.125 Mg Bid; Cinacalcet 30 Mg Daily; Eplerenone 25 Mg Bid; Fluoxetine 40 Mg Daily; Mirtazapine 7.5 Mg Hs; Pan

Current Illness: No illnesses at time of vaccination or up to one month prior

Died: Y

Date Died: 01/19/2021

ID: 0956962
Sex: M
Age: 74
State: NY

Vax Date: 01/06/2021
Onset Date: 01/19/2021
Rec V Date: 01/19/2021

Lab Data: none

Allergies: NKDA

Symptoms: COVID 19 vaccine, unknown which company Chronically ill in a skilled nursing facility found diaphoretic, hypotensive, hypoxia to 85% arrived to Emergency dept in cardiac arrest Died within 65 minutes of nursing finding patient in distress Wife felt it may have been related to vaccine date of vaccination 1/6/20 hx covid 19 PNA in April 2020

Other Meds: Unavail

Current Illness: CVA seizure disorder all chronic HTN CAD had COVID 19 in April 2020

Died: Y

Date Died: 01/19/2021

ID: 0956994
Sex: M
Age: 73
State: CA

Vax Date: 01/15/2021
Onset Date: 01/15/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies: Aspirin, penicillin, vicodin, acetaminophen, niacin

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

Other Meds: Cholecalciferol, duloxetine, fenofibrate, gabapentin, hydrocortisone suppository, melatonin, metformin, metoprolol succinate, mineral oil, nitroglycerin, omeprazole, pravastatin, quetiapine, selenium sulfide shampoo, quetiapine, sumatriptan

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0957116
Sex: M
Age: 75
State: HI

Vax Date: 01/14/2021
Onset Date: 01/18/2021
Rec V Date: 01/19/2021

Lab Data: none

Allergies: Cipro caused nausea, Coreg caused bradycardia, Hydrocodone, calcium acetate

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

Other Meds: Atovastatin, Ferrous sulfate, Finasteride, Flomax, Humulin N, Pantoprazole, ProAir, Reglan, Spiriva, Turmeric

Current Illness: Diabetes, Chronic renal failure on hemodialysis, Atrial fibrillation, Quadriplegia, Thrombocytopenia, Gastroparesis, Vitamin D deficiency, BPH, Neurogenic bladder, distant history of small intestine carcinoid tumor, right cerebral artery aneurysm, Barrett's esophagus, MGUS, Hypertension, obstructive sleep apnea, Pulmonary hypertension, Junctional tachycardia.

Died: Y

Date Died: 01/12/2021

ID: 0957163
Sex: M
Age: 54
State: NJ

Vax Date: 01/11/2021
Onset Date: 01/11/2021
Rec V Date: 01/19/2021

Lab Data:

Allergies:

Symptoms: Resident received 1st on 1/11/21 at 12:10am (1/12/21) resident was found unresponsive. Code Blue, 911 called at 12:11am. FD and EMS arrived, resident pronounced at 12:51am.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/15/2021

ID: 0957799
Sex: M
Age: 81
State: VA

Vax Date: 01/14/2021
Onset Date: 01/15/2021
Rec V Date: 01/20/2021

Lab Data: CBC - unremarkable CMP - stable known renal disease otherwise unremarkable Troponin normal EKG - non acute

Allergies: Lipitor

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

Other Meds: sotaloL (BETAPACE) 80 mg Tablet omeprazole (PRILOSEC) 20 mg Capsule, Delayed Release(E.C.) sevelamer carbonate (RENVELA) 800 mg Tablet polyethylene glycol 3350 (MIRALAX PO) acetaminophen (TYLENOL EXTRA STRENGTH PO) fluticasone propionate (F

Current Illness:

Died: Y

Date Died: 01/20/2021

ID: 0958069
Sex: F
Age: 94
State: FL

Vax Date: 01/14/2021
Onset Date: 01/19/2021
Rec V Date: 01/20/2021

Lab Data:

Allergies: Codeine

Symptoms: Started with cough, mild shortness of breath and feeling terrible in evening of 1/19.

Other Meds: Cartia XT 120mg daily, Zaditor 0.025% 1 drop into eye twice a day, Folic Acid 1mg daily, Metoprolol Succinate ER 100mg twice a day, Lasix 40mg daily, Erythromycin 2% to area twice a day, Hydroxychloroquine Sulfate 200mg 2 tabs daily, Ferrou

Current Illness: None

Died: Y

Date Died: 01/19/2021

ID: 0958072
Sex: F
Age: 57
State:

Vax Date: 01/16/2021
Onset Date: 01/18/2021
Rec V Date: 01/20/2021

Lab Data:

Allergies:

Symptoms: Death 3 days after receiving 2nd dose of COVID vaccine, unknown if related to vaccine administration.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0958228
Sex: M
Age: 83
State: IL

Vax Date: 01/12/2021
Onset Date: 01/18/2021
Rec V Date: 01/20/2021

Lab Data: Collection time: Jan 17, 2021@06:00 Test Name Result Units Range --------- ------ ----- ----- GLUCOSE 166H mg/dL 70 - 99 UREA NITROGEN 138H mg/dL 7 - 18 CREATININE 6.93H mg/dL .7 - 1.3 SODIUM 165H* mmol/L 136 - 145 POTASSIUM 5.2H mmol/L 3.5 - 5.1 CHLORIDE 130H mmol/L 98 - 107 CO2 21 mmol/L 21 - 32 CALCIUM, TOTAL 9.2 mg/dL 8.5 - 10.1 PROTEIN, TOTL 7.8 g/dL 6.4 - 8.2 ALBUMIN 3.2L g/dL 3.4 - 5.0 AST 16 U/L 15 - 37 ALT 22 U/L 16 - 63 BILI,TOTAL 0.3 mg/dL 0.2 - 1.0 ALKAL PHOS 168H U/L 46 - 116 EGFR canc ANION GAP 20.0 mmol/L 10 - 20

Allergies: Niacin - rash

Symptoms: Patient has end stage renal disease and rapidly worsening dementia, family could no longer care for him at home, and he was admitted for 14-day quarantine prior to admission to inpatient hospice. Received vaccine on 1/12 without apparent adverse reactions. Patient started refusing oral intake on 1/16, and CMP on 1/17 showed hypernatremia 165 (new issue). His BUN 138 CREAT 6.93 K 5.2 were his baseline. He was found to be deceased on 1/18 at 11:18 pm.

Other Meds: 1) AMLODIPINE BESYLATE TAB 5MG PO QPM ACTIVE 2) ASPIRIN (OTC) TAB,CHEWABLE 81MG PO QDAILY ACTIVE 3) CARVEDILOL TAB 12.5MG PO BID ACTIVE 4) CHOLECALCIFEROL (VIT D3) 25MCG=100

Current Illness: none other than chronic conditions as listed under item 12.

Died: Y

Date Died: 01/19/2021

ID: 0958322
Sex: M
Age: 62
State: FL

Vax Date: 01/19/2021
Onset Date: 01/19/2021
Rec V Date: 01/20/2021

Lab Data: Was sent to ER

Allergies: None

Symptoms: Shaking and then became unresponsive

Other Meds: ASPIRIN ASPIRIN EC 325 MG TABLET TAKE 1 TABLET BY MOUTH DAILY ATORVASTATIN 40 MG TABLET LIPITOR 40 MG TABLET TAKE 1 TABLET BY MOUTH IN THE EVENING AT 5PM OLANZAPINE 10 MG TABLET ZYPREXA 10 MG TABLET TAKE ONE-HALF (1/2) TABLET BY MOUTH TWICE

Current Illness: Hyperlipidemia, Head Trauma, Hx of Seizures, Unspecified Psychosis, Depression, Mood Disorder, Substance Abuse

Died: Y

Date Died: 01/12/2021

ID: 0958565
Sex: M
Age: 71
State: FL

Vax Date: 01/11/2021
Onset Date: 01/11/2021
Rec V Date: 01/20/2021

Lab Data: Unknown

Allergies: None Known

Symptoms: Clients wife reported on 1/18/2021, that her husband died unexpectedly the day after receiving the COVID 19 vaccine. I called and spoke with her. She stated that the client had started experienced some tightness in his chest the evening of 1/11/2021. She stated that it was normal for him to have the tightness in his chest if he got stressed. She stated that she found him on the garage floor on 1/12/2021 at 2120. He was taken by ambulance to the hospital. She stated that the hospital told her that his COPD had caused him to go into arrythmia.

Other Meds: Albuterol nebulizer, Saline nebulizer, Metoprolol, Vespi, Albuterol Inhaler, antibiotic 2-3 times per week

Current Illness: lung infection treated with antibiotics a couple of weeks ago

Died: Y

Date Died: 01/16/2021

ID: 0958745
Sex: M
Age: 73
State: CO

Vax Date: 01/12/2021
Onset Date: 01/14/2021
Rec V Date: 01/20/2021

Lab Data: None

Allergies: No Known Allergies

Symptoms: Resident was noted to have increase weakness on 1/15/2021. Resident was warm to touch with low grade fever of 99.3 F. Resident was up propelling self in w/c on 1/16/2021 he was pleasant, accepted medications and ate lunch. He was found slumped over in his w/c not responding and vital signs absent.

Other Meds: Divalproex Sodium Tab DR 250mg and 500mg, Lexapro 20mg, Quetiapine Fumarate 200mg tab, Senna 8.6 mg, Latanoprost drops,

Current Illness: Hx of TBI and schizophrenia with worsening behaviors over the past few months including refusing care including meals and medications and striking out with care. Resident had a fall on 1/14/2021. Resident received treatment for a UTI with Keflex for 7 days starting 12/6/2020.

Died: Y

Date Died: 01/15/2021

ID: 0958914
Sex: F
Age: 87
State: GA

Vax Date: 12/30/2020
Onset Date: 01/15/2020
Rec V Date: 01/20/2021

Lab Data:

Allergies: NKA

Symptoms: Death on 1/15/2020

Other Meds: Melatonin, Sertraline, Omeprazole, Resperidone, Depakote ER, vitamin E, multi vit, ASA, Lasix, gabapentin, potassium, Imodium, Zofran, Buspar, benztropine.

Current Illness:

Died: Y

Date Died: 01/20/2021

ID: 0958935
Sex: F
Age: 92
State: NC

Vax Date: 01/19/2021
Onset Date: 01/20/2021
Rec V Date: 01/20/2021

Lab Data:

Allergies: Penicillin

Symptoms: Sudden Death within 24 hours of vaccine

Other Meds: Aspirin, Biotin, Levothyroxine, melatonin, Namenda, Zyprexa, Trazodone, B12, B6, Vit D, Xanax

Current Illness:

Died: Y

Date Died: 01/14/2021

ID: 0958971
Sex: M
Age: 84
State: FL

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/20/2021

Lab Data: CT scan

Allergies: NKDA

Symptoms: Hemorrhagic Stroke, Right Basal Ganglion

Other Meds: Simvastatin

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0959001
Sex: M
Age: 55
State: IL

Vax Date: 01/15/2021
Onset Date: 01/16/2021
Rec V Date: 01/20/2021

Lab Data: N/A

Allergies: Penicillin's, Chocolate, Lactase, Fish, Nuts, Strawberry

Symptoms: Patient woke apx 0200 complaining of nausea to group home staff. Vitals were checked at that time and WNL. Patient went back to bed. When staff went to wake patient apx 0530, he was unresponsive and had no pulse. Chest compressions were started and EMS called.

Other Meds: triamcinolone (KENALOG) 0.1 % Ointment amLODIPine (NORVASC) 5 MG Tablet Take 5 mg by mouth. ondansetron (ZOFRAN-ODT) 4 MG TABLET DISPERSIBLE Take 1 Tab by mouth every 8 hours as needed for Nausea - 1st line. acetaminophe

Current Illness: Unknown

Died: Y

Date Died: 01/10/2021

ID: 0959079
Sex: M
Age: 91
State: CO

Vax Date: 01/06/2021
Onset Date: 01/09/2021
Rec V Date: 01/20/2021

Lab Data: 1/9/2021- 12 lead EKG performed which states sinus tachycardia with supraventricular complexes and low voltage QRS as well as right bundle 1/9/2021- CXR ordered but discontinued at request of POA

Allergies: No Known Allergies

Symptoms: On 1/9/2021 observed with elevated respirations of 38-42 per minute, BP manually 72/50. pulse is jumping rapidly between 110-16 bpm. oxygen sat 76% RA, resident refusing oxygen at first attempt, allowed oxygen to be placed, is now 84% on 4L. resident shaking head yes that he is hurting, and yes that he would take medication for pain. Dr. notified, branch block. Received order for morphine 2mg per hr as needed for elevated respirations and pain. Dr. also gave orders to D/C Tamsulosin and finasteride. Resident continue with decreased O2 sats and elevated respirations. Absence of vital signs on 1/10/21 at 826PM.

Other Meds: Ascorbic Acid 500mg, Cetirizine HCL 5mg, Escitalopram Oxalate 10mg, Finasteride 5mg, Metoprolol succinate ER 25mg, Tamsulosin 0.4mg, Teriparatide 20mcg injection, Vitamin D3 Tablet, voltaren Gel 1%, Eliquis 5mg, Pantoprazole Sodium 40mg, Ac

Current Illness: Residents condition was declining over the past several months and has been treated for depression and dementia. Resident refusing care including meals, medication and ADL care.

Died: Y

Date Died:

ID: 0959147
Sex: F
Age: 83
State: OH

Vax Date: 12/28/2020
Onset Date: 01/02/2021
Rec V Date: 01/20/2021

Lab Data: none as resident was comfort care only

Allergies: penicillin

Symptoms: Unknown as to any correlation with vaccine as this was a hospice patient that was already experiencing decline. Patient became Jaundice for approximately one week prior to expiring.

Other Meds:

Current Illness: Alzheimer's disease, Type 2 with chronic kidney disease,

Died: Y

Date Died: 01/16/2021

ID: 0959167
Sex: M
Age: 84
State: AL

Vax Date: 01/14/2021
Onset Date: 01/16/2021
Rec V Date: 01/20/2021

Lab Data:

Allergies: NKDA

Symptoms: Patient received COVID 19 vaccine 01/14/2021. Patient died in his sleep 01/16/2021.

Other Meds: unknown

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0959179
Sex: M
Age: 79
State: CO

Vax Date: 01/14/2021
Onset Date: 01/17/2021
Rec V Date: 01/20/2021

Lab Data: COVID-19 negative (1/18/2021); Blood X 2 ngtd (1/17/2021); urine ngtd (1/17/2021); ECHO (1/18/2021) - Left Ventricle: The left ventricle is normal in size. There is mild asymmetric left ventricular hypertrophy. Left ventricular function is mildly reduced. Considering 2D visualization and technical calculations the left ventricular ejection fraction estimate is 40-45%. The inferolateral wall is hypokinetic. There is no evidence of a thrombus in the left ventricle. There is echocardiographic evidence of diastolic dysfunction; CMP (1/18/2021) Na 144, K 4.6, Cl 96, gluc 290, BUN 73, Scr 7.68, Ca 7.2, Mg 1.8, Phos 7.3, AST 436, ALT 271, Alb 2.7, T bili 0.4, lactate > 12.0; CBC (1/18/2021) WBC 24.6, Hgb 12.4, Hct 38.4, Plt 383

Allergies: None

Symptoms: Patient received COVID-19 vaccination on 1/14/2021. On 1/17/2021, patient was transferred to Hospital s/p multiple cardiac arrests. Patient was hyperkalemic and in acute renal failure at time of transfer. Hyperkalemia was treated, but the patient suffered PEA vs VFib. At the time of transfer, patient was on vasopressin, norepinephrine, and epinephrine. The patient had an EF of 40-45% and elevated troponins. Patient was made DNR and placed on comfort care. Patient passed away on 1/18/2021. Ultimately we suspect that the patients condition was a direct result of his underlying disease states, but wanted to make sure reporting was made available.

Other Meds: losartan 100 mg QD, metformin 1000 mg BID, simvastatin 40 mg QD, tamsulosin 0.4 mg QD

Current Illness:

Died: Y

Date Died: 02/07/2019

ID: 0959237
Sex: F
Age: 0
State: WA

Vax Date: 02/05/2019
Onset Date: 02/07/2019
Rec V Date: 01/20/2021

Lab Data: Blood work was performed at the hospital on 2/6/2019 to check her calcium level; normal results

Allergies: N/A

Symptoms: My daughter was given 2 vaccines in her first 24 hours of life. We were released from the hospital at hour 28 of life, and she died at home at hour 39, due to "unknown causes" which they later diagnosed as SUIDS.

Other Meds: N/A

Current Illness: N/A

Died: Y

Date Died: 01/15/2021

ID: 0959272
Sex: M
Age: 85
State: KS

Vax Date: 01/12/2021
Onset Date: 01/15/2021
Rec V Date: 01/20/2021

Lab Data: n/a

Allergies: none

Symptoms: Patient died 4 days after immunization. Probably unrelated to immunization, as patient has been in poor health and was receiving hospice services. I have no details related to his illness or symptoms. Daughter is the HIPAA/emergency contact and will have all the information needed.

Other Meds: unknown

Current Illness: uncertain illness, however, patient was on Hospice.

Died: Y

Date Died: 01/14/2021

ID: 0959356
Sex: F
Age: 89
State: MN

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/20/2021

Lab Data: unknown

Allergies: n/a

Symptoms: Pt passed away the day after the vaccine was given.

Other Meds: N/A not a resident at the living center.

Current Illness: n/a

Died: Y

Date Died: 01/20/2021

ID: 0959568
Sex: F
Age: 70
State: CO

Vax Date: 01/16/2021
Onset Date: 01/19/2021
Rec V Date: 01/20/2021

Lab Data: ROI not signed and we do not have access to these records as Clinic is not patient's PCP

Allergies: None disclosed

Symptoms: Patient received her first dose of the Moderna COVID-19 Vaccination on Saturday January 16th 2021 at approximately 12pm. She completed all necessary screening forms and was deemed to be at low risk for serious allergic reactions. She tolerated the vaccination well, and no complications or immediate adverse events occurred. She was observed for a full 15 mins per CDPHE/CDC guidelines and left the Clinic in stable condition after her observation period was complete. On the morning of Tuesday, January 19th, 2021, the patient was found unconscious and unresponsive by her husband. She was transferred by Ambulance to Hospital shortly thereafter. She was diagnosed with a brain bleed that was determined to be inoperable. She was transferred to other Hospital for higher level care. She was seen by neurosurgery and diagnosed with a ruptured aneurysm. She was treated in the ICU for 24 hours, at which point her team determined that the severity of her brain bleed would not respond to treatment. Supportive cares were withdrawn on Wednesday Jan 20th, and she passed away shortly thereafter.

Other Meds: None disclosed

Current Illness: None disclosed

Died: Y

Date Died: 01/17/2021

ID: 0959591
Sex: M
Age: 70
State: CO

Vax Date: 12/22/2020
Onset Date: 12/31/2020
Rec V Date: 01/20/2021

Lab Data: BMP and CBC done 1/3/2021 - low sodium 131, chloride 94, Glucose 131, BUN 80, WBC 18.9

Allergies: Amoxicillin, Ceftriaxone, Lisinopril, Niacin, Pilglitazone, Rosiglitazone, Penicillins

Symptoms: Resident has increase weakness and lethargy with abnormal labs. He was transferred to the ER. He was admitted to the hospital and treated for worsening AKI and hypotension.

Other Meds: Allopurinol 300mg, Atrovastatin 80mg, CaroSpir Suspension 25mg/5mL, Clopidogrel Bisulfate 75mg, Duloxetine HCL 30mg, Insulin- Lantus 14 units, Levothyroxine 137mcg, Lidocaine patch 5%, Potassium Chloride ER 20MEQ, Prilosec DR 40mg, Psylliu

Current Illness: He was treated for pneumonia and C-Diff at the beginning of December. He had abnormal blood work with elevated BUN and WBC on 12/31 and 1/3/21. Appetite was fluctuating and recently began increase medication for depression. Decrease responsiveness sent to ER on 1/4/2021.

Died: Y

Date Died:

ID: 0959729
Sex: M
Age: 82
State: MD

Vax Date: 12/30/2020
Onset Date: 12/30/2020
Rec V Date: 01/20/2021

Lab Data: unknown

Allergies: NKDA

Symptoms: Per Nursing Staff- patient died within 24 hours of receiving the vaccine. patient has hospice. Please contact director of nursing for more details.

Other Meds: unknown

Current Illness: Tachycardia, Hypertension

Died: Y

Date Died:

ID: 0959747
Sex: M
Age: 90
State: MD

Vax Date: 12/30/2020
Onset Date: 12/30/2020
Rec V Date: 01/20/2021

Lab Data: Unknown

Allergies: unknown - no

Symptoms: per staff at facility patient died 24 hours post vaccination. Please contact Director of Nursing for further details.

Other Meds: Unknown

Current Illness: Unknown

Died: Y

Date Died: 01/19/2021

ID: 0959929
Sex: M
Age: 69
State:

Vax Date: 01/17/2021
Onset Date: 01/18/2021
Rec V Date: 01/20/2021

Lab Data:

Allergies:

Symptoms: Narrative: Patient seen in ED 1-17-21 with c/c of "bloated with epigastric pain". Patient with complicated medical history including stage 1B pancreatic cancer (was currently on chemotherapy mFOLFIRINOX), and a leadless permanent pacemaker implantation on 1-11-21 for long episodes of SR with complete heart block following symptoms of syncope (other cardiac history: CAD s/p CABG 2009, PAF, and HTN). Regarding ER visit for epigastric pain, nothing notable was found on workup and patient was to discharge home to rest. There were available doses of COVID-19 Vaccine following a vaccine clinic that same day, and patient was offered and agreed to a dose of vaccine. Patient was monitored for 15 minutes post vaccine with no notable issues. The following day, Monday 1-18-21, patient's caregiver called facility at 22:30 to report he had a fever of 102.8 degrees and that he had been "feeling kind of bad all day". Patient was advise to seek urgent medical care and reported back to ED on 1-19-21 at 00:55. Patient wasd admitted for SIRS (tachycardia and febrile) -- patient also reported diffuse myalgia. WBC WNL, CXR unremarkable for infection, UA neg for bacteria, LFTs WNL, blood cultures negative. Procalcitonin elevated at 17.8 -- suggesting inflammatory response. Patient initially reported feeling better on the morning of 1-19-21, but around 13:00 began rapidly declining (confusion, unable to walk) and started experiencing EKG changes (9 beats of SVT). Patient then coded and resuscitation was attempted for approximately 30 minutes. Patient did not survive the code. Coroner has been notified and family is considering autopsy at time of this report.

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0960426
Sex: U
Age:
State: OH

Vax Date: 12/22/2020
Onset Date:
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar death events for 8 patients. This report is for 1st of 8 patient. A patient of unspecified age and gender received first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history was and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender's Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.,Linked Report(s) : US-PFIZER INC-2021034597 same drug, reporter and event but different patient;US-PFIZER INC-2021034598 same drug, reporter and event but different patient;US-PFIZER INC-2021034599 same drug, reporter and event but different patient;US-PFIZER INC-2021034600 same drug, reporter and event but different patient;US-PFIZER INC-2021034601 same drug, reporter and event but different patient;US-PFIZER INC-2021034603 same drug, reporter and event but different patient;US-PFIZER INC-2021034596 same drug, reporter and event but different patient.; Reported Cause(s) of Death: expired before receiving the second dose

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0960427
Sex: U
Age:
State: OH

Vax Date: 12/22/2020
Onset Date:
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 2nd of 8 patients. A patient of unspecified age and gender received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender's Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: expired before receiving the second dose

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0960428
Sex: U
Age:
State: OH

Vax Date: 12/22/2020
Onset Date:
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 3rd of 8 patients. A patient of unspecified age and gender received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender's Comments: Based on the reasonable temporal association, the Company cannot completely exclude the possible causality between the reported death and the administration of COVID 19 vaccine, bnt162b2. However, more information on the patient's underlying medical condition, concomitant medications, patient's age group, clinical course and relevant lab tests would be helpful for the Company to make a more meaningful causality assessment. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to RA, IEC, as appropriate.; Reported Cause(s) of Death: expired before receiving the second dose

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0960429
Sex: U
Age:
State: OH

Vax Date: 12/22/2020
Onset Date:
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 4th of 8 patient. A patient of unspecified age and gender received the first dose bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunization. The patient's medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. The patient died on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number has been requested.; Sender's Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: expired before receiving the second dose

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0960430
Sex: U
Age:
State: OH

Vax Date:
Onset Date:
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: 7 residents expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 6th of 8 patients. A patient of unspecified age and gender received first dose bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at SINGLE DOSE for covid-19 immunisation. The patient's medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information on the lot/batch number has been requested.; Sender's Comments: The event death is assessed as related to BNT162b2 vaccine and documented as such in the global safety database until sufficient information is available to allow an unrelated causality assessment. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: 7 residents expired before receiving the second dose

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0960431
Sex: U
Age:
State: OH

Vax Date: 12/22/2020
Onset Date:
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar death events for 8 patients. This report is for 7th of 8 patient. A patient of unspecified age and gender received first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history was and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender's Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: expired before receiving the second dose

Other Meds:

Current Illness:

Died: Y

Date Died: 01/17/2021

ID: 0960460
Sex: M
Age:
State: IL

Vax Date: 12/30/2020
Onset Date: 01/07/2021
Rec V Date: 01/21/2021

Lab Data: Test Date: 20210107; Test Name: COVID-19 virus test; Test Result: Positive

Allergies:

Symptoms: died; tested positive for COVID; tested positive for COVID; This is a spontaneous report from a contactable consumer from a Pfizer-sponsored program, Pfizer First Connect. A 97-year-old male patient received the first dose of the bnt162b2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration on 30Dec2020 at 97-years-old at a single dose for COVID-19 immunization; administered by the nursing home. Medical history included glaucoma from an unknown date and unknown if ongoing. Concomitant medications included: "used a sav for skin tears", and "eye drops for glaucoma" from an unknown date to an unknown date. On 07Jan2021, the patient experienced: tested positive for COVID (medically significant). The patient died (death, medically significant) on 17Jan2021. The clinical course was reported as follows: The reporter stated that in regard to the patient's height and weight: "was probably getting down to about five foot eight. Shrinking." The reporter stated that If she remembered correctly, they were trying to maintain the patient's weight 135 to 136 pounds. The reporter stated that her father was in a nursing home. The patient received his first dose of the COVID vaccine on 30Dec2020. The patient died on 17Jan2021. The reporter stated that she "wanted Pfizer to know that the little old people in the nursing might not be strong enough for the vaccine." The reporter stated that she was "not calling to complaining." The reporter stated that there was nothing wrong with her dad. He was elderly with no health issues. "He was literally on no medications. The only reason he was in the nursing home was because he was afraid to walk." The reporter stated that she received a call about giving the patient the vaccine and she said yes because she wanted him to have the vaccine. One week after the vaccine, the patient tested positive for COVID "like all the other people" (no further details provided). The reporter stated that her dad had no symptoms of COVID. The director of nursing said the patient was doing so well. The patient ate his lunch, he laid down for nap, and at 14:30 he was gone. The patient "went peacefully in his sleep." The reporter then again stated that the patient literally had nothing wrong with him. "They were shocked. They fed him and he took a nap. He was sleeping, but it was eternally." The reporter stated that, "it might not have been the Pfizer vaccine, maybe his heart wore out." In regard to an autopsy: the reporter stated that they would get it done if needed. The patient underwent lab tests and procedures which included COVID-19 virus test: positive on 07Jan2021. History of all previous immunization with the Pfizer vaccine considered as suspect: none. It was unknown if there were additional vaccines administered on the same date of the Pfizer suspect, but the reporter doubted it. There were no prior vaccinations within 4 weeks. There were no adverse events following the prior vaccinations. The clinical outcome of the event, died, was fatal. The clinical outcome of the event, tested positive for COVID, was unknown. The patient died on 17Jan2021 due to an unknown cause of death. An autopsy was not performed. The batch/lot numbers for the vaccine, PFIZER-BIONTECH COVID-19 MRNA VACCINE, were not provided and will be requested during follow up.; Reported Cause(s) of Death: died

Other Meds:

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0960552
Sex: F
Age: 78
State:

Vax Date: 01/18/2021
Onset Date: 01/18/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: No known Allergies

Symptoms: At approximately 930am I arrived at Memory Care. I met with the director of the facility and she directed me to where my team would be setting up. My team consisted of (technician), (nurse) and I. As we were setting up, the director asked how she can help. I explained to her that we would need a designated area for patients to be monitored after vaccination for 15 minutes and maybe even longer . I also explained that we would need one of her staff monitoring while we vaccinate. She agreed, and proceeded to designate her staff and the cafeteria area, facing the vaccination station,the monitoring station. Throughout the day, nurse and I were both vaccinating,while the staff of the facility would monitor the vaccinated patients. I would also stop occasionally to mix the vaccine and check the temperature of the aero safe. At approximately 12:50pm, the director rushed in and stated that a patient is not responding, and that she had been vaccinated. At that point, I grabbed epipens and a thermometer and I also instructed nurse to grab an Epipen and come with me. We followed the director to pt's room. Once we got to the room, the patient was in bed and there were 4 staff members standing bedside and one of them turned and stated the patient has passed. At that point I asked the staff how long ago did the patient get the vaccine, they stated about 30 minutes ago. They also stated that the patient was a hospice patient and that the patient had declined, and was rapidly detiorating and had not eaten or drank anything all day . They also stated that the patient had been monitored for 15 minutes post vaccination. I then left the room and grabbed the patients COVID Vaccine intake consent form. I looked at the answered questionaire and all the responses were circled NO. Patient had a temp of 96.5 at the time of vaccination.The vaccine administration information for Immunizer Section was filled out by Nurse. I then proceeded to ask the director once again if there were staff that was monitoring her for 15 minutes, the director stated they had staff monitoring her. She also stated the Hospice nurse has to announce her death, so they waited for the Hospice Nurse to come. I then called Corporate and explained the situation. After speaking to corporate, I also asked nurse, if she remembered the patient. She stated that she did and at the time of the vaccination the patient was not alert, there were two staff members with the patient. She was non oriented and she kept closing her eyes. At that point, Nurse stated that she asked the two staff members with her if this is how she usually is and if its ok to vaccinate her. Both Staff members stated that it its ok,this is how she is. The Nurse then proceeded to vaccinate. At approximately 3:10pm, as I was leaving I spoke to the director, and one of her Staff members. Staff that the patient has actually not eaten/ or drank anything for the past several days, including today(01/18/21). Staff also stated that on Friday, Jan 15th,2021, they had informed the family that the patient was rapidly detiorating. Staff also stated that the family knowingly gave the consent to vaccinate her. She also stated that the hospice Nurse believes that the death was primarily caused by her detiorating state. She also stated that the hospice Nurse informed that the death was not due to the Vaccine. Per Lead Pharmacist at the clinic.

Other Meds: Unknown

Current Illness: Patient was a hospice patient who was not doing well for several days per nurse. Patient had not eaten or consumed liquids in a few days.

Died: Y

Date Died: 01/16/2021

ID: 0960752
Sex: M
Age: 69
State: LA

Vax Date: 01/14/2021
Onset Date: 01/14/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: No

Symptoms: Extreme Fatigue

Other Meds: Several .. I have a list

Current Illness: No

Died: Y

Date Died: 01/21/2021

ID: 0960841
Sex: M
Age: 23
State: NY

Vax Date: 01/17/2021
Onset Date: 01/19/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: none

Symptoms: Patient developed 104.4 temp approximately 48 hours after being given the vaccine. I treated him with antibiotics, IV fluids, cooling methods. CXR does show a new right perihilar infiltrate. However, his fever came down within the next 24-48 hours. Unfortunately, he suffered a cardiac arrest on 1/21/21 in the early morning and expired.

Other Meds: Amantadine, clonazepam, clobazam, lovenox, dextroamphetamine-amphetamine , famotidine, gabapentin, keppra, robinul, polyethylene glycol, propanolol, sertaline, senna, valproic acid, vimpat, cefepime

Current Illness: none

Died: Y

Date Died: 01/20/2021

ID: 0961010
Sex: M
Age: 92
State: PA

Vax Date: 01/19/2021
Onset Date: 01/19/2021
Rec V Date: 01/21/2021

Lab Data: 1/19/2021 CT of head negative 1/19/2021 Troponin 3,000

Allergies: Hydralazine

Symptoms: Resident returned to the memory support unit at 1500. Resident was than toileted and transferred in to bed per his request. At 1515 resident was observed face down beside bed, resident sustained a 1inX1in eccyhmotic/hematoma to the forehead. Neuro Checks with in normal limes Vital signs: 100/52, 100, 97.2, 28. Resident sent to ED for further medical evaluation via EMS.

Other Meds: n/a

Current Illness: n/a

Died: Y

Date Died: 01/19/2021

ID: 0961339
Sex: F
Age: 45
State: GA

Vax Date: 01/18/2021
Onset Date: 01/19/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: contrast die

Symptoms: possibly got it at clinic, possibly who administered shot. Pts. daughter said the pts boyfriend denied any symptoms the whole day but that in the middle of the night the pt passed away.

Other Meds: Wellbutrin, Ambien

Current Illness:

Died: Y

Date Died: 01/21/2021

ID: 0961434
Sex: M
Age: 94
State: OH

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: No know allergies

Symptoms: This is a 94-year-old male who is brought in by ambulance after being found on the floor with unknown downtime. He was in asystole upon EMS arrival. He remains in asystole. No advanced airway is in place. The patient is getting compressions from Lucas device upon arrival. It was reported that he was last talked to by family at 2 PM. The patient got his SARS-CoV-2 vaccination this morning. The patient is evaluated emergently. CPR was ongoing with 3 rounds of epinephrine given. The patient remains in asystole. He has rigor mortis. The patient's pupils are fixed and dilated. The patient has compressions paused and ultrasound is used to evaluate for cardiac activity. None is detected. The patient has no electrical activity on monitor. The patient's time of death is 2113.

Other Meds: Tamsulosin 0.4 mg daily Metoprolol Succinate ER 100 mg daily Rivaroxaban 15 mg daily Levothyroxine 100 mcg daily Furosemide 40 mg daily Atorvastatin 40 mg daily Amiodarone 200 mg daily Nitroglycerin 0.4 mg SL PRN Aspirin 81 mg daily Polyeth

Current Illness: Chronic back pain

Died: Y

Date Died: 01/20/2021

ID: 0961705
Sex: M
Age: 60
State: OH

Vax Date: 01/18/2021
Onset Date: 01/20/2021
Rec V Date: 01/21/2021

Lab Data: none

Allergies: no known allergies

Symptoms: approximately 3 hours prior to expiring the patient was experiencing forceful emesis. later was found to have expired, patient was comfort care only.

Other Meds: Phenergan, melatonin, clonazepam, vit d, asorbic acid, zinc, cholecalciferol, lomotrigine, cimetadine, quetiapine,

Current Illness: none

Died: Y

Date Died:

ID: 0961741
Sex: M
Age: 89
State: NY

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: The patient received his vaccine in the. morning of 1/20/2021, while getting into car to go see his pulmonologist, about 2 hours after, collapsed, unresponsive with asystolic cardiac arrest. No symptoms prior other than chronic dyspnea. No allergic type symptoms reported by family. Asystole with EMS, no response to ACLS, presented to ED, DOA.

Other Meds:

Current Illness: copd/chf/sleep apnea/afib/lymphoma

Died: Y

Date Died: 01/14/2021

ID: 0961776
Sex: M
Age: 69
State: FL

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: None Known

Symptoms: 1/13/2021 12:00 PM: Patient received COVID-19 Vaccine. 1/14/2021 21:00: Nurse performed routine rounds and the patient appeared okay. 1/14/2021 22:00: CNA discovered patient unresponsive in bed, began CPR, and called 911. 1/14/2021 23:08: Pronounced deceased.

Other Meds: Acetaminophen 325mg, Aspirin 81mg, Celecoxib 200mg, Docusate Sodium 100mg, Furosemide 40mg, Glimepiride 2mg, Lantus SoloStar 100unit/ml Pen-Injector, NovoLog FlexPen 100 Unit/ml Injection Pen, Senokot 8.6mg, Nu-Iron 150mg, Lisinopril, 20mg,

Current Illness: None

Died: Y

Date Died: 01/18/2021

ID: 0961845
Sex: M
Age: 76
State:

Vax Date: 01/12/2021
Onset Date: 01/17/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: Narrative:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/10/2021

ID: 0961848
Sex: M
Age:
State:

Vax Date:
Onset Date: 01/09/2021
Rec V Date: 01/21/2021

Lab Data: AST 1826, ALT 1462 (01/09/2021) up from 01/07/2021 when it was downtrading to AST 52, ALT 193. Initially increased from 12/28/2020 AST 28, ALT 24. 01/01/2021 up to AST 134, ALT 130, increasing and then trending down.

Allergies:

Symptoms: Narrative: Was pt previously covid positive?- Yes. Initial- 10/27/2020, 11/29/2020, 12/22/2020 Are there any predisposing factors for patient experiencing adverse drug event?- Yes, patient had multiple co-morbidities including GI bleed, hepatitis congestion due to cardiac issues, treatment for PE, NSTEMI, or antibiotics for PNA, also on concurrent medications APAP, Atorvastatin, Mirtazapine and Duloxetine. Pt with 2 doses of covid-19 vaccine, second one on 01/08/2021, 2 days pre-death Any occurrence of an ADR at time of administration? Did not specify injection site issues, per RN admin note- Vaccine "administered without complications." Did patient recover from event? Not s/p dose on 01/08/2021. First dose given on 12/21/2021, LFTS increased ~01/01/2021, peaked on 01/03/2021 and were decreasing on 01/07/2021 Was there an ADR between observation period and date of death? No Did patient recover from event? No (01/08/2021 event, died 01/10/2021) Was patient hospitalized prior to vaccination? Yes, in between inpatient and nursing home Was patient hospitalized prior to death--was hospitalization attributable to ADE? Yes re-admitted to inpatient on 12/31/2020. GI bleed Is there an alternative cause of death? Yes, as noted above. Quite a complicated case with many comorbidities/concurrent medications as noted above. Primary Diagnosis: Upper GI Bleed in the death note from 01/10/2021

Other Meds:

Current Illness:

Died: Y

Date Died: 01/04/2021

ID: 0962307
Sex: M
Age:
State: SD

Vax Date: 01/04/2021
Onset Date: 01/04/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: tired; legs felt heavy; stopped breathing; This is a spontaneous report from a Pfizer-sponsored program a non-contactable consumer. A 93-year-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 04Jan2021 11:00 at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. Patient received vaccine around 11:00 a.m. About two hours later, he said he was tired and couldn't continue with the physical therapy he was doing. He was taken back to his room, where he said his legs felt heavy. Soon after, he stopped breathing. A nurse declared a do-not-resuscitate order. The patient died on 04Jan2021. It was not reported if an autopsy was performed. Outcome of stopped breathing was fatal. Outcome of tired and legs felt heavy was unknown. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: stopped breathing

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0962308
Sex: F
Age:
State: UT

Vax Date:
Onset Date:
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: died; This is a spontaneous report from a Pfizer-sponsored program. A contactable consumer reported that an 83-year-old female patient (reporter mother) received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunization. Medical history included hospice care and dementia. The patient's concomitant medications were not reported. The patient died one day after getting vaccine. She was reportedly in good health the day before receiving vaccine. She was on hospice, frail, but in good condition and checked by a hospice nurse the day before which she reported her in good health considering. She was with dementia but stable in her health. The reporter read investigating 23 deaths of people receiving vaccine in similar conditions. The patient died on an unspecified date. It was not reported if an autopsy was performed.; Reported Cause(s) of Death: died

Other Meds:

Current Illness:

Died: Y

Date Died: 01/19/2021

ID: 0962318
Sex: M
Age: 80
State: KY

Vax Date: 12/29/2020
Onset Date: 01/19/2021
Rec V Date: 01/21/2021

Lab Data: unknown

Allergies: unknown

Symptoms: Called to schedule second vaccine and daughter reports that he died on01/19/2021 with "COVID"

Other Meds: Unknown

Current Illness: unknown

Died: Y

Date Died: 01/20/2021

ID: 0962325
Sex: M
Age: 80
State: VA

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: Patient's wife called this morning stating that her husband has passed away last night. After receiving first dose of Pfizer COVID-19 vaccine at around 0830, patient remained in the Immunizations Department for the 15-minute monitoring period. Per wife, patient's only complaint was pain at the injection site. At 1300, wife states that patient complaint of dizziness which "dissipated after a few minutes" followed by a headache which "dissipated after a few minutes" as well. Then patient complained of nausea, no vomiting and "couldn't relax." Per wife, from around 1400/1500, patient stayed on his recliner while still having a conversation with her--"he didn't get up to eat." Last conversation they had was around 2000/2100. Per wife, at around 2100/2200, patient was quiet and when she checked on him, "he wasn't responding anymore." Wife then called 911, "but they couldn't revive him."

Other Meds:

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0962390
Sex: M
Age: 81
State:

Vax Date: 01/10/2021
Onset Date: 01/10/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: ASPIRIN

Symptoms: Admitted to hospital after vaccination with Acute hypoxemic respiratory failure, Septic shock; Aneurysm of arteriovenous dialysis fistula; expired 1/16/2021

Other Meds:

Current Illness: intestinal adhesions with obstruction; Intestinal adhesions with partial obstruction; S/P colon resection; SBO (small bowel obstruction)

Died: Y

Date Died: 01/10/2021

ID: 0962714
Sex: M
Age: 80
State: AK

Vax Date: 12/19/2020
Onset Date: 01/10/2021
Rec V Date: 01/21/2021

Lab Data: None, no adverse events were observed relating to the COVID vaccine.

Allergies: lisinopril, shellfish

Symptoms: We do not believe that the patient's death was an adverse event from the vaccine. Patient received COVID vaccine from Pfizer Dose #1 12/19/2020 (lot # EK5730) and Dose #2 1/7/2021 (lot # EL1284). No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Patient died 1/10/2021 from chronic respiratory failure and congestive heart failure after recent aspiration pneumonia requiring hospitalization. Death was anticipated and not sudden. We were told to report his death to VAERS even though his death was anticipated and not related to his vaccination.

Other Meds: Acetaminophen suppository 650mg PRN, atropine 1% opthamlic solution, biotine moisturizing mouth solution, lorazepam concentrate 2mg/ml, milk of magnesia suspension 400mg/5ml, morphine sulfate solution 20mg/ml, zofran ODT tablet 4mg.

Current Illness: Aspiration pneumonia (dx on 12/16/2020)

Died: Y

Date Died: 01/19/2021

ID: 0962716
Sex: F
Age: 62
State: ND

Vax Date: 12/30/2020
Onset Date: 01/19/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: CEPHALEXIN, CODEINE, PENICILLIN, TETRACYCLINE

Symptoms: Patient deceased

Other Meds: TRAMADOL, CHOLESTYRAMINE, DICOLFENAC SODIUM TOPICAL GEL, GABAPENTIN, TRAZODONE, LEVETIRACETAM, HYDROXYZINE HCL, FUROSEMIDE, DIVALPROEX SODIUM, ELIQUIS, LEVOTHYROXINE

Current Illness:

Died: Y

Date Died: 12/23/2020

ID: 0962764
Sex: M
Age: 73
State: AK

Vax Date: 12/17/2020
Onset Date: 12/21/2020
Rec V Date: 01/21/2021

Lab Data: None.

Allergies: lisinopril, seroquel, penicillins, beer

Symptoms: Patient did not have any adverse reaction to the COVID vaccine, but we were asked by our health dept to submit a VAERS report since the patient died between his first and second dose. Received Pfizer Dose #1 12/17/2020. No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Date of death 12/23/2020 from aspiration pneumonia complicated by end-stage heart failure and ischemic cardiomyopathy. Death was anticipated and not sudden.

Other Meds: acetaminophen suppository 650mg, polyvinyl alcohol solution 1.4%, atropine 1% ophthalmic solution, fentanyl patch 72hr 50mcg/hr, lorazepam concentrate 2mg/ml, morphine sulfate solution 20mg/ml.

Current Illness: Scrotal edema, aspiration pneumonia

Died: Y

Date Died: 01/15/2021

ID: 0962784
Sex: M
Age: 88
State:

Vax Date: 01/09/2021
Onset Date: 01/15/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: LATEX, NATURAL RUBBER

Symptoms: patient expired 1/15/2021; had been treated as outpatient for pneumonia, likely COVID-19 but no positive test result in December 2020. PMH diabetes

Other Meds:

Current Illness: PNEUMONIA

Died: Y

Date Died: 01/14/2021

ID: 0962827
Sex: F
Age: 93
State:

Vax Date: 01/14/2021
Onset Date: 01/14/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: ATORVASTATIN; CODEINE; DOXY

Symptoms: Admitted 1/14/21: Patient is an elderly 93-year-old female with multiple medical problems including chronic combined CHF, P 80, diabetes mellitus, HTN, hyperlipidemia, CKD stage 3, has been complaining of generalized weakness, fatigue, decreased appetite for the past few days. She had an outpatient COVID-19 vaccine earlier today. Within 2 hr of admitting the patient to the hospital, condition clinically deteriorated. Patient elected to be DNR/DNI while in the ED. Patient was pronounced dead at 10:30 p.m. earlier today. Preliminary cause of death: Hypoglycemia induced lactic acidosis.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/20/2021

ID: 0962940
Sex: M
Age: 83
State: WI

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/21/2021

Lab Data: None

Allergies: Galantamine

Symptoms: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt's room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127.

Other Meds: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin

Current Illness: Unknown

Died: Y

Date Died: 01/18/2021

ID: 0962957
Sex: F
Age: 88
State: IL

Vax Date: 01/15/2021
Onset Date: 01/18/2021
Rec V Date: 01/21/2021

Lab Data: Unknown

Allergies: NKDA

Symptoms: Patient became lethargic with labored breathing and decreased oxygen saturation. Expired after sent out of facility for treatment.

Other Meds: Atorvastatin, Enalapril maleate, Metoprolol, Maxzide

Current Illness: COVID recovered

Died: Y

Date Died: 01/16/2021

ID: 0962966
Sex: F
Age: 80
State:

Vax Date: 01/14/2021
Onset Date: 01/16/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: Codeine

Symptoms: On Saturday, 1/16/2021, Patient went to the grocery store. Upon her return, she indicated she was experiencing N/V and some throat swelling. Patient subsequently collapsed and expired before she could be brought to an emergency room. During investigation by Coroners Office, it has been reported that Patient may have gotten some takeout food while she was out. Labs are pending and the Coroners investigation is ongoing. Spouse believes that her death was caused by the vaccine.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/19/2021

ID: 0962995
Sex: M
Age: 61
State: CA

Vax Date: 01/15/2021
Onset Date: 01/19/2021
Rec V Date: 01/21/2021

Lab Data: N/A

Allergies: No known allergies.

Symptoms: No immediate reaction. Patient-reported deceased four days later on Jan. 19, 2021. As of this date cause of death is unknown to our clinic.

Other Meds: Unknown

Current Illness: Unknown

Died: Y

Date Died: 01/15/2021

ID: 0963016
Sex: F
Age: 65
State: PA

Vax Date: 01/14/2021
Onset Date: 01/15/2021
Rec V Date: 01/21/2021

Lab Data: unknown

Allergies: unknown. Denied allergies on vaccine form

Symptoms: unknown. Event occurred after leaving vaccination site

Other Meds: unknown

Current Illness: denied ill symtpoms at time of vaccination

Died: Y

Date Died: 01/17/2021

ID: 0963057
Sex: F
Age: 96
State:

Vax Date: 01/09/2021
Onset Date: 01/09/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: presented to ED 1/9/21 with abdominal pain, progressive worsening weakness and fatigue and new onset A fib with RVR likely due to hypertensive urgency . Patient progressed clinically with severe hypoxia and transferred to ICU and started on BiPAP; progressive decline with decreased urinary output with uremia likely secondary to sepsis. Concern with patient worsening clinical decline, palliative care had been consulted on end of life care. Patient expired 1/17/21

Other Meds:

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0963235
Sex: F
Age: 94
State: TX

Vax Date: 01/04/2021
Onset Date: 01/09/2021
Rec V Date: 01/21/2021

Lab Data: COVID test

Allergies: Lisinopril

Symptoms: Patient diagnosed with COVID on January 9, 2021 after being exposed to family member that was under quarantine in the same household. Admitted to the hospital and was discharged on January 14, 2021 with home hospice. Patient passed away on January 18, 2021

Other Meds: Klonipin, Myrbetriq, Zoloft, Carafate, Isosorbide, Allopurinol, Colace, Calcium Carbonate, Synthroid, Famotidine, Metoprolol, Losartan, Tylenol

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0963269
Sex: F
Age: 87
State: TX

Vax Date: 01/04/2021
Onset Date: 01/18/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies: NKDA

Symptoms: Patient passed away on 01/18/2021

Other Meds: Lisinopril, Januvia, Fosamax, Trazodone, Metoprolol, Colace Simvastatin, Levoxyl, Lantus, Zocor

Current Illness:

Died: Y

Date Died: 01/10/2021

ID: 0963388
Sex: F
Age: 88
State: ND

Vax Date: 01/05/2021
Onset Date: 01/10/2021
Rec V Date: 01/21/2021

Lab Data: None

Allergies: Ceftriaxone sodium, Augmentin

Symptoms: Patient died unexpectedly 5 days after receiving vaccine (1/10/2021).

Other Meds: Albuterol, Aspirin, Ativan, Ayr Saline Nasal, Biotene Dry mouth moisturizing spray, docusate sodium, Florajen 3, gabapentin, hydralazine HCL, Hydrocortisone acetate/LI, Isosource VHN 1.5 cal, ketoconazole, Lasix, lopressor, multivitamin, pl

Current Illness: No known illnesses at time of vaccination.

Died: Y

Date Died: 01/17/2021

ID: 0963610
Sex: M
Age: 63
State: NM

Vax Date: 01/14/2021
Onset Date: 01/17/2021
Rec V Date: 01/21/2021

Lab Data: Rapid COVID swab done after death 1/18/21 1:04pm. The result was positive. Previous rapid done on 1/4/21 and was negative.

Allergies: NKDA

Symptoms: Patient deceased on 01/17/2021

Other Meds: Asprin 81mg Calcium Acetate 667mg Ensure Plus Eucerin Furosemide 80mg Glipizide 5mg Omeprazole 20mg Renvela 800mg Rifampin 300mg Sensipar Vitamin D3

Current Illness: TB DMII Hyperlipidemia GERD CKD Renal Failure

Died: Y

Date Died: 01/19/2021

ID: 0967743
Sex: M
Age: 77
State: TX

Vax Date: 01/19/2021
Onset Date: 01/19/2021
Rec V Date: 01/21/2021

Lab Data:

Allergies:

Symptoms: Possible seizer, unknown at this time, aprox 1hr and 20min after vac given. Passed away aprox 2hrs after vac.

Other Meds:

Current Illness: n/A

Died: Y

Date Died: 12/30/2020

ID: 0963902
Sex: M
Age:
State:

Vax Date: 12/28/2020
Onset Date: 12/30/2020
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: Death; This is a spontaneous report from four non-contactable consumers via a Pfizer-sponsored program Corporate (Pfizer) Social Media Platforms. A 78-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, on 28Dec2020 at a single dose for COVID-19 immunization. Ongoing medical history included Alzheimer's Disease, encephalopathy, hypertension, acute kidney failure, urinary retention and recent urinary tract infection (UTI), all from an unspecified date. Concomitant medication included acetaminophen (MANUFACTURER UNKNOWN), bisacodyl (MANUFACTURER UNKNOWN), bupropion (MANUFACTURER UNKNOWN), escitalopram (MANUFACTURER UNKNOWN), hydrocodone bitartrate, paracetamol (HYDROCODONE/ACETAMINOPHEN), loperamide (MANUFACTURER UNKNOWN), ondansetron (MANUFACTURER UNKNOWN), senna alexandrina (SENNA PLUS), vitamin d3 (MANUFACTURER UNKNOWN). The patient had no known drug allergies. The patient experienced death on 30Dec2020. The vaccine was given on 28Dec2020 with no adverse events and no issues on 29Dec2020. The patient died on 30Dec2020, at approximately 2:00 AM. It was unknown if an autopsy was performed. It was unknown if the event was related to the suspect drug, the administrator marked as natural causes. No follow-up attempts are possible; information about batch/lot number cannot be obtained.; Reported Cause(s) of Death: Death

Other Meds: ACETAMINOPHEN; ; ; ; HYDROCODONE/ACETAMINOPHEN; ; ; SENNA PLUS [SENNA ALEXANDRINA]; VITAMIN D3

Current Illness: Acute kidney failure; Alzheimer's disease; Encephalopathy; Hypertension; Urinary retention; UTI

Died: Y

Date Died: 01/16/2021

ID: 0964401
Sex: M
Age: 56
State: IL

Vax Date: 01/12/2021
Onset Date: 01/16/2021
Rec V Date: 01/22/2021

Lab Data: none

Allergies:

Symptoms: Pt died 4 days after vaccine, no known reaction to the vaccination

Other Meds:

Current Illness:

Died: Y

Date Died: 01/21/2021

ID: 0964617
Sex: F
Age: 77
State: AK

Vax Date: 01/08/2021
Onset Date: 01/21/2021
Rec V Date: 01/22/2021

Lab Data: none

Allergies: Codeine

Symptoms: Death, which I believe is unrelated to vaccination

Other Meds: Oxycodone, ventolin, quetiapine, pantoprazole, metoprolol, lorazepam, haloperidol, senna, levetiracetam

Current Illness: Alzheimers, Covid, COPD, Mood disorder, convulsions, HTN, anxiety, DM, parkinson's,

Died: Y

Date Died: 01/05/2021

ID: 0964671
Sex: M
Age: 100
State: AK

Vax Date: 12/18/2020
Onset Date: 01/02/2021
Rec V Date: 01/22/2021

Lab Data: None

Allergies: NKDA, NKFA

Symptoms: Death on 1-5-21

Other Meds: Omeprazole, metoprolol, prilosec,, isorbide, senna, nitro, lasix, fluticasone

Current Illness: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,

Died: Y

Date Died: 01/15/2021

ID: 0964724
Sex: M
Age: 76
State: AK

Vax Date: 12/18/2020
Onset Date: 01/15/2021
Rec V Date: 01/22/2021

Lab Data: none

Allergies: NKDA, NKFA

Symptoms: Death 1-15-21

Other Meds: prozac, olanzapine, alendronate, divalproex, mirabegron, metoprolol, proair,

Current Illness: Dementia, Bipolar, COPD, HTN, Schizoaffective

Died: Y

Date Died: 01/21/2021

ID: 0964795
Sex: M
Age: 67
State: OH

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/22/2021

Lab Data: 1/14/21 CT head unremarkable, blood culture no growth. Normal WBC 1/18/21 blood cultures no growth

Allergies: Penicillin- Swelling of tongue and neck

Symptoms: Symptoms of fever (Tmax 102.9), diarrhea, and altered mental status started ~ 24 hours after vaccination. No evidence of septicemia with negative blood cultures Minimal improvement over 3 days, transferred to tertiary care center for MRI brain after which LP was recommended. However family declined as intubation would have been required and was not consistent with patient's goals of care.

Other Meds: Acetaminophen, Aspirin, Axitinib (Inlyta), Bisacodyl, Duloxetine, Ferrous Sulfate, Glucosamine Chondroitin, Norco, Tresiba, Lovastatin, Magnesium, Senna, Tamsulosin, Warfarin

Current Illness: Metastatic Renal Cell Carcinoma Diagnosed with COVID-19 on 12/7/2020, unknown severity of disease. Received first Pfizer SARS-COV-2 vaccine at the end of December

Died: Y

Date Died: 01/19/2021

ID: 0965256
Sex: M
Age: 38
State: GA

Vax Date: 12/23/2020
Onset Date: 01/19/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies: NKDA

Symptoms: Found deceased, presumed while exercising

Other Meds: Atorvastatin calcium 20mg daily

Current Illness:

Died: Y

Date Died: 12/29/2020

ID: 0965547
Sex: M
Age:
State:

Vax Date: 12/28/2020
Onset Date: 12/29/2020
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: resident coded and expired; This is a spontaneous report from a non-contactable consumer via Pfizer Sponsored Program. A 63-year-old male patient received the 1st dose of bnt162b2 (BNT162B2, Lot # EH9899) intramuscular at single dose at left arm on 28Dec2020 for Covid-19 immunisation. Medical history included no current Illness, no known allergies, but preexisting conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gastrooesophageal reflux disease (GERD), hyperlipidaemia, bipolar disorder, rectal bleeding, hypertension. The patient had no birth defect. Concomitant medication included asa (ASA) at 81mg, lisinopril (LISINOPRIL) at 10mg daily, ferrous sulfate (FERROUS SULFATE) at 325 (unit unknown), olanzapine (ZYPREXA) at 20mg, morniflumate (FLOMAX [MORNIFLUMATE]) at 0.4 (unit unknown), famotidine (FAMOTIDINE) at 20mg, ascorbic acid (VIT C), carbamazepine (CARBAMAZEPINE) at 250mg bid, valproate semisodium (DEPAKOTE) at 750mg bid, metformin (METFORMIN) at 1000 (unit unknown) bid, sertraline (SERTRALINE) at 100 (unit unknown) bid, albuterol [salbutamol] (ALBUTEROL [SALBUTAMOL]), buspirone hydrochloride (BUSPAR) at 10mg tid, polycarbophil calcium (FIBERCON). The patient died on 29Dec2020. The patient had no ER or Doctor visit and was not hospitalized. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: resident coded and expired

Other Meds: ASA; ; ; ZYPREXA; FLOMAX [MORNIFLUMATE]; ; VIT C; ; DEPAKOTE; ; ; ALBUTEROL [SALBUTAMOL]; BUSPAR; FIBERCON

Current Illness:

Died: Y

Date Died: 12/30/2020

ID: 0965548
Sex: F
Age:
State:

Vax Date: 12/30/2020
Onset Date: 12/30/2020
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: passed away; This is a spontaneous report from non-contactable consumers received via a Pfizer-sponsored program An 88-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot EL0142) via an unspecified route of administration on 30Dec2020 at a single dose (1 dose) in the left arm (LA) (administered by: senior living) as Covid vaccine. Medical history included patient was 14 plus days post COVID and unresponsive. The patient had no listed allergies. Concomitant medications were not reported. The patient passed away with an hour and half of receiving vaccine on 30Dec2020. Per nursing staff, they did not expect the patient to make it many more days. She was unresponsive in the room when shot was given. It was unknown if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: passed away

Other Meds:

Current Illness:

Died: Y

Date Died: 12/26/2020

ID: 0965561
Sex: F
Age:
State:

Vax Date: 12/23/2020
Onset Date: 12/26/2020
Rec V Date: 01/22/2021

Lab Data: Test Name: covid-19 test; Result Unstructured Data: Test Result:Negative

Allergies:

Symptoms: respiratory distress; fever; anxiety developed requiring oxygen; Passed away; This is a spontaneous report via a Pfizer-sponsored program from a non-contactable consumer. A 63-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot and expiry not reported), via an unspecified route of administration on 23Dec2020 at a single dose for COVID-19 immunization. Medical history included 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 (broad), hypoglycaemia (broad), COVID-19 (broad) and chronic obstructive pulmonary disease (COPD); all from an unknown date and unknown if ongoing. Concomitant medications included levothyroxine sodium and lorazepam (ATIVAN). Within 24 hours of receiving the vaccine, the patient experienced fever, respiratory distress, and anxiety developed requiring oxygen, morphine and lorazepam (ATIVAN). The patient passed away on the evening of 26Dec2020. The patient underwent lab tests and procedures which included SARS-COV-2 antibody test: negative on an unspecified date. The outcome of the event death was fatal, while of the other events was unknown. It was not reported if an autopsy was performed. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Passed a

Other Meds: LEVOTHYROXINE [LEVOTHYROXINE SODIUM]; ATIVAN

Current Illness:

Died: Y

Date Died: 01/20/2021

ID: 0965564
Sex: M
Age: 58
State:

Vax Date: 01/14/2021
Onset Date: 01/20/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: Cardiac arrest Narrative:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/05/2021

ID: 0965565
Sex: M
Age: 84
State: NE

Vax Date: 12/26/2020
Onset Date: 01/05/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: Narrative: Please note that patient is a hospice patient. Death occurred 10 days post vaccination. Providers do not believe that there was a correlation. Facility requires that we reports all death even if we suspect no correlation between death and vaccine. Symptoms: & death

Other Meds:

Current Illness:

Died: Y

Date Died: 01/20/2021

ID: 0965571
Sex: F
Age: 83
State: MA

Vax Date: 01/13/2021
Onset Date: 01/20/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies: Unknown

Symptoms: 1/13/21 pt came into clinic for vaccine. Had difficulty remembering age. Called me Mon. 1/18/21 stating she was sick. When asked what her sx were, she stated fatigue. She was well the night of the shot, Thur. and Fri. but became tired on Sat. and Sun. I went through other sx with her such as h/a, fever, n/v, muscle aches, weakness and she said she experienced none of those. I questioned her about eating and drinking and she said she ate and drank water. She seemed fine so I told her to call her doctor if she was worse or the fatigue persisted or call 911. She agreed. Two staff from clinic called her Mon. and Tues, (1/18 and 1/19). On Tues. she may have had sl slurred speech. She was found deceased on

Other Meds: Unknown

Current Illness: Unknown

Died: Y

Date Died: 01/16/2021

ID: 0965807
Sex: F
Age: 90
State: GA

Vax Date: 01/08/2021
Onset Date: 01/09/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies: Penicillin

Symptoms: began itching within 24 hours, within 5 days couldn't move on her own, by 6th day was having respiratory issues, by day 7 unresponsive, by day 8 dead

Other Meds: metoprolol, methotrexate, calcitrol, digoxin, calcium prednisone, clopidogrel, levothyroxine, folic acid, pantoprazole, eliquis, atorvastatin, latanoprost, melatonin

Current Illness: nose bleeds

Died: Y

Date Died: 01/20/2021

ID: 0965831
Sex: F
Age: 74
State: MI

Vax Date: 01/18/2021
Onset Date: 01/20/2021
Rec V Date: 01/22/2021

Lab Data: N/A

Allergies: Allergies: Brilinta, ACE Inhibitors, Bactrim, Cipro, Codeine Derivatives, Penicillins, Statins, sulfa

Symptoms: Patient received her first dose of vaccine on Monday, January 18th. Two days later on Wednesday, January 18th, she retired to bed early. Later that night when her husband went to bed, he found her in the bed deceased. No other details of the event are know.

Other Meds: Albuterol Sulfate HFA 108 MCG/ACT AERS Allopurinol 300 MG Oral Tablet Aspirin Low Dose 81 MG TABS Baclofen 10 MG Oral Tablet Bystolic 10 MG Oral Tablet Clobetasol Propionate 0.05 % External Cream Cyanocobalamin 1000 MCG TABS Fish Oil

Current Illness: Emergency Room Visit 1/7/2021 complaining of shortness of breath and swelling. She and elevated D-dimer with no evidence of a Pulmonary Embolus. Persantine Myoview showed small mild area of reversible ischemia to the inferolateral apical wall. Mild symptoms of vague discomfort in her chest, but nothing that has been reproducible with activity. She is chronically short of breath with limited activities because of problems with her hip

Died: Y

Date Died: 01/21/2021

ID: 0965860
Sex: M
Age: 84
State: OH

Vax Date: 01/21/2021
Onset Date: 01/21/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: Patient had increased SOB while at home. EMS was called. Patient coded in the squad

Other Meds:

Current Illness:

Died: Y

Date Died: 01/01/2021

ID: 0965910
Sex: F
Age: 53
State: DC

Vax Date: 01/11/2021
Onset Date: 01/22/2021
Rec V Date: 01/22/2021

Lab Data: Not known at this time.

Allergies: not known

Symptoms: The employee found dead at her home on 1/21/2021.

Other Meds: not known

Current Illness: not known

Died: Y

Date Died: 01/22/2021

ID: 0965922
Sex: M
Age: 75
State: MD

Vax Date: 01/19/2021
Onset Date: 01/22/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies: pt answered no

Symptoms: We were alerted that the patient died at home.

Other Meds: unknown

Current Illness: pt denied

Died: Y

Date Died: 01/22/2021

ID: 0966178
Sex: M
Age: 89
State: WI

Vax Date: 01/19/2021
Onset Date: 01/22/2021
Rec V Date: 01/22/2021

Lab Data: none

Allergies: aminoglycosides and sulfa meds

Symptoms: Pt called son to let him know he couldn't breath around 2 AM. Pts son showed up at his house 10 minutes later and ambulance arrived with in 20 minutes at 2:15

Other Meds: acetaminophen 600 mg every 4 hrs, albuterol 2 puffs every 6 hrs, Symbicort 2puffs 2 x days, vitamin D, B12, Prozac 20 mg once per day, Veramyst 1 spray once per day, Lisinopril 5 mg once per day, Prilosec 40 mg once per day, Probiotic daily

Current Illness: skin ulcer of lower right leg due to old gun shot wound

Died: Y

Date Died: 01/20/2021

ID: 0966359
Sex: F
Age: 77
State: IN

Vax Date: 01/19/2021
Onset Date: 01/20/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies: Aleve

Symptoms: Headache, pain in the injection site, threw up. A few hours later she died.

Other Meds: Levothyroxine, Gabapentina, furosemide, Losartan, pravastatin

Current Illness: Diabetes, hyper tension

Died: Y

Date Died: 01/14/2021

ID: 0966844
Sex: M
Age: 76
State: NM

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/22/2021

Lab Data: None

Allergies: KNA

Symptoms: Patient is reported to have died at home, the day after his COVID test. Family member states that he did good the afternoon and evening after his COVID-19 injection, but that he started not feeling good the next day. The patient "was having palpitations". The family tried to convince him to go to the Emergency Room, but he refused. Patient died at home.

Other Meds: Unknown

Current Illness: DM II

Died: Y

Date Died: 01/13/2021

ID: 0966856
Sex: F
Age: 90
State: KY

Vax Date: 12/31/2020
Onset Date: 01/04/2021
Rec V Date: 01/22/2021

Lab Data: 1/8: White blood cell count 11.6, hemoglobin 12.2, platelets 369. Sodium is 165, potassium 3.2. BUN/creatinine creatinine are 48 and 1.2. Bilirubin is 1.6. Glucose 127. Urinalysis has 25 leukocytes, negative nitrites, 10-15 white blood cells, 1+ bacteria. Chest x-ray shows no acute cardiopulmonary disease. CT scan of the head shows a tiny left frontal scalp hematoma, with nothing else acute. - 1/9: White blood cell count is 13.5, hemoglobin 12.1. Sodium is 168, potassium 3.4. BUN/creatinine are 47 and 1.3, glucose 145. - 1/10: WBC 15.5, Hgb 10.6. Plt 268. Na 169, K 4.0, Glucose 174. BUN/Cr 38/1.1. Urine culture showed NO GROWTH. - 1/11: WBC: 12.7 HGB: 10.2 PLT: 223 SODIUM: 164 POTASSIUM: 3.9 GLUCOSE: 172 BUN: 32 CREATININE: 1.2 SArs-cor-2 RDRp gen detected 1/4/2021 ( NEDS ID 7797449)

Allergies: unk

Symptoms: Patient is a 90-year-old female. She is a nursing home resident with and ongoing COVID 19 outbreak occurring . She has been diagnosed with corona virus on 1/4/21. She apparently has not eaten or drank anything in about a week. She was being hydrated at the nursing home with normal saline, but has failed to improve. She was sent to the ER and was admitted on 1/8/21 to hospital At no time during the hospital stay has she been more than minimal responsive. She need O2 for Comfort but on CXR and CT cardiopulmonary imagining was clear. Discharge note stated that he was requiring supplemental oxygen, but her chest x-ray on admission actually showed no acute cardiopulmonary disease. She was diagnosed with COVID-19 on 1/4/21. Most likely, this disease set her level of function back to the point that she was no longer eating and drinking, and she just overall rapidly declined after that. There was no evidence of an actual COVID pneumonia or pneumonitis. On 1/12/2021 family made patient a DNR and IVF were stopped and switched to comforted care. Patient expired 1/13/21

Other Meds: Covid outbreak in the facility tested two week before negative.

Current Illness: unk

Died: Y

Date Died: 01/22/2021

ID: 0966888
Sex: F
Age: 56
State: NV

Vax Date: 01/22/2021
Onset Date: 01/22/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: At 04:30 on 1/22/2021, facility was notified of employee death at home.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/06/2021

ID: 0967240
Sex: M
Age: 47
State: MN

Vax Date: 12/29/2020
Onset Date: 01/06/2021
Rec V Date: 01/22/2021

Lab Data:

Allergies:

Symptoms: Patient unexpectedly died on o1/6/2020. No known signs or symptoms.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/21/2021

ID: 0967399
Sex: M
Age: 56
State: TN

Vax Date: 01/12/2021
Onset Date: 01/21/2021
Rec V Date: 01/23/2021

Lab Data: no

Allergies: No

Symptoms: Sudden death

Other Meds:

Current Illness: No

Died: Y

Date Died: 01/21/2021

ID: 0967506
Sex: M
Age: 73
State: TX

Vax Date: 01/16/2021
Onset Date: 01/01/2021
Rec V Date: 01/23/2021

Lab Data:

Allergies:

Symptoms: Died within 5 days of receiving vaccine. Exact cause and day unknown.

Other Meds: Ketoconazole, lisinoprol, atravastatin, xarelto, bupropion, sertraline

Current Illness:

Died: Y

Date Died: 01/21/2021

ID: 0967830
Sex: M
Age: 64
State: CA

Vax Date: 01/21/2021
Onset Date: 01/21/2021
Rec V Date: 01/23/2021

Lab Data:

Allergies: unknown

Symptoms: Patient was was brought to the ED from facility which he received the vaccine via ambulance with BiPAP, hypoxia, and one dose of Epi of 0.3 mg. He then required intubation, and had struggled with hypoxia, even on increasing PEEP. CODE BLUE called in the ED for PEA. He was medicated for such (please see the code run sheet for details), and he came in and out of the code 5 times. After 95 minutes, with the wife at the bedside, and family conference by phone, the code was called, and he was pronounced at 18:20. He received in total 8 me of Epi, 3 shots of Atropine, 3 amps bicarb. He got lasix 40 mg, lovenox 60 mg subcutaneous once. He had a CVC into the right internal jugular, and levophed was started, then Epinephrine drip was started. Prior to the code he got steroids (solumedrol 125 mg, then later decadron 6 mg iv), benadryl iv, antibiotics (ceftraixone / zithromax), and lasix 40 mg. All this time while in the ED, the Rt was at the bedside, and lots of secretions from the lungs were aspirated, bloody color. Code was the result of PEA secondary to hypoxia (

Other Meds: AMLODIPINE BENZOATE , ATORVASTATIN CALCIUM, LOSARTAN POTASSIUM, METOPROLOL SUCCINATE, metFORMIN

Current Illness: HTN, DM2. COVID-19 infection, 12/24/20.

Died: Y

Date Died: 01/13/2021

ID: 0968195
Sex: M
Age: 82
State: FL

Vax Date: 01/12/2021
Onset Date: 01/12/2021
Rec V Date: 01/23/2021

Lab Data:

Allergies: None known.

Symptoms: My dad got the Moderna Vaccine on Tuesday, January 12, 2021 in his left arm at the Mall injection site for the Health Department. He was told that the side effects could mean his arm hurting, tiredness, headache, and even a low grade fever. Additionally, the site informed us both (as I was with him to get the injection) that this was all normal and not to seek medical attention unless these symptoms last longer than 72 hours. That evening, my dad was experiencing all of those symptoms, and went to bed at 7pm. A little after 10am on Wednesday, January 13, 2021, when he awoke, my dad went to the bathroom vomiting. This was where he collapsed and went into cardiac arrest. Fire/Rescue was dispatched about 10:30am after my mom started CPR. County Fire Rescue EMTs and Paramedics continued CPR and other attempts at reviving him all the way to Hospital Emergency Department. He was pronounced dead at 12:14pm on Wednesday, January 13, 2021. We have no doubt my dad, following the instructions of the injection facility, thought he was just experiencing the side effects of the vaccine. He had no chance. Had this injection been done in the RIGHT arm, perhaps he could have recognized the arm numbness being that of an impending heart attack. We really miss Dad. He served this country with distinction for over 50 years, and we believe his country failed him.

Other Meds: I do not have that information at the time of this filing. I?m his Son making the filing

Current Illness: None known

Died: Y

Date Died: 01/19/2021

ID: 0968707
Sex: F
Age: 91
State: OH

Vax Date: 01/19/2021
Onset Date: 01/19/2021
Rec V Date: 01/24/2021

Lab Data:

Allergies: unknown

Symptoms: My mother died 12 hours after the vaccine was administered

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/24/2021

ID: 0968846
Sex: F
Age: 81
State: FL

Vax Date: 01/22/2021
Onset Date: 01/22/2021
Rec V Date: 01/24/2021

Lab Data:

Allergies: Dust mites and outdoor allergens

Symptoms: Within 15 minutes of the injection, the individual became aphasia and stroke like symptoms. She was taken to the ER where she was later diagnosed with a cerebral hemorrhage and passed away.

Other Meds: Bisoprolol 10-62, Fluticasone, Montelukast, Oxybutynin 15mg

Current Illness: None

Died: Y

Date Died: 01/24/2021

ID: 0969219
Sex: M
Age: 61
State: SC

Vax Date: 01/23/2021
Onset Date: 01/24/2021
Rec V Date: 01/24/2021

Lab Data: none

Allergies: no known allergies

Symptoms: patient received the Moderna Covid 19 vaccine on 1/23/2021 around 5:45pm wife called management today and reported that he had collapsed and passed away today around noon

Other Meds: furosemide 40 mg indomethacin er 75 mg venlafaxine 75 mg tab hydralazine 50 mg metoprolol tart 100 mg verapamil er 240mg captopril 100 mg tamsulosin 0.4 mg oxybutynin er 15 mg pot cl micro er 20 meg spironolactone 25 mg gabapentin 300 mg

Current Illness: reported on profile were hypertension, pain, gout, bladder and urine flow issues

Died: Y

Date Died: 01/22/2021

ID: 0969220
Sex: F
Age: 65
State: AR

Vax Date: 01/15/2021
Onset Date: 01/22/2021
Rec V Date: 01/24/2021

Lab Data:

Allergies: Unknown

Symptoms: Patient expired one week after vaccine. Cause of death unknown to me.

Other Meds: Unknown

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0969363
Sex: F
Age: 79
State: CA

Vax Date: 01/14/2021
Onset Date: 01/16/2021
Rec V Date: 01/24/2021

Lab Data:

Allergies: None

Symptoms: Patient obtained initial dose of Moderna vaccine on Thurday, Jan 14. No adverse effects reported during initial 15 minute post vaccine waiting period. Saturday morning (Jan 16), patient developed severe cough, labored breathing, and fever. Additionally patient mental status changed suddenly, became non-communicative (unable to speak, but would scream if she was touched). O2 status was irregular, dropping to 78. Sunday morning, EMT and then hospice was hospice called. Monday morning, after hospice emergency kit was initiated, patient passed away.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0969488
Sex: F
Age: 90
State: VA

Vax Date: 01/11/2021
Onset Date: 01/11/2021
Rec V Date: 01/24/2021

Lab Data: CBC, BMP, CT

Allergies: No

Symptoms: Fatigue, muscle aches, vomiting, hematoma

Other Meds: losartan, doxazosin, metoprolol, Areds 2 eye vitamins

Current Illness: Covid 19

Died: Y

Date Died: 01/14/2021

ID: 0973814
Sex: M
Age: 94
State:

Vax Date: 01/12/2021
Onset Date: 01/12/2021
Rec V Date: 01/24/2021

Lab Data:

Allergies:

Symptoms: DEATH Narrative:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0973820
Sex: M
Age: 73
State:

Vax Date: 12/23/2020
Onset Date: 01/13/2021
Rec V Date: 01/24/2021

Lab Data:

Allergies:

Symptoms: Narrative: Symptoms: & DEATH DUE TO COVID 01/13/21 Treatment:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/09/2021

ID: 0969636
Sex: M
Age: 65
State:

Vax Date: 01/05/2021
Onset Date: 01/01/2021
Rec V Date: 01/25/2021

Lab Data: Test Name: ecg; Result Unstructured Data: AV Block and occasional PVC's

Allergies:

Symptoms: Found dead at home slumped on the floor; Loss of appetite; Body aches; Feverish; A spontaneous report was received from a physician, concerning a 65-years-old male patient, who received Moderna's COVID-19 Vaccine and experienced feverish, body aches, loss of appetite, and death. The patient's medical history, as provided by the reporter, included diabetes, hypertension, Hashimoto's, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia. Concomitant medications reported included metformin, glimepiride, lisinopril, atorvastatin, aspirin, methimazole, propranolol, and cilostazol. On 05 Jan 2021, prior to the onset of events, the patient received the first of two planned doses of mRNA-1273 (lot number 037k20a) for COVID-19 infection prophylaxis. On an unknown date in Jan 2021, some time after receiving the vaccine, the patient was feeling feverish with body aches and loss of appetite. On 09 Jan 2021 at approximately 21:30, the patient was found dead at home slumped on the floor. According to the paramedics, the patient was dead longer than when his wife found him, and no resuscitation was performed. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the events, feverish, body aches, loss of appetite, was considered resolved. The patient died on 09 Jan 2021. The cause of death was not reported. The reporter assessed the event, death, as not related to Moderna's COVID-19 Vaccine. The reporter did not provide assessment for the events, feverish and body aches, in relation to Moderna's COVID-19 Vaccine.; Reporter's Comments: This case concerns a 65 year old male patient with medical history of diabetes, hypertension, Hashimoto's, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia, who experienced the serious unexpected event of death, non-serious unexpected event of loss of appetite, and non-serious expected events of fever and body pain. The event of death occurred 5 days after the first dose of mRNA-1273. The events of fever, body pain and loss of appetite occurred an unspecified period of time after the first dose of mRNA-1273. Very limited information regarding these events has been provided at this time. Based on temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Definitive causal association is confounded by age and medical history of diabetes, hypertension, Hashimoto's, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia.

Other Meds: METFORMIN; GLIMEPIRIDE; LISINOPRIL; ATORVASTATIN; ASPIRIN (E.C.); METHIMAZOLE; PROPRANOLOL; CILOSTAZOL

Current Illness:

Died: Y

Date Died: 01/01/2021

ID: 0969648
Sex: F
Age:
State:

Vax Date: 12/29/2020
Onset Date: 12/30/2020
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: death of unknown cause; Swelling on Right side of the neck and under chin; Warmth on right side of neck and under chin; Redness on right side of neck and under chin; A spontaneous report was received from a healthcare professional concerning an 89-year-old, female patient who received Moderna's COVID-19 vaccine (mRNA-1273) and experienced events of redness, warmth and swelling on right side of neck and under chin, and death of unknown cause. The patient's medical history included Alzheimer's and chronic obstructive pulmonary disease (COPD). No concomitant medications were reported. On 29 Dec 2020, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Lot number: Unknown) intramuscularly for prophylaxis of COVID-19 infection. On 30 Dec 2020, the patient experienced the events of redness, warmth and swelling on right side of neck and under chin. There was no indication that the patient was transferred out to hospital, which was unlikely because she was under hospice care. On 01 Jan 2021, the patient died due to an unknown cause of death. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 01 Jan 2020. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter's Comments: This case concerns a 89-year-old, female subject with a medical history of Alzheimer's and chronic obstructive pulmonary disease (COPD) who experienced redness, warmth and swelling on R side of neck and under chin and expired from an unknown cause. The events of redness, warmth and swelling on R side of neck and under chin occurred 2 days after administration of the first and only dose of the mRNA-1273 vaccine and patient expired 4 days after mRNA-1273 vaccine administration. Lot # of the vaccine was not provided. De-challenge and re-challenge are not applicable. The events of redness, warmth and swelling on R side of neck and under chin are temporarily associated with the administration of the mRNA-1273 and thus, a causal relationship cannot be excluded. Due to limited information, the fatal outcome was considered unrelated to mRNA-1273 administration pending additional information. Fatal outcome is confounded by the patient's underlying condition and advanced age.; Reported Cause(s) of Death: Unknown cause of death

Other Meds:

Current Illness: Alzheimer's disease; COPD

Died: Y

Date Died: 01/20/2021

ID: 0969699
Sex: M
Age: 83
State: CA

Vax Date: 01/19/2021
Onset Date: 01/19/2021
Rec V Date: 01/25/2021

Lab Data: NA

Allergies: None

Symptoms: Patient died.

Other Meds: Creon 36K -114K Doxycycline Hyciate 100 MG Eliquis 5 mg Furosemide 40 mg Losartan Potassium Pantoprazole Sodium 40 MG Sildenafil Citrate 100 MG Stendra 200 MG Tadalafil 20 MG Tramadol Hcl 50 MG Trazodone Hcl 100 MG Triamcinolone Acetonide

Current Illness: Metastatic duodenal adenocarcinoma , bladder cancer, undergoing chemotherapy with success. Dual chamber pacemaker

Died: Y

Date Died: 12/30/2020

ID: 0970042
Sex: F
Age:
State:

Vax Date: 12/30/2020
Onset Date: 12/30/2020
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: patient passed away with in 90 minutes of getting vaccine; This is a spontaneous report from three non-contactable consumer reporting on behalf of the patient via a Pfizer sponsored program, Corporate (Pfizer) Social Media Platforms. A 90 (unspecified unit) old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; Solution for injection, lot number: EL0142, unknown expiration), via an unspecified route of administration in right arm (reported as AR) on 30Dec2020 at a single dose for COVID-19 immunization. The patient's medical history and concomitant medications were not reported. It was reported that the patient was a nursing home patient and received the first dose of COVID vaccine on 30Dec2020. The patient was monitored for 15 minutes after getting shot. Staff reported that the patient was 15 days post COVID. The patient passed away with in 90 minutes of getting vaccine on 30Dec2020. The patient did not require office/ ER visit. An autopsy was not performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Patient passed away with in 90 minutes of getting vaccine

Other Meds:

Current Illness:

Died: Y

Date Died: 12/10/2020

ID: 0970043
Sex: U
Age:
State:

Vax Date: 12/10/2020
Onset Date:
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: Reported causes of death: Diarrhoea; This is a spontaneous report from a contactable healthcare professional via agency and a non-contactable consumer via a Pfizer-sponsored program Corporate (Pfizer) Social Media Platforms. An elderly patient of an unspecified age (also reported as were in their early to mid-60's) and gender received BNT162B2 (Pfizer-BIONTECH Covid-19 Vaccine), via an unspecified route of administration on 10Dec2020 at a single dose for COVID-19 immunisation. Medical history included pseudomembranous colitis (broad), gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), and noninfectious diarrhoea (narrow) . The patient's concomitant medications were not reported. The patient experienced diarrhoea on an unspecified date in 2020. It was reported that most of the deaths after the COVID-19 vaccine occurred within 24-48 hours after the shot. The write-ups that accompanied the reports furnished details about these sad fatalities, including the astonishing fact that some of the decreased had actually experienced and recovered from COVID-19 (raising questions about why they were vaccinated). It was also reported that the event was not life-threatening, did not result to a birth defect or permanent disability, did not require any office/ER/doctor visit, and did not require any hospitalization. The patient died on 10Dec2020. It was not reported if an autopsy was performed. The reported cause of death: diarrhoea. No follow up attempts are possible, information about the lot/batch number cannot be obtained.; Sender's Comments: Based on the available information the event diarrhea resulting in death is attributed to patients preexisting medical conditions including pseudomembranous colitis, gastrointestinal nonspecific symptoms and therapeutic procedures, and noninfectious diarrhea. However, based on a close chronological association (same day) contributory role of BNT162B2 (Pfizer-BIONTECH Covid-19 Vaccine) to event exacerbation cannot be completely excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Reported causes of death: Diarrhoea

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0970162
Sex: M
Age:
State: MD

Vax Date:
Onset Date:
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: received the vaccine on Tuesday and was found dead at his kitchen table Wednesday afternoon; This is a spontaneous report from a contactable consumer. An 89 years old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on an unknown date, at single dose, for COVID-19 immunization. Medical history and concomitant medications were not reported. The patient received the vaccine on Tuesday (unspecified date) and was found dead at his kitchen table on Wednesday afternoon (unspecified date). Cause of death was unknown. It was unknown if an autopsy was performed. Information about batch/lot number has been requested.; Reported Cause(s) of Death: received the vaccine on Tuesday and was found dead at his kitchen table Wednesday afternoon

Other Meds:

Current Illness:

Died: Y

Date Died: 01/22/2021

ID: 0970412
Sex: F
Age: 79
State: NY

Vax Date: 01/18/2021
Onset Date: 01/18/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies: no

Symptoms: Fever Feeling tired short of breath all night and morning after the vaccine My grandma had to be intubated and then passed away to a heart distress we think it was the vaccine because she was fine even with dialysis. When she got the vaccine it took hours and her health conditions changed.

Other Meds: thiamine 100 MG tablet sevelamer carbonate 800 MG tablet Multiple Vitamins-Minerals (MULTIVITAMIN ADULT) Tab carvedilol 3.125 MG tablet ascorbic acid 500 MG tablet lisinopril 10 MG tablet

Current Illness: High blood pressure. Dialysis

Died: Y

Date Died: 01/16/2021

ID: 0970495
Sex: F
Age: 77
State: NC

Vax Date: 01/13/2021
Onset Date: 01/16/2021
Rec V Date: 01/25/2021

Lab Data: Unknown.

Allergies:

Symptoms: Patient expired three days after receiving first dose of Moderna COVID-19 vaccine. The death certificate states cause of death is sudden cardiac arrest.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0970618
Sex: F
Age: 89
State: AR

Vax Date: 01/22/2021
Onset Date: 01/23/2021
Rec V Date: 01/25/2021

Lab Data: HOSPITAL STATED PATIENT HAD A STROKE

Allergies: UNKNOWN

Symptoms: SON SAID PATIENT WAS FOUND UNRESPONSIVE AND CALLED 911

Other Meds: UNKNOWN

Current Illness: UNKNOWN

Died: Y

Date Died: 01/25/2021

ID: 0970930
Sex: M
Age: 91
State: NC

Vax Date: 01/09/2021
Onset Date: 01/14/2021
Rec V Date: 01/25/2021

Lab Data: Patient had positive PCR test on 1/21. IgG to COVID was negative on 1/19.

Allergies: Penicillins

Symptoms: Pt developed COVID-19 infection, symptoms starting 7 days after first dose was given. Patient was admitted to hospital on 1/21 after falling (secondary to weakness) and striking head on toilet. Patient expired due to respiratory complications of COVID on 1/25.

Other Meds: I-caps

Current Illness: -

Died: Y

Date Died: 01/21/2021

ID: 0970976
Sex: F
Age: 94
State: CT

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/25/2021

Lab Data: n/a

Allergies: NKA

Symptoms: At approximately 12:15 pm the resident had a brief unresponsive episode that resolved quickly. Her Vital signs were stable and her mentation was at baseline. Later that evening approximately 10 pm she had labored respirations, shortness of breath, lethargy with bilateral crackles, Oxygen desaturated to 76% on room air, tachycardia and hypotension. She expired at 6:30 a.m. the following day.

Other Meds: VEntolin inhaler, Ursodial, Protonix, MVI, Mirtazapine, Lasix, Coumadin

Current Illness: Admitted from home to hospital on 1/5 for pancreatitis, Chocystitis, GI bleed. HAd a biliary stent placed. TEsted positive for Covid 19 on 1/7/21. Transferred from hospital to a covid recovery Short term facility and transferred to this facility on 1/18/21 for long term care. She was admitted on comfort measures due to prior decline

Died: Y

Date Died: 01/21/2021

ID: 0971166
Sex: M
Age: 94
State: KS

Vax Date: 01/01/2021
Onset Date: 01/21/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: The decedent reportedly was vaccinated 3-4 days before 01/19/21. The decedent was admitted to Hospital on 01/19/21 for end of life care and passed on 01/21/2021.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/21/2021

ID: 0971176
Sex: M
Age: 84
State: OH

Vax Date: 01/20/2021
Onset Date: 01/21/2021
Rec V Date: 01/25/2021

Lab Data: Autopsy being done.

Allergies: none

Symptoms: Pt. woke up the next morning after vaccination and "didn't feel well", described by wife as fatigue, no energy. At approximately 2 PM, he vomited. His wife checked on him at 4:20 PM and he wasn't breathing sitting in his chair. EMS squad was called but when they arrived he was asystole and mottling present. Did not start CPR since he was already gone too long. Pronounced by coroner on scene.

Other Meds: atorvastatin 10 mg avodart 0.5 mg finasteride 5 mg colace 100 mg fish oil capsule over the counter nabumetone 750 mg omiprazole 20 mg tamsulosin 0.4 mg calcium plus D3 over the counter

Current Illness: last doctor visit on 10/27/2020 and no illness at that time, routine follow up

Died: Y

Date Died: 01/19/2021

ID: 0971559
Sex: F
Age:
State: TX

Vax Date: 01/01/2021
Onset Date: 01/19/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: her mother passed away 7-8 days after receiving the vaccine; This is a spontaneous report from a contactable consumer, the daughter of the patient. A female patient of an unspecified age received the first dose of COVID-19 mRNA VACCINE (MANUFACTURER UNKNOWN), via an unspecified route of administration in Jan2021 as a single dose for COVID-19 immunization. The patient's medical history and concomitant medications were not reported. On 19Jan2021 about 7-8 days after receiving the vaccine, the patient passed away. The patient was fine before she received the vaccine and then passed away 7-8 days later. The cause of death was not reported. It was not reported if an autopsy was performed. The reporter thought her mother's death had everything to do with the COVID-19 vaccine. The lot number for the vaccine was not provided and will be requested during follow up.; Reported Cause(s) of Death: Death

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0971562
Sex: U
Age:
State: NY

Vax Date:
Onset Date:
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: died; acute immune thrombocytopenia; This is a spontaneous report from two contactable consumers. A patient of unspecified age and gender received BNT162B2(lot number and expiration date not provided) via an unspecified route of administration on unspecified date at single dose for COVID-19 immunization. The patient's medical history and concomitant medications were not reported. The patient died after receiving the covid vaccine on an unknown date. The patient developed acute immune thrombocytopenia on an unknown date. It was unknown if autopsy was performed. The cause of death was unknown. The outcome of the event "died" was fatal and of the event " acute immune thrombocytopenia" was unknown. The reporter wondered if a platelets blood problem may lead to death and if who have a blood platelets condition like essential thrombocytosis should not risk taking the vaccine. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: Died

Other Meds:

Current Illness:

Died: Y

Date Died: 01/19/2021

ID: 0971676
Sex: F
Age: 82
State: IA

Vax Date: 12/31/2020
Onset Date: 01/01/2021
Rec V Date: 01/25/2021

Lab Data: resident hospitalized on 1/6/21

Allergies: hydrocodone, metformin, niacin, Aricept, lipitor

Symptoms: muscle aches-increased pain to lower back

Other Meds: Tylenol, aleve, aspirin, bisacodyl, calcium carb-cholecalciferol, diclofenac, fluticasone-Salmeterol inhaler, hydromorphone, hycacyamine sulfate, ketoconazole cream, levemir, lidocaine patch, lisinopril, mematine, methcarbamol, metoprolol,

Current Illness: HYPERLIPIDEMIA, UNSPECIFIED(E78.5), CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED(J44.9), VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE(F01.50), OTHER SPECIFIED ANXIETY DISORDERS(F41.8), VENTRAL HERNIA WITHOUT OBSTRUCTION OR GANGRENE(K43.9), NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED(K52.9), CHRONIC VASCULAR DISORDERS OF INTESTINE (K55.1), SACROCOCCYGEAL DISORDERS, NOT ELSEWHERE CLASSIFIED(M53.3), OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE(M85.80), PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM(Z86.718), PRESENCE OF INTRAOCULAR LENS(Z96.1), ANEMIA, UNSPECIFIED(D64.9), DISORDER OF WHITE BLOOD CELLS, UNSPECIFIED(D72.9), IRRITABLE BOWEL SYNDROME(K58), ABDOMINAL AORTIC ANEURYSM, WITHOUT RUPTURE(I71.4), PAIN IN RIGHT ANKLE AND JOINTS OF RIGHT FOOT(M25.571), TYPE 2 DIABETES MELLITUS WITH DIABETIC PERIPHERAL ANGIOPATHY WITHOUT GANGRENE(E11.51), ACUTE HEMATOGENOUS OSTEOMYELITIS, OTHER SITES(M86.08), ESSENTIAL (PRIMARY) HYPERTENSION(I10), GROSS HEMATURIA(R31.0), MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED(F33.9), CHRONIC KIDNEY DISEASE, STAGE 2 (MILD)(N18.2), WEDGE COMPRESSION FRACTURE OF T11- T12 VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING(S22.080D), PERIPHERAL VASCULAR DISEASE, UNSPECIFIED(I73.9), BODY MASS INDEX [BMI]40.0-44.9, ADULT(Z68.41), HYPERMETROPIA, BILATERAL(H52.03), OTHER MYELODYSPLASTIC SYNDROMES(D46.Z), MUSCLE WEAKNESS (GENERALIZED)(M62.81

Died: Y

Date Died: 01/21/2021

ID: 0971736
Sex: M
Age: 88
State: IA

Vax Date: 01/21/2021
Onset Date: 01/21/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies: terbinafine, ACE inhibitors, tetanus toxoids

Symptoms: Vomit 30 minutes after administration. approx. 9 hours later, resident has Stroke-like symptoms. He was previously on Hospice before admitting to our facility and planned to be readmitted to hospice upon discharge.

Other Meds: acetaminophen, aspirin, atorvastatin, bicalutamide, Plavix, lisinopril, metoprolol, multivitamin, oxycodone, Seroquel, sertraline, vanicream

Current Illness: DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING (S72.142D), MALIGNANT NEOPLASM OF PROSTATE(C61), UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE(F03.90), ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS(I25.10), DISPLACED FRACTURE OF BASE OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING(S72.041D), ESSENTIAL (PRIMARY) HYPERTENSION(I10), ANEMIA, UNSPECIFIED(D64.9), HYPOKALEMIA(E87.6), ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE(I21.3), MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED(F33.9), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), ALZHEIMER'S DISEASE WITH LATE ONSET(G30.1), OTHER ABNORMALITIES OF GAIT AND MOBILITY(R26.89), DISORIENTATION, UNSPECIFIED(R41.0), MUSCLE WEAKNESS (GENERALIZED)(M62.81), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12)

Died: Y

Date Died: 01/21/2021

ID: 0971813
Sex: F
Age: 85
State: AL

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies: Iodine

Symptoms: patient received vaccine on 1/20/2121, later that night husband found her slumped in chair, called EMS and patient was taken to Hospital where she died on 1/21/2021

Other Meds: not known

Current Illness: A fib, type 2 diabetes, HTN, seizure disorder, CHF

Died: Y

Date Died: 01/21/2021

ID: 0971969
Sex: F
Age: 72
State: LA

Vax Date: 01/15/2021
Onset Date: 01/21/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies: NKA

Symptoms: brought by EMS to ED; seizures at home in bed; 6 Epi and 1 bicarb; no hx of seizure

Other Meds:

Current Illness:

Died: Y

Date Died: 01/19/2021

ID: 0972092
Sex: F
Age: 88
State: CA

Vax Date: 01/19/2021
Onset Date: 01/19/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies: None reported

Symptoms: Reportedly, this employee's mother died the night of the vaccine. The details are not known at this time.

Other Meds: Diabetes Prescription

Current Illness: Diabetes Mellitus

Died: Y

Date Died: 01/14/2021

ID: 0972113
Sex: F
Age: 91
State: TN

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/25/2021

Lab Data: No test performed. Resident's family did not wish for any tx to be provided. Comfort measures only

Allergies: NKA

Symptoms: Resident became lethargic and reports of blood coming from resident's nose and mouth on the morning of 1/13/21. Resident went out to ER for eval, and came back to facility with dx of pneumonia and recommendations for resident to be placed on hospice. Resident deceased on 1/14/21. Unknown if vaccine related, but with timeline of events I was advised to report this per medical director of facility, as well as Pharmacy who administered the vaccine.

Other Meds: Pantoprzole, Miralax, Potassium, buspirone, Aspirin 81mg, Atenolol, Depakote, Glucosamine-chondroitin, mirabegron ER, Zyprexa, Atorvastatin, Ocuviteeye&MVM

Current Illness: Resident was Dx with pneumonia the day after vaccine.

Died: Y

Date Died: 01/13/2021

ID: 0972148
Sex: F
Age: 91
State: MI

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/25/2021

Lab Data: X-RAY OF PELVIS/HIP CT SCAN OF BRAIN

Allergies: NKDA

Symptoms: VACCINATION WAS RECEVIED THE MORNING OF 1/5/2021- IN THE EVENING OF THAT DAY RESIDENT SUSTAINED A FALL AND WAS TRASNPORTED TO FACILITY FOR TREATMENT. IT IS NOT UNUSUAL THAT RESIDENT WAS SELF TRANSFERRING AND HAS A HISTORY OF FALLS.

Other Meds: ATIVAN 0.5MG EVERY 6 HOURS SYNTHROID 75MCG DAILY METOPROLOL TARTRATE 50MG TWICE DAILY MED PASS 2.0 THREE TIMES DAILY COLACE 200MG DAILY DICYCLOMINE 10MG TWICE DAILY NORCO 5-325MG FOUR TIMES DAILY NEURONTIN 100MG TWICE DAILY NEURONTIN 3

Current Illness: RESIDENT SUSTAINED A FALL ON 1/5/2021.

Died: Y

Date Died:

ID: 0972167
Sex: M
Age: 74
State: AL

Vax Date: 01/22/2021
Onset Date: 01/22/2021
Rec V Date: 01/25/2021

Lab Data: None known

Allergies: None listed

Symptoms: Wife reported that 3 hours after receiving vaccine, pt had MI.

Other Meds: None listed

Current Illness: none listed

Died: Y

Date Died: 01/21/2021

ID: 0972370
Sex: M
Age: 60
State:

Vax Date: 01/20/2021
Onset Date: 01/21/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: patient received covid vaccine and had a heart attack the next day and died

Other Meds:

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0972392
Sex: F
Age: 78
State: IL

Vax Date: 12/30/2020
Onset Date: 01/02/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: Patient sent to hospital 1/2 and 1/5. Returned both times to nursing home covid unit without a hospital admission. Resident had been diagnosed with COVID later in the day on 12/30, when routine testing PCR results returned to facility, after resident had already had her first covid vaccination on 12/30/20 in the morning. Resident continued decline, was again sent to hospital on 1/24/21, and expired in hospital 1/25/21.

Other Meds:

Current Illness: Left femur fx 12-7-20 UTI 12-7-20

Died: Y

Date Died: 01/20/2021

ID: 0972394
Sex: M
Age: 65
State: CA

Vax Date: 01/19/2021
Onset Date: 01/20/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies: Unknown

Symptoms: Died about 24 hours later

Other Meds:

Current Illness: Unknown

Died: Y

Date Died: 01/23/2021

ID: 0972610
Sex: M
Age: 65
State: CA

Vax Date: 01/21/2021
Onset Date: 01/23/2021
Rec V Date: 01/25/2021

Lab Data: N/A

Allergies: No known allergy

Symptoms: Patient was tested positive for Covid-19 on 12/9/20. Patient received Covid Vaccine on 1/21/21. Patient was observing for 15 minutes in treatment room by Nursing staff. Patient denied any signs/symptoms adverse effect: headache, dizziness & weakness, difficulty breathing, muscle pain, chills, nausea and vomiting, and fever . Patient seated on treatment table appeared to be relaxed, respiration even and unlabored. Health teaching provided. Patient educated to report any changes in condition to staff immediately. Patient verbalized understanding and able to verbalize signs and symptoms and adverse effects to be aware of related vaccine. On 1/22/21: patient was seen by medical provider for "altered behavior". Per medical provider's documentation: "Patient was fallen on 1/2/21 and was sent out to outside hospital on 1/4/21. CT head: no intracranial abnormality, age-related changes. Patient had labs (B12, RPR, folate) were within normal limit". We did MMSE today: 22/30 score "mild dementia" On 1/23/20: "Patient was inside his cell. He was walking towards cell door to obtain his breakfast, when custody witnessed him collapse and activated the alarm. Nursing staff arrived at cell front at 06:34 am and found the patient pulseless and unresponsive, and CPR was immediately initiated. AED was attached at 06:35 am and no shock advised. AMR then arrived and patient did not have ROSC, and was pronounced dead at 06:54 am."

Other Meds: Aspirin EC 81mg, Atorvastatin 10mg, Glipizide 5mg, Lisinopril 40mg, Metoprolol tartrate 25mg, Latanoprost, Sertraline 25mg, Paliperidone 324mg q28 days, Acetaminophen 325mg, Naproxen 500mg, Capsaicin 0.025%, Glucose 40%, Naloxone Nasal Sp

Current Illness: Fall on 1/2/2021

Died: Y

Date Died: 01/24/2021

ID: 0972706
Sex: F
Age: 88
State: HI

Vax Date: 01/22/2021
Onset Date: 01/24/2021
Rec V Date: 01/25/2021

Lab Data:

Allergies:

Symptoms: I do not know which Covid-19 vaccine my mother had received the day before but she reported pain in her shoulder and arm to her caregiver on Sun morning Jan 24th. She did not report any problems with breathing. The caregiver gave her a massage before letting her take an afternoon nap. She was later discovered to be unresponsive and not breathing around 5pm. EMS declared her dead at 5:59pm and were already gone by the time I arrived at the caregiver's house around 6:05pm. She was still slightly warm. Her mouth was slightly opened and her left hand was in a fist. My father had been in the room the whole time and thought she was still sleeping.

Other Meds: Not know at this time

Current Illness:

Died: Y

Date Died: 01/23/2021

ID: 0972782
Sex: F
Age: 81
State: CA

Vax Date: 01/18/2021
Onset Date: 01/23/2021
Rec V Date: 01/25/2021

Lab Data: Not Applicable

Allergies: Compazine Trazadone, Augmentin Penicillin

Symptoms: Resident expired on 1/23/21 . Resident receiving care under hospice ,diagnosis Acute Myeloid Leukemia.

Other Meds: Amlodipine 2.5 mg Eliquis 2.5mg Aspirin 81 mg Cholecalciferol 1.25 mg Ondansetron 4mg , Thiamine HCL 100, Inrebic 100mg Oral Capsule

Current Illness: Acute Myeloid Leukemia

Died: Y

Date Died: 01/24/2021

ID: 0972836
Sex: F
Age: 88
State: MA

Vax Date: 01/20/2021
Onset Date: 01/24/2021
Rec V Date: 01/25/2021

Lab Data: no

Allergies: Levofloxacin, ACE inhibitors

Symptoms: sudden death

Other Meds: lorazepam, trazodone, levothyroxine , acetaminophen, multivitamin, senna

Current Illness: no

Died: Y

Date Died: 01/17/2021

ID: 0972890
Sex: F
Age: 96
State: NY

Vax Date: 12/29/2020
Onset Date: 01/10/2021
Rec V Date: 01/25/2021

Lab Data: Unknown

Allergies: None

Symptoms: On the evening of 10JAN2021, patient experienced a low grade fever, decreased oxygen saturation of 38%, heart rate of 124, confusion. Patient received oxygen via face mask, morphine and ativan. By 11JAN2021, patient was no longer verbal, able to eat or communicate and was kept on comfort measure only. On the morning of 17JAN2021, the patient passed away.

Other Meds: unknown

Current Illness: COVID-19 positive on November 19, 2020 and didn't test negative until December 26, 2020

Died: Y

Date Died: 10/09/2019

ID: 0972898
Sex: M
Age: 68
State: OH

Vax Date: 09/30/2019
Onset Date: 10/05/2019
Rec V Date: 01/25/2021

Lab Data: Many tests performed during hospitalization 10/06/2019 through 10/09/2019

Allergies: NKDA

Symptoms: 5 days after receiving the vaccination the patient developed generalized malaise progressing to encephalopathy. He was admitted to the hospital with presumed septic shock, and work-up revealed hemophagocytic lymphohistiocytosis. He died from the disease process 9 days after vaccination.

Other Meds: pred forte right eye, zaditor right eye, finasteride 5 mg daily, aspirin 81 mg daily, MVI, xyzal 5 mg daily, saw palmetto, antivert 25 mg TID PRN, pantoprazole 40 mg daily, lisinopril 20 mg daily, verapamil 180 mg daily, atorvastatin 20 mg

Current Illness:

Died: Y

Date Died: 01/10/2021

ID: 0973808
Sex: M
Age: 73
State:

Vax Date: 12/17/2020
Onset Date: 12/31/2020
Rec V Date: 01/25/2021

Lab Data: Covid tests- negative: Jan 10, 2021 10:30 Not Detected Jan 03, 2021 14:13 Not Detected Dec 31, 2020 17:25 Not Detected Dec 31, 2020 08:40 Not Detected Dec 10, 2020 09:45 Not Detected Nov 05, 2020 16:58 Not Detected Nov 01, 2020 18:15 Not Detected Aug 25, 2020 12:20 Not Detected Aug 12, 2020 Not Detected Jan 01, 2021@11:25 SERUM BD GLUCAN: >500 H Jan 01, 2021@11:25 SERUM BD GLUCAN INTERPRETATION:POSITIVE normalcy status - Abnormal INTERPRETATION REFERENCE RANGE: <60 pg.mL Fungal serology 1/8/21 Crypto: not detected CocLPA: negative CocIDTP: negative 1/15/21: Outside Coccidioidomycosis serology laboratory report received. Complement fixation serum 1/13/21 2:40pm: Negative. Immunodiffusion Serum 1/15/21 11:17am: Negative. Interpretation Serum 1/15/21 11:17am: Any coccidioidal infection is so well focalized that serology is not positive to a diagnostic level. If onset of illness has been within the past four weeks you may wish to follow up with another specimen in 2 to 3 weeks.

Allergies:

Symptoms: shortness of breath, chest xray with pulmonary edema, periorbital edema Narrative: 73 yo M w/ PMH HTN, HLD, EVAR (2013) for AAA c/b persistent type II endoleak s/p multilple repairs (2015 & 2017) c/b glue embolization down into the R CIA secured with additional stent placement with the R iliac limb, s/p b/l Iliac artery aneurysm stent 08/31/20, and PTSD. Former smoker, quit 12+ yrs ago. 11/1/20-11/6/20: Hospitalized for acute on chronic back pain, found to multiple hypermetabolic lesions in the axial skeleton. Diagnosed with epithelioid angiosarcoma. Patient discharged to facility. 12/17/20: Patient received his 1st COVID-19 vaccine w/o complications at facility. 12/21/20: Underwent cyberknife treatment. 12/31/20: Transferred from facility to ER for new O2 requirement, SOB, cough, chest X ray / pulm edema, tachycardic and new periorbital edema. 12/31/20: Admitted to ICU before transfer to acute care. 1/1/21: Pulmonary consult, "Labs are notable for progressive left shift with bandemia, markedly elevated inflammatory markers (D-dimer, ESR, CRP, ferritin, LDH), mild elevation in procalcitonin, mild elevation in lactate that has improved, and negative viral panel including COVID-19 x2. CT chest is notable for b/l GGOs along with some interstitial infiltrates with an upper and particularly mid zone and perihilar predominance, septal thickening and crazy paving, and numerous cystic lesions or pneumatoceles. There is a lack of lobar consolidation and pulmonary nodules. Of note, PET/CT about 2 months ago only demonstrated some mild to moderate emphysema mostly in the upper lobes. Therefore, there has been a relatively dramatic change in a few months, suggesting a more subacute process, rather than an acute infectious process such as a viral pneumonia, including COVID-19 infection, in which the GGOs tend to be subpleural and peripheral. Overall, our suspicion for COVID-19 is relatively low, with negative testing x2 yesterday, negative testing a few weeks ago, and lack of sick contacts, but it is possible. Therefore, higher on the differential is a more subacute infection or chemotherapy-induced pneumonitis. Risk factors include malignancy, chemotherapy, and use of steroids (equivalence of about 27 mg of Prednisone in the form of Dexamethasone since 11/6/20 without PJP prophylaxis). These risk factors, along with consistent imaging and elevated LDH, make PJP quite likely. Fungal infection is less likely based on imaging. Chemotherapy-induced pneumonitis is a possibility, especially given the more subacute picture based on imaging. Both Gemcitabine and Docetaxel can cause pneumonitis. However, the patient has been on steroids, which is used to treat drug-induced pneumonitis, although this does not exclude it completely." 1/2/21: Transferred to ICU for worsening hypoxemia as patient reached 40L/100% FIO2 and remained on COVID isolation/COVID patient under investigation per ID recommendation. 1/4/21: Isolation precautions discontinued due to lower suspicion for active COVID infection to explain current presentation 1/6/21: Went into atrial fibrillation w/o RVR overnight 1/6. Tolerating, with MAPs in low 60s and HR in high 90s/low 100s. Suspect due to being-1L yesterday from diuresis, lasix stopped. S/p amiodarone bolus + drip, albumin 5% bolus 1/5/21: Macrocytic anemia NOS w/ slowly worsening H/H s/p PRBC x 1 unit 1/7/21: Per ICU Life-sustaining treatment note, "Following discussion w/ patient that his lung dx has been refractory to txt and hasn't improved despite maximal therapy, patient agreed to transition to hospice after he settles affairs. " 1/7/21 Infectious Disease note: "This is an immunocompromised host due to cancer on active chemotherapy (albeit ANC>4000 on admission) and notably had been on daily PO dexamethasone 1 mg TID (total daily dose 3 mg, equivalent to 20 mg PO prednisone) since 11/6/20 without any PJP ppx. There was elevated c/f COVID-19 infection in setting of patient's presenting symptoms, especially in conjunction with b/l GGOs on imaging. Has undergone multiple COVID test that have all resulted negative. Discussed radiographic findings with radiology colleagues, and overall, it is difficult to definitively narrow the differential with imaging alone, but overall density of GGOs seem to appear less likely PJP and more in line with chemical pneumonitis vs COVID, although less typical for viral pneumonia as well. Given false-negative COVID tests are not unheard of, especially in the immunocompromised population, patient was kept on isolation precautions as a PUI for abundance of caution. He is now off precautions. In setting of patient having been on prednisone for some time without PJP ppx, he was also started on treatment dose TMP/SMX. Beta-d-glucan has returned positive, and although not the ideal test for PJP, this can certainly support a potential dx of PJP. Unfortunately, DFA from sputum was not performed due to insufficient sample and currently the patient is unable to produce an additional sample for testing. He is tolerating the high-dose TMP/SMX; we adjusted the dose to three SS tablets TID based on his somewhat declining UOP. Other fungal etiologies are pending work-up as well. Lastly, patient's chemotherapy is known to cause pneumonitis, but per pulmonology team, he receives prophylactic dexamethasone with his chemo cycles that should help to prevent drug-induced pneumonitis. Remains on the differential for now and this should also be concurrently treated with the steroids he is receiving." 1/10/21: Comfort care initiated. All non-comfort measures were discontinued. Time of death: Jan 10,2021@14:56; immediate cause of death per death note is "hypoxic respiratory failure"

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0973889
Sex: M
Age: 65
State: CT

Vax Date: 01/19/2021
Onset Date: 01/19/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: none

Symptoms: Systemic: Other- unknown, depot store received call from facility on 1/22 that patient passed around 7pm

Other Meds:

Current Illness:

Died: Y

Date Died: 01/26/2021

ID: 0973957
Sex: M
Age: 81
State: NC

Vax Date: 01/20/2021
Onset Date: 01/24/2021
Rec V Date: 01/26/2021

Lab Data: PT 36.0 PTT 39.0 INR 3.1 platelets 195 Head CT - Large Geographic left parietal/occipital parenchymal hemorrhage with 12mm rightward shift. Subarachnoid and subdural hemorrhage of the left hemisphere.

Allergies: penicillin

Symptoms: 5 days after receiving his COVID vaccination the patient had a spontaneous (nontraumatic) subarachnoid hemorrhage which was fatal. The patient had previously been stable on his coumadin dosing with therapeutic INRs for the past several months per his wife. At time of presentation his blood pressure in the ER was elevated to 223/94 and his INR was risen to 3.1

Other Meds: pantoprazole 40 mg daily potassium chloride 10 meq daily sotalol 120mg BID warfarin 2.5mg daily warfarin 5mg weekly furosemide 40mg daily allopurinol 200 mg daily donepezil 10mg daily lisinopril 5mg daily

Current Illness: none

Died: Y

Date Died: 01/26/2021

ID: 0973966
Sex: M
Age: 82
State: FL

Vax Date: 01/25/2021
Onset Date: 01/26/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies:

Symptoms: death

Other Meds: Toujeo 300 unit/ml,trulicity 3mg/0.5ml, hydrochlorthiazide 12.5mg, actos 45mg, onglyza 2.5mg, olmeprazole 40mg, repaglinide 1mg, olmesartan 40mg, simvastatin 40mg, amlodipine 10mg

Current Illness:

Died: Y

Date Died: 01/26/2021

ID: 0974033
Sex: F
Age: 69
State: IN

Vax Date: 01/13/2021
Onset Date: 01/26/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: Macrobid, depacote, sulfamethoxazole/trimethorpim, lisinopril, lyrica, sumatriptan succinate

Symptoms: Resident deceased on 1/26 at 445am. No signs ahead of time.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/23/2021

ID: 0974138
Sex: F
Age:
State: GA

Vax Date: 01/18/1920
Onset Date: 01/23/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: UNKNOWN

Symptoms: DEATH- NO OTHER INFORMATION KNOWN

Other Meds: UNKNOWN

Current Illness: UNKNOWN

Died: Y

Date Died: 01/25/2021

ID: 0974172
Sex: F
Age: 94
State: WA

Vax Date: 01/24/2021
Onset Date: 01/25/2021
Rec V Date: 01/26/2021

Lab Data: none

Allergies: lisinopril

Symptoms: Resident passed away 1/25/2021 at 1048pm after the vaccine was given on 1/24/2021. Resident had been being monitored but death was not expected.

Other Meds: guaiFENesin, aspirin, celexa, Buprenorphine, zinc, vitamin D, voltaren gel, miralax, hydralazine, ascorbic acid, coreg, tramadol, metolazone, melatonin, potassium, gabapentin, senna, magnesium, ocuvite, losartan potassium, doss, vitamin B1

Current Illness: COVID-19 diagnosis 12/29/2020, pneumonia, CHF, depression, rheumatoid arthritis and anemia.

Died: Y

Date Died: 01/23/2021

ID: 0974422
Sex: F
Age: 85
State: MD

Vax Date: 01/18/2021
Onset Date: 01/19/2021
Rec V Date: 01/26/2021

Lab Data: none-family wanted no medical testing

Allergies: none

Symptoms: Patient developed fever to 102 within 24 hours with decreased mentation. Stopped eating/drinking despite aggressively treating fever. Was DNR B status. Family agreed to a trial of IV fluids on 1/21 but was not successfully started until 1/22 after several attempts. Family wanted only comfort measures with no transfer to hospital. Patient continued to have fevers to 102-103 range. Patient passed on 1/23 . Patient did test positive for COVID in early September without significant illness. She was in usual state of health prior to vaccination.

Other Meds: depakote, seroquel, aspirin, loratidine, prilosec, senna plus, vitamin D, gabapentin

Current Illness: none

Died: Y

Date Died: 01/03/2021

ID: 0974443
Sex: M
Age: 76
State: TN

Vax Date: 12/30/2020
Onset Date: 01/02/2021
Rec V Date: 01/26/2021

Lab Data: CBC/CMP 1/2/21 - Normal Rapid COVID test 1/2/21 - Negative Unsure of tests performed at hospital

Allergies: N/A

Symptoms: Patient received Moderna COVID vaccine on 12/30/2020 at a Pharmacy clinic where he was a resident. Nurses at the facility reported that he was responsive and showed no signs of any adverse effects until 1/2/2021 when he was observed slightly unresponsive and staring at the ceiling and trembling. He had a fever of 101F at this time. The facility ordered labs and a rapid COVID test (all of which came back normal) and started IV antibiotics. A few hours later, patient began bleeding from his eyes, nose, and mouth and was sent to the local ER. The patient refused being admitted to the ICU for possible sepsis/hemorrhage and died the following day on 1/3/2021. All healthcare professionals involved agreed that this was not likely due to the vaccine, but needed to be reported nonetheless.

Other Meds: Unknown

Current Illness: Unkown

Died: Y

Date Died: 01/20/2021

ID: 0974454
Sex: F
Age: 78
State:

Vax Date: 12/28/2020
Onset Date: 01/20/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies:

Symptoms: Patient passed away 23 days after receiving COVID vaccine

Other Meds:

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0974489
Sex: F
Age: 80
State: MI

Vax Date: 01/19/2021
Onset Date: 01/25/2021
Rec V Date: 01/26/2021

Lab Data: Medical Examiner does not believe this is related to vaccine.

Allergies: Clarithromycin, cefaclor, ciprofloxacin, codeine, erythromycin, penicillins, tramadol, naproxen. All of these cause shortness of breath. Generic lisinopril-HCTZ caused severe headache and nausea. Statins cause joint pain and stiffness, couldn't walk.

Symptoms: No immediate symptoms. No symptoms ever reported. Patient was found dead in her home on 1/25/2021 and last seen on 1/24/2021. Neighbor called for welfare check because they had not seen her and she had not checked mailbox. No evidence of foul play.

Other Meds: Ipratropium and prednisone prescribed on 1/6/2021. Other medications include albuterol inhaler & nebulizer solution, calcium carbonate, cetirizine, cyclobenzaprine, fluticasone nasal spray, Advair HFA, home oxygen, guaifenesin, lidocaine 5

Current Illness: Asthma, COPD exacerbation.

Died: Y

Date Died:

ID: 0974553
Sex: F
Age: 66
State: NY

Vax Date: 01/20/2021
Onset Date: 01/24/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: NKA

Symptoms: RESIDENT RECEIVED THE VACCINE ON 1/20/2021, RESIDENT HAD BEEN MONITORED EVERY SHIFT AND HAS NOT EXHIBITED ANY SYMPTOMS. RESIDENT WAS OBSERVED TO BE UNRESPONSIVE WITH NO PRESENCE OF VITAL SIGNS ON 1/24/2021. RESIDENT WAS A FULL CODE, CPR INITIATED UNSUCESSFULLY. BASED ON REVIEW WITH PRIMARY CARE PHYSICIAN AND MEDICAL DIRECTOR, THE RESIDENT HAD NOT HAVE ANY OTHER EVENTS PRIOR TO RECEIVING THE COVID VACCINE 4 DAYS PRIOR TO EVENT.

Other Meds: MOBIC, MVI, OLANZAPINE, REMERON, COLACE, TYLENOL

Current Illness:

Died: Y

Date Died: 01/22/2021

ID: 0974573
Sex: M
Age: 95
State: MI

Vax Date: 01/05/2021
Onset Date: 01/21/2021
Rec V Date: 01/26/2021

Lab Data: NONE- PALLIATIVE CARE

Allergies: STATINS

Symptoms: ON 1/21/2020 RESIDENT WAS EXPERINCING CHILLS AND LOOSE STOOLS. FOLLOWING THIS EPISODE BECAME UNRESPONSIVE, PALE, DIAPHORETIC AND BRADYCARDIC. PALLIATIVE CARE WAS PROVIDED. RESIDENT PASSED AWAY APPROX. 10 HOURS LATER.

Other Meds: SYNTHROID 25MCG DAILY PRILOSEC 10MG DAILY CASODEX 50MG DAILY TYLENOL 500MG THREE TIMES DAILY MULTIVITAMIN DAILY ZOLOFT 25MG DAILY NAPROXEN 440MG DAILY

Current Illness: URINARY TRACT INFECTION

Died: Y

Date Died: 01/21/2021

ID: 0974794
Sex: F
Age: 89
State: NE

Vax Date: 01/12/2021
Onset Date: 01/21/2021
Rec V Date: 01/26/2021

Lab Data: LAB: WBC 37.7, HGB 7.3, CRP, 24.4, platelet 867, negative for MRSA screen, normal flora sputum culture, PCT 5.69, UA 1+bacteria, Na+130, K+ wnl, ALK phos 183, albumin 1.5, Creatinine 1.88, troponin neg. Radiology:

Allergies: Sulfa, duloxetine

Symptoms: Patient presented to Vaccine clinic 1/12/21 to receive COVID vaccination. Patient denied any ill feeling, no fever, cleared for vaccination. Is chronically SOB due to COPD, but patient reported no different than usual. Presented to the ED the next day c/o SOB and weakness for the last week. Patients condition ultimately declined over the next few days and died 01/21/21 from pneumonia (not COVID). Patient did admit she lied about her symptoms on the day of vaccination to get the shot.

Other Meds: albuterol, amlopidine, aspirin, atorvastatin, lasix, gabapentin, HCTZ, hydroxyzine, lansoprazole, levalbuterol, losartan, meloxicam, Norco, Nystatin, Preservision, Prolia, Refresh eye drops, Spiriva, Wixela

Current Illness: Pneumonia, pleural effusion, COPD,

Died: Y

Date Died: 01/25/2021

ID: 0974833
Sex: M
Age: 85
State: ND

Vax Date: 01/19/2021
Onset Date: 01/24/2021
Rec V Date: 01/26/2021

Lab Data: 1/24/21 0445:hematology, chemistry, coagulation, UA, CXR, Chest CT. 1/24/21 1705: hematology, chemistry, CXR, Head CT.

Allergies: NKA

Symptoms: 1/24/21 0445- patient presents to the ED with complaints of neck pain, chest pain, and back pain for about a week. States also feels SOB, intermittent fever with temperature 100.3 on arrival. Patient was worked up for his cardiac type symptoms, found to have elevated WBC and CRP with no explanation. D-Dimer was elevated with CT showing no sign of PE. Patient was sent home from the ED with instructions to follow up with primary care and/or return if s/s worsen. 1/24/21 1705- patient is returned to the ED via ambulance after becoming unresponsive and some seizure like activity. Patient was intubated. Head CT showed large brain bleed that was irreparable and not compatible with life. Patient was also found with positive blood cultures x2 with gram positive cocci in clusters growing after 9 hours.

Other Meds: isosorbide mononitrate ER 30mg daily, allopurinol 300mg daily, aspirin 81mg daily, nitroglycerin 0.4mg PRN, rosuvastatin 10mg daily, codine/guaifenesin syrup 5lm PO Q6H PRN, fursemide 40mg BID, levothyroxine 75mg daily, metoprolol succinate

Current Illness: unknown

Died: Y

Date Died: 01/25/2021

ID: 0974855
Sex: F
Age: 76
State: MA

Vax Date: 01/25/2021
Onset Date: 01/25/2021
Rec V Date: 01/26/2021

Lab Data: sent to the Medical Examiner office for Autopsy

Allergies: No Known Allergies

Symptoms: decedent had shortness of breath and hypoxia, cardiac arrested in front of the EMS crew, ACLS initiated, arrived in the Hospital ED asystole and pronounced dead

Other Meds: pantoprazole, levothyroxine, lisinopril, lamotrigine, atenolol, mirtazapine, furosemide, dronabinol

Current Illness: hypothyroid, hypertension

Died: Y

Date Died: 01/20/2021

ID: 0974960
Sex: M
Age: 53
State: MI

Vax Date: 01/05/2021
Onset Date: 01/14/2021
Rec V Date: 01/26/2021

Lab Data: 1/14/2021- URINALYSIS WITH CULTURE, CBC

Allergies: AMOXIL

Symptoms: ON 1/14/2021 TYPICAL UTI SYMPTOMS FOR RESIDENT DEVELOPED INCLUDING FEVER AND RIGIDITY. RESIDENT IS NON-VERBAL. IV ANTIBIOTICS WERE STARTED. FREQUENT UTI'S ARE COMMON FOR THIS RESIDENT.

Other Meds: JEVITY, FAMOTIDINE, VALIUM, ATROPINE, LABETALOL, PROSCAR, LASIX, DUONEB, KEPPRA, GUIAFENESIN, ERYTHROMYCIN ETHYLSUCCINATE

Current Illness: UTI

Died: Y

Date Died: 01/14/2021

ID: 0975002
Sex: M
Age: 88
State: WI

Vax Date: 01/12/2021
Onset Date: 01/13/2021
Rec V Date: 01/26/2021

Lab Data: 1/13/2021 CT scan head

Allergies: Bee venum, shellfish, adhesive tape, cardizem, primidone

Symptoms: on 1/13/2021 at 3:40am Cliff called for assistance. He lost his balance and had fallen. Cliff refused vitals, refused emergency department, denied hitting his head. As the day progressed patient developed a headache, diarrhea, and vomiting. He again declined the offer for the emergency room. At supper time wife and staff found Cliff unresponsive, 911 was called and he was taken to the emergency department. The ER did a CT scan and found an acute subdural hematoma. Patient was placed on comfort cares and expired at 3pm on 01/14/2021. Cliff did not have a history of falls.

Other Meds: Cholecalciferol 1000 ius daily, Magnesium Oxide 400mg BID, Vi

Current Illness: Stable

Died: Y

Date Died: 01/25/2021

ID: 0975023
Sex: M
Age: 76
State: NY

Vax Date: 01/25/2021
Onset Date: 01/25/2021
Rec V Date: 01/26/2021

Lab Data: SARS-CoV-2 by PCR - NEGATIVE, FLU-A./B/RSV NEGATIVE

Allergies: SULFA, IODINE-BASED CONTRAST MEDIA

Symptoms: CARDIAC ARREST THAT LEAD TO DEATH - IT WAS REPORTED BY EMS THAT THE PT HAD RECEIVED THE VACCINE ABOUT 30 MINS PRIOR. HE ARRIVED HOME, BECAME SHORT OF BREATH & COLLAPSED. 911 WAS CALLED AND HE WAS TRANSPORTED VIA EMS TO HOSPITAL (16:17) WHERE HE LATER EXPIRED (23:01).

Other Meds: ATORVASTATIN 20MG DAILY, GABAPENTIN 300MG TWICE DAILY, HYDRALAZINE 10MG 3 TIMES DAILY, LANTUS 30UNITS AT BEDTIME, LUMIGAN OPHTHALMIC SOLN BOTH EYES EVERY EVENING, METOLAZONE 2.5MG DAILY, OMPERAZOLE 20MG DAILY, PREDNISONE 15MG DAILY, TORSEMI

Current Illness:

Died: Y

Date Died: 01/19/2021

ID: 0975184
Sex: F
Age: 89
State: AR

Vax Date: 01/14/2021
Onset Date: 01/19/2021
Rec V Date: 01/26/2021

Lab Data: unknown

Allergies: none

Symptoms: The patient had a heart attack and died at a local hospital morning of 1/19/2021.

Other Meds: Unknown

Current Illness: none

Died: Y

Date Died: 01/22/2021

ID: 0975206
Sex: F
Age: 87
State: OH

Vax Date: 12/22/2020
Onset Date: 01/22/2021
Rec V Date: 01/26/2021

Lab Data: CBC & BMP on 1/8/21 Routine labs Chest X-ray on 1/18/21- no acute pathology Urine culture 1/18/21 final results on 1/21/21 E. Coli infection

Allergies: No known allergies

Symptoms: 1 fall after first dose on 1/8/2021 at 1930; no injuries; 4 falls after second dose on 1/14/21 at 1545, 1/15/21 at 1700, 1/21/21/at 1220 and 1/21/21 at 1330 all falls with no injuries. Started Ceftriaxone 1 GM IM daily for 5 dyas on 1/21/21 for UTI: E. Coli

Other Meds: Aricept 10 mg at bedtime; Cerovite Sr, Tablet 1 tablet daily; Coreg 6.25 mg two times a day; Ferrous Sulfate 325 mg two times a day; Folidc Acid 1 mg daily; Lexapro 5 mg daily; Lisinopril Hydrochlorothizide 20-12.5 mg daily; Methimazole 5 m

Current Illness: 11/30/2020 positive for Covid-19

Died: Y

Date Died:

ID: 0975223
Sex: F
Age: 105
State: TX

Vax Date: 01/13/2021
Onset Date: 01/14/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: Azithromycin and Sulfa antibiotics

Symptoms: Systemic: Headache-Severe, Systemic: Other- Death 8 days after receiving the vaccine-Severe

Other Meds:

Current Illness:

Died: Y

Date Died: 01/23/2021

ID: 0975318
Sex: F
Age: 62
State: KY

Vax Date: 01/22/2021
Onset Date: 01/23/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: NKDA

Symptoms: PATIENT RECIEVED 2ND DOSE OF SHINGRIX VACCINE AROUND 9:30 AM ON 1/22/2021, RECEIVED NOTIFICATION PATIENT SUFFERED FATAL HEART ATTACK MORNING OF 1/23/2021.

Other Meds: RX: ALPRAZOLAM 0.5MG, TRAZODONE 100MG, TIZANIDINE 2MG, OXYBUTYNIN ER 10MG, LINZESS 290MCG, LEVOTHYROXINE 175MCG, OXYCODONE-ACETAMINOPHEN 7.5MG/325MG, GABAPENTIN 800MG, ALBUTEROL HFA 90MCG, METFORMIN 500MG

Current Illness: UNKNOWN

Died: Y

Date Died: 01/23/2021

ID: 0975382
Sex: M
Age: 83
State: FL

Vax Date: 01/20/2021
Onset Date: 01/22/2021
Rec V Date: 01/26/2021

Lab Data: 01/20/21-Routine labs ordered, BUN elevated and BNP at 55, 01/22/21-Stat labs ordered-WBC-23, BNP-1426, Xray- 01/22/21-Right lung opacities

Allergies: none

Symptoms: 01/22/20When transferring resident from bed to W/C Resident became unresponsive to voice with eyes fix open and point up to the right. Placed resident back in bed found 82% o2 sats B/P 110/106 pulse 110 resp below 16 placed o2 via non rebreather with 20 l/min 02 up to 90% then stabilized at 89% Resident following all commands encouraged to take do breathing exercises, with some compliance, continues ABT/pneumonia , no s/s adverse 1/23/2021 16:48 Discharge Summary Note Text: Resident found unresponsive with no pulse or respirations in bed with emesis on gown. Time of death verified at 1645 with LPN. Funeral Home called at 1900 and body released at 2000.

Other Meds: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 4 hou

Current Illness: Anemia, Dementia, COPD

Died: Y

Date Died: 01/01/2021

ID: 0975421
Sex: M
Age: 60
State: MO

Vax Date: 01/07/2021
Onset Date: 01/01/2021
Rec V Date: 01/26/2021

Lab Data: Unknown by this reporter

Allergies: none known

Symptoms: Resident was discovered deceased in his apartment on 1/23/2021. Family had

Other Meds: unknown medications for COPD, nebulizers, inhalers

Current Illness: Patient had reported on 8/8/2019 having arthritis, leg wounds, COPD, asthma, incontinence of bladder. Resident may also have had blood clots in his legs, per his sister.

Died: Y

Date Died: 01/09/2021

ID: 0975434
Sex: M
Age: 67
State: IL

Vax Date: 01/02/2021
Onset Date: 01/07/2021
Rec V Date: 01/26/2021

Lab Data: Spoke to RN at ER. Resident had fever of 102.9 upon arrival to the ER. He coded on the way back from his CT scan. He was diagnosed with right sided pnuemonia, respiratory failure and sepsis. Resident just passed away in ER and was not even admitted. Family was there with him

Allergies: No Known Allergies

Symptoms: vomiting x3 1/8/21 1/9/21 00:34 - called to resident room by CNAs, staff stated resident was "different". Vitals taken and 02 sat was low, O2 in room and applied via NC @3L, O2 sat returned to 98 and all other vitals WNL including BS. Resident asked how he felt, stated he felt "okay". Resident exhibiting some shakey movements and clearing throat, states he does not have any phlegm or drainage or trouble swallowing. MD called and updated on situation, voicemail left. 1/9/21 11am- resident has been making a "growling" noise this shift. resident also has tremors. resident alert and answers questions appropriately. when asked if resident wants to go to hospital, resident firmly states "no". vitals wnl. no emesis noted. will continue to monitor resident. 1/9/21 12p- resident not answering questions appropriately. resident only answering yes or no. resident cannot tell me name, or the year, resident cannot state where he is currently or birthdate.

Other Meds: Renvela, Clopidogrel, Coreg, Aceteminophen, amLODIPine Besylate, Atorvastatin Calcium, Benzonatate, Calcium Acetate, Citalopram Hydrobromide, cloNIDine, Cozaar, Diclofenac, Docusate Sodium, Fluticasone-Umeclidin-Vilant Aerosol Powder Breath

Current Illness: OTHER INJURY OF UNSPECIFIED BODY REGION, SUBSEQUENT ENCOUNTER , LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED , CELLULITIS OF LEFT LOWER LIMB, CELLULITIS OF RIGHT LOWER LIMB , END STAGE RENAL DISEASE , DEPENDENCE ON RENAL DIALYSIS , TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE,UNSTEADINESS ON FEET , CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED , MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE , COGNITIVE COMMUNICATION DEFICIT, REPEATED FALLS, OTHER LACK OF COORDINATION, SPINAL STENOSIS, LUMBAR REGION WITH NEUROGENIC CLAUDICATION, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION, ESSENTIAL (PRIMARY) HYPERTENSION

Died: Y

Date Died: 01/20/2021

ID: 0975689
Sex: F
Age: 97
State: AR

Vax Date: 01/06/2021
Onset Date: 01/20/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: PCN and NKFA

Symptoms: Resident vaccinated on 01/06/21 she acquired COVID 19 on 01/10/2021. Resident had multiple co morbidities and was declining prior to the vaccine. Resident expired on 01/20/2021

Other Meds: IBUPROFEN, VITAMIN D, ZINC, TRAMADOL, CRANBERRY, DULOXETINE, MIRALAX, ACIDOPHYLIS, ATIVAN, ASA, GUAUFENISEN

Current Illness: COVID 19 01/10/2021 HYPEROSMOLOTY AND HYPERNATREMIA HERNIA HYPERGLYCEMIA LOW BACK PAIN ANEMIA OSTEOPOROSIS DEMENTIA WITH BEHAVIORS CONSTIPATION CARDIAC MURMUR/HEART DISEASE POLYNEUROPATHY HX OF BREAST CANCER HTN DEPRESSION

Died: Y

Date Died: 01/25/2021

ID: 0975735
Sex: F
Age: 83
State: AR

Vax Date: 01/06/2021
Onset Date: 01/25/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: Aricept, codeine, hydrocodone, sulfa abx

Symptoms: VACCINE ADMINISTERED 01/06/21 ACQUIRED COVID 19 01/10/21 RESIDENT HAD MULTIPLE CO MORBIDITIES AND WAS DECLINING PRIOR TO VACCINE. RESIDENT EXPIRED ON 01/25/2021

Other Meds: zinc, acidophylis, albuterol inhaler, vitamin d, mirtazapine, Pepcid, vitamin c, Lasix, magnesium oxide, Depakote, cranberry, melatonin, Zoloft, folic acid, pericolace, simethicone, xarelto, asa, mvi with mineral, synthroid, evista,

Current Illness: COVID 19 01-10-2021 GERD DELUSIONS VASCULAR DEMENTIA WITH BEHAVIORS INSOMNIA CHRONIC DVT LEFT LOWER EXTREMITY HEMOCHROMATOSIS PSYCHOSIS MAJOR DEPRESSIVE DISORDER WITH ANXITY IMPULSE DISORDER VITAMIN DEFICIENCY EDEMA CONSTIPATION HALLUCINATIONS HYPOTHYROIDISM HX OF SKIN CANCER CARPAL TUNNEL LT HAND DYSTHYMIC HTN

Died: Y

Date Died: 01/15/2021

ID: 0975744
Sex: F
Age: 87
State: CA

Vax Date: 01/07/2021
Onset Date: 01/15/2021
Rec V Date: 01/26/2021

Lab Data: UA, CBC, CMP

Allergies: NKA

Symptoms: See initial report

Other Meds: Atorvastatin Calcium 10mg, Ceftriaxone 1GM, Famotidine, Hydrocodone-Acetaminophen 5-325mg, Levothyroxine 25mcg, Senna, ASA, Docusate

Current Illness: The resident was febrile on 1/9/2021 after receiving the Pfizer vaccine on 1/7/2021. On 1/9/2021 UA, CBC, and CMP ordered indicating she had UTI. SARS-CoV-2 testing was performed using POCT GeneXpert on 1/9/2021. No SARS-CoV-2 was detected. The resident continued to decline and on 1/15/2021 she became tachycardiac and was having trouble breathing. She was transferred to ER where she later died.

Died: Y

Date Died: 01/24/2021

ID: 0975762
Sex: F
Age: 57
State: ID

Vax Date: 01/20/2021
Onset Date: 01/24/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: - Fish containing products - Kale - PCN

Symptoms: Pt deceased

Other Meds:

Current Illness: N/A

Died: Y

Date Died: 01/17/2021

ID: 0975918
Sex: M
Age: 60
State:

Vax Date: 01/12/2021
Onset Date: 01/17/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies:

Symptoms: death Narrative:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/18/2021

ID: 0975952
Sex: M
Age: 91
State:

Vax Date: 01/15/2021
Onset Date: 01/16/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies:

Symptoms: Narrative:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/26/2021

ID: 0976032
Sex: M
Age: 92
State: CA

Vax Date: 01/22/2021
Onset Date: 01/26/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: No known allergies

Symptoms: Patient stated he wasn't feeling well on January 25, 2021, wasn't eating and complained of abdominal pain. Patient noted to have indigestion and was constipated. Meds provided and labs ordered. On morning of January 26, 2021, patient became weak, lethargic and hypoxic and was sent to emergency department around 0700 hours on January 26, 2021. At approximately 1100 hours, emergency physician notified this writer that patient was not going to overcome his illness and would be placed on comfort care. At approximately 1130 hours, this writer was notified that patient had passed away from multi-organ failure.

Other Meds: Acetaminophen, Aspirin, Sinemet, Docusate, Eliquis, Finasteride, Fluticasone, Furosemide, Klor-con, Melatonin, Nortriptyline, Pantoprazole, Simvastatin, EMU muscle and joint relief cream, Synthroid, Tamsulosin, Vitamin B12, Vitamin D3, TUMS

Current Illness: CHF exacerbation in November 2020

Died: Y

Date Died: 01/24/2021

ID: 0976111
Sex: M
Age: 84
State:

Vax Date: 01/23/2021
Onset Date: 01/24/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: Statins (muscle weakness)

Symptoms: CC:full arrest HPI:HPI and ROS limited due to patient's condition. History is via EMS, medical record, and son. Per Son patient had Covid vaccine on Saturday morning. Slept all day Sunday. Woke up Sunday night a bit "like coming out of a deep sleep per son, around 10 pm. Shortly after that patient was having a hard time breathing. Emergency called. Arrested around the time EMS arrived. King airway, I/O and CPR initiated. Patient has been in v fib. Was shocked multiple times, given 4 rounds of epi, bicarb and amiodarone. ACLS continued on arrival. Multiple rounds of epi, and attempted defib. Patient given epi, bicarb. Rhythms included fine v fib, asystole, and PEA. Unrecoverable with no cardiac motion. Time of death 11:50 pm.

Other Meds: warfarin (COUMADIN) 2.5 mg tablet zinc sulfate 220 (50) mg capsule nutritional supplements (NUTREN 1.5) 0.07 gram-1.5 kcal/mL liqd acetaminophen (TYLENOL) 325 mg tablet senna (SENOKOT) 8.6 mg tab furosemide (LASIX) 40 mg tablet spironolacto

Current Illness: Pt admitted with closed-loop bowel obstruction with subsequent surgery for ex-lap, SBR ~160cm jejunem and ileum, left with open abdomen with Abthera wound vac 12/22. Now s/p Exploratory laparotomy, primary stapled small bowel anastomosis, abdominal fascial and skin closure on 12/24.

Died: Y

Date Died: 01/21/2021

ID: 0976112
Sex: F
Age: 81
State: CA

Vax Date: 01/07/2021
Onset Date: 01/10/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: ASPIRIN PENICILLIN

Symptoms: Resident expired on january 21, 2021

Other Meds: Metoprolol Tartrate Tablet 25 MG BID Norvasc Tablet 10 MG (amLODIPine Besylate) QD Namenda Tablet 5 MG (Memantine HCl) BID Cozaar Tablet 100 MG (Losartan Potassium) QD hydrALAZINE HCl Tablet 25 MG TID Amiodarone HCl Tablet 200 MG QD CloNID

Current Illness: Resident started manifesting loss of appetite and body weakness on January 10,2021 a few days after vaccination. She expired in our facility 1/21/2021.

Died: Y

Date Died: 01/21/2021

ID: 0976146
Sex: F
Age: 86
State: CA

Vax Date: 01/07/2021
Onset Date: 01/21/2021
Rec V Date: 01/26/2021

Lab Data: none

Allergies: None

Symptoms: Resident is asymptomatic

Other Meds: Multivitamin Liquid (Multiple Vitamins-Minerals) Give 5 ml via G-Tube one time a day for (SUPPLEMENT) Aspirin Tablet Chewable 81 MG Give 1 tablet via G-Tube one time a day for (CVA PROPHYLAXIS) Norvasc Tablet 5 MG (amLODIPine Besylate) G

Current Illness: No symptoms after COVID vaccinations

Died: Y

Date Died: 01/18/2021

ID: 0976166
Sex: F
Age: 93
State: CA

Vax Date: 01/07/2021
Onset Date: 01/18/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: NONE

Symptoms: ASYMPTOMATIC

Other Meds: Gabapentin Capsule 100 MG, Give 1 capsule orally one time a day for (NEURALGIA) Losartan Potassium Tablet 50 MG, Give 1 tablet orally one time a day for (HYPERTENSION) HOLD IF SBR<110 OR HR<60 Norvasc Tablet 5 MG (amLODIPine Besylate), Give

Current Illness: NONE

Died: Y

Date Died: 01/21/2021

ID: 0976280
Sex: F
Age:
State: LA

Vax Date:
Onset Date: 01/21/2021
Rec V Date: 01/26/2021

Lab Data:

Allergies: GABAPENTIN; PREGABALIN

Symptoms: Death on 21 Jan 2021 - coroner called provider office

Other Meds:

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0977319
Sex: M
Age: 46
State: MI

Vax Date: 12/29/2020
Onset Date: 01/25/2021
Rec V Date: 01/27/2021

Lab Data: N/A

Allergies: Unknown

Symptoms: Notified by patient's sister on 1/26/2021 that patient died in his sleep on 1/25/2021. She did not know cause of death.

Other Meds: Unknown

Current Illness: Unknown

Died: Y

Date Died: 01/26/2021

ID: 0977320
Sex: F
Age: 83
State: MI

Vax Date: 01/25/2021
Onset Date: 01/26/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies: azathioprine (Imuran)

Symptoms: about 20+ hours after vaccination resident was having hard time breathing, 911 was called. Resident coded multiple times at the facility after CPR she was taken to ICU. She coded again and was placed on life support. Due to her choice to not be on life support she passed on 11/26/2021.

Other Meds: unknown

Current Illness: acute pancreatitis, gerd, ibs, OA, rheumatoid arthritis, HTN, H/o falls, osteoporosis, pre-diabetes, hyperlipidemia, diverticulosis, interstitial lung disease, permatomyoitis

Died: Y

Date Died: 01/21/2021

ID: 0977358
Sex: M
Age: 99
State: FL

Vax Date: 01/08/2021
Onset Date: 01/12/2021
Rec V Date: 01/27/2021

Lab Data: CBC, SMA6 Jan 18, Jan20 Covid 19 test Jan 20 Chest X Ray Jan 20 Chest ultrasound Jan 20

Allergies: none

Symptoms: cough congestive heart failure death

Other Meds: Lisinopril, ASA, Paxil, Amlodipine

Current Illness:

Died: Y

Date Died: 01/21/2021

ID: 0977426
Sex: M
Age: 70
State: GA

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/27/2021

Lab Data: None. He was under hospice care.

Allergies: None

Symptoms: Patient has a history of advanced melanoma with brain metastasis. He developed seizure disorder as well and had some mild seizures at home over the prior month. He received the vaccine at 4pm and was monitored in the office for 15 minutes. He then went home with his daughter whom he lives with. He ate dinner with her and read until 8pm when he went to his room. She found him in his room at 9pm unresponsive with seizures. Hospice was alerted and recommend oral valium. He continued to be unresponsive and expired the following day at 7:30 pm.

Other Meds: Tramadol, Dexamethasone, Pantoprazole, Dilatin, Plaxis, Aspirin, VImpat, Keppra, Clopidogrel

Current Illness: 1. Melanoma with brain metastasis 2. Seizure disorder

Died: Y

Date Died: 01/26/2021

ID: 0977963
Sex: M
Age: 81
State: AL

Vax Date: 01/26/2021
Onset Date: 01/26/2021
Rec V Date: 01/27/2021

Lab Data: Unknown

Allergies: Unknown

Symptoms: (Report per patients wife ) Patient took his usual nap around 12pm. She found him lying in the bed unresponsvie at 2pm. EMS was not called. Patient's wife called the Funeral home.

Other Meds: Unknown

Current Illness: Unknown

Died: Y

Date Died: 01/07/2021

ID: 0978199
Sex: M
Age: 71
State: TX

Vax Date: 01/06/2021
Onset Date: 01/07/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies:

Symptoms: Arm hurting used his oxygen at time of bed appeared vomited.

Other Meds:

Current Illness: Heart disease

Died: Y

Date Died: 01/15/2021

ID: 0978529
Sex: F
Age: 88
State: WV

Vax Date: 12/31/2020
Onset Date: 01/15/2021
Rec V Date: 01/27/2021

Lab Data: Chest XR 1/15/21 CT chest/abdomen 1/15/21

Allergies: Bee Stings, Statins, Flecinide

Symptoms: Patient developed Covid pneumonia dx 1/15/21, patient expired

Other Meds: Lasix 20 mg daily, KCL ER 20 MEQ daily, Eliquis 2.5 mg twice daily, allopurinol 300 mg daily, Lyrica 50 mg daily, Metoprolol Succinate ER 50 mg daily, Amlodipine 5 mg daily, Pravstatin 20mg daily, Vit d3 25mcg daily

Current Illness: None

Died: Y

Date Died: 01/24/2021

ID: 0978567
Sex: M
Age: 82
State: CA

Vax Date: 01/12/2021
Onset Date: 01/24/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies: NKA

Symptoms: Resident received the first dose of Moderna Vaccine on 01/12/2021 and Tested for COVID-19 on 01/12/2021. Resident tested positive on 01/13/2021. Resident was transferred to acute hospital on 01/19/2021 due to desaturation. Resident expired at Hospital on 01/24/2021.

Other Meds: Metformin 500mg PO BID for DM Phenobarbital 97.2mg QD for Seizure Dilantin 100mg, 2 caps, QHS for Seizure Eliquis 5mg BID for DVT Lipitor 10mg QHS for Hyperlipidemia

Current Illness: None

Died: Y

Date Died: 01/26/2021

ID: 0978754
Sex: F
Age: 93
State: CO

Vax Date: 01/26/2021
Onset Date: 01/26/2021
Rec V Date: 01/27/2021

Lab Data: Body released to funeral home

Allergies: Fosamax, Codeine derivatives

Symptoms: No symptoms appeared immediately after vaccination, although patient passed away around 6:00 pm unexpectedly. Staff talked with her last time at 5:30 pm and then found her at 6:00 pm passed away. Unknown at this time if death is directly related to receiving the vaccine.

Other Meds: B12 vitamin 1 tab po daily Triamcinolone acetonide cream 0.5% apply 2-3 times per day Tylenol 500 mg as needed- Had not taken at all in January Loperamide 2 mg as needed-Had not taken at all in January

Current Illness: Hospice client Some diarrhea with colostomy bag in place general decline

Died: Y

Date Died:

ID: 0978873
Sex: U
Age:
State: CA

Vax Date:
Onset Date:
Rec V Date: 01/27/2021

Lab Data: Test Date: 202012; Test Name: Covid-19; Test Result: Positive

Allergies:

Symptoms: died several hours after receiving a Covid-19 vaccine; This is a spontaneous report from a contactable consumer. A patient of unspecified age and gender received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunization. The patient's medical history and concomitant medications were not reported. The patient died several hours after receiving a Covid-19 vaccine on an unspecified date. The patient died on an unspecified date. It was not reported if an autopsy was performed. The person had tested positive for the virus (Covid-19) in late Dec2020. Information on the batch/lot number has been requested.; Reported Cause(s) of Death: died several hours after receiving a Covid-19 vaccine

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0978876
Sex: M
Age:
State:

Vax Date:
Onset Date:
Rec V Date: 01/27/2021

Lab Data:

Allergies:

Symptoms: Autoimmune disease; This is a spontaneous report from a Pfizer-sponsored program from a contactable nurse. A male patient of an unspecified age received bnt162b2 (BNT162B2, Manufacturer Pfizer-BioNTech), via an unspecified route of administration, on an unspecified date, at single dose, for COVID-19 immunisation. The patient's medical history and concomitant medications were not reported. The patient experienced autoimmune disease on an unspecified date. The patient died on an unspecified date due to autoimmune disease. It was unknown if an autopsy was performed. The information on the lot/batch number has been requested.; Sender's Comments: The information available in this report is limited and does not allow a medically meaningful assessment of the case. The company cannot completely exclude a causal relationship between the fatal autoimmune disease and suspect vaccine BNT162B2. Additional information regarding therapy duration, relevant medical history, underlying conditions, concomitant medications and detailed clinical course around the event onset will aid in comprehensive assessment of the case. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics committees and Investigators, as appropriate.; Reported Cause(s) of Death: Autoimmune disease

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0978959
Sex: M
Age: 90
State: CA

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies:

Symptoms: Presented with stroke like symptoms at 10:30, right sided weakness and slurred speach. 911 was call, patient was transported to hospital. Per ED note, patient experienced TIA which resolved, actue exacerbation of CHF. Patient was admitted. Discharge summary on 1/22 indicates same diagnosis, plan was home with hospice. Family notified hospital on 1/25 that patient had expired on 1/23 at home.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/22/2021

ID: 0979081
Sex: M
Age: 89
State: CA

Vax Date: 01/21/2021
Onset Date: 01/22/2021
Rec V Date: 01/27/2021

Lab Data: none

Allergies: NKA

Symptoms: Patient found dead in home the next morning. May or may not be connected to vaccination. Instructed to report it from our medical director and director of nursing.

Other Meds: Warfarin, Tamsulosin, Metoprolol, Vitamin D3, Lasix

Current Illness: None

Died: Y

Date Died: 01/25/2021

ID: 0979101
Sex: F
Age: 64
State: IA

Vax Date: 01/22/2021
Onset Date: 01/25/2021
Rec V Date: 01/27/2021

Lab Data: none

Allergies: Penicillin, Chocolate

Symptoms: cardiac arrest - no warning signs

Other Meds: Allopurinol, Amiodorone, Vitamin C, Budesonide, Chlorhexadine gluconate, Clonidine, Eliquis, Polyethylene glycol, Ipratopium-Albuterol, Lantus, Lasix, Loratadine, Magnesium Oxide, Melatonin, Metolazone, Metoprolol Tartrate, Nepro Carb Stea

Current Illness: none

Died: Y

Date Died: 01/23/2021

ID: 0979155
Sex: M
Age: 65
State: AZ

Vax Date: 01/03/2021
Onset Date: 01/04/2021
Rec V Date: 01/27/2021

Lab Data: Jan 9 sent to emergency room, jan 11 tested pos for influneza A

Allergies:

Symptoms: Jan 3 vaccine administered, jan 4 started headaches, vomiting, pain in the back of the neck, Headaches, chills, loss of speech,

Other Meds: Atrovastatin Calcium 80mg, Cholecalclfer0l Tablet 5000 Unit, Clopidogrel Bisulfate Tablet 75 mg, Colace Capsule 100 mg, Cyanocobalamin tablet 1000 Mcg, Famotidine Tablet 20mg, Gilmepiride Tablet 1 mg, Loperamide HCI Capsule 2Mg, Melatonin T

Current Illness:

Died: Y

Date Died: 01/22/2021

ID: 0979223
Sex: M
Age: 77
State: CA

Vax Date: 01/05/2021
Onset Date: 01/12/2021
Rec V Date: 01/27/2021

Lab Data: (ER event)

Allergies: NKA

Symptoms: Patient developed SOB but reported good O2Sats. Instructed on going to ER if worsening symptoms. Patient eventually expired on 1/22/21

Other Meds: Pravastatin 40 mg, KCL ER 10meq, Metoprolol 25 mg, losartan 100 mg, glyburide 2.5 mg, furosemide 40 mg, ASA 81 mg, amlopidine 10 mg, allopurinol 300 mg

Current Illness: CHF, hypertension, type 2 DM

Died: Y

Date Died: 01/19/2021

ID: 0979255
Sex: M
Age: 65
State: CA

Vax Date: 01/18/2021
Onset Date: 01/18/2021
Rec V Date: 01/27/2021

Lab Data: Patient had 3 EKGs, which did not show STEMI, but did show nonspecific conduction delay and sinus arrest with junctional escape vs sinus bradycardia (HR 50's). Laboratory work done indicated that cardiac enzymes were normal, and that the patient had metabolic acidosis. Cardiology was called, but no need for emergent cath noted. Pt. has POCUS echocardiogram, which showed severe cardiomyopathy with LVEF 20%, and no pericardial effusion. Portable CXR read as: Extensive opacity in R upper lobe and diffuse opacities throughout the L hemithorax are nonspecific, but suggestive of multifocal pneumonia, including COVID-19. CTA Chest for PE w/ Contrast: Impression: no evidence of pulmonary embolism; bilateral extensive airspace consolidation, cannot exclude pneumonia, aspiration; follow-up barium series recommended to foreign body/filling defect in esophagus (Mediastinum findings: There is thickening involving esophagus and a small hiatal hernia. Gastric bypass surgery. There is dense artifact from the mid lumen of the esophagus measuring 8mm).

Allergies: none; + bee allergy listed in records

Symptoms: Patient received COVID 19 vaccine the morning of 1/18/21 at Public Health COVID-19 vaccine clinic. I (person completing this report) work for PH. Later that night while in bed, patient reported difficulty breathing to his wife, then turned blue, and became unresponsive. Family report pt was without any symptoms prior to event. 911 called; CPR started by family member 15 min. after pt became unresponsive. EMS performed resuscitation for about 30-40 minutes with multiple defibrillation for V-fib. Between EMS and Medical Center ER, pt had 9 rounds of epi, CPR w/ LUCAS machine, given 2 doses of amiodarone (150 mg and 300 mg). Patient had 3 EKGs, which did not show STEMI, but did show nonspecific conduction delay and sinus arrest with junctional escape vs sinus bradycardia (HR 50's). Pt had return of spontaneous circulation. Pt intubated, and started on Levophed. Pt transferred to ICU, and had central line placed. Family decided to make patient DNR. Pt went into coarse VFib again, and as per wishes of family, code blue not called. Patient expired at 01:53 on 1/19/21.

Other Meds: per hospital list: Nitrostat 0.4 mg SL prn, famotidine 10 mg, ASA 81 mg, atorvastatin 20 mg, benazepril 5 mg, carvedilol dose unspecified

Current Illness: unknown; family report pt without symptoms prior to event

Died: Y

Date Died:

ID: 0979309
Sex: F
Age: 51
State: NV

Vax Date: 01/22/2021
Onset Date: 01/22/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies:

Symptoms: Systemic: patient had no known medical history per supervisor

Other Meds:

Current Illness:

Died: Y

Date Died: 01/01/2021

ID: 0979495
Sex: M
Age:
State: WY

Vax Date:
Onset Date: 01/19/2021
Rec V Date: 01/27/2021

Lab Data: none

Allergies: Amiodarone Mild Pulmonary fibrosis

Symptoms: No adverse events noted Patient past away was notified by Public Health the record is at Vital Statistics

Other Meds: Budesonide/formoter Fish Oil Aspirin Albuterol Terazosin Potassium Pantoprazole Metoprolol Metolazone Levothyroxine Furosemide Alopurinol Apixaban Lactobacillus Acidophilus

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0979533
Sex: F
Age: 82
State: AZ

Vax Date: 01/19/2021
Onset Date: 01/20/2021
Rec V Date: 01/27/2021

Lab Data: labs were fairly normal; chest xray showed no acute changes; hip xrays showed no fractures, covid 19 rapid screen was negative

Allergies: none

Symptoms: Patient recieved vaccine 1 of covid 19 i 1/19/2021. She felt poorly on 1/20/2021. She felt dizzy and fell at 3 AM on 1/23/2021. She felt poorly and did not know her son's name which was not normal. She went to ER on 1/24. She was assessed as not having fractures. She was going to be transferred to a skilled nursing facility. She was not having respiratory complaints. She was awaiting transfer when her O2 levels started dropping substantially. She declined aggressive intervention and she died within a few hours.

Other Meds: dexamethasone, losartan, amlodipine, Ensure supplement drink

Current Illness: chronic copd is stable condition; no illnesses at time of vaccination

Died: Y

Date Died: 01/23/2021

ID: 0979709
Sex: M
Age: 56
State:

Vax Date: 01/06/2021
Onset Date: 01/11/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies: PCN

Symptoms: Pt passed away 1/23/2021. Exact details unknown.

Other Meds: ZOLOFT 25 MG QD COREG 12.5 MG BID IMDUR 30 MG QD CALCIUM ACETATE 667 MG QID HEPARIN QHD MIRCERA Q4W FERRLECIT 125 MG TIW

Current Illness: NONE

Died: Y

Date Died: 01/16/2021

ID: 0979773
Sex: F
Age: 75
State: TX

Vax Date: 12/30/2020
Onset Date: 01/16/2021
Rec V Date: 01/27/2021

Lab Data: none that i know of

Allergies: none reported

Symptoms: 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

Other Meds: none as far as i know

Current Illness: none per care giver

Died: Y

Date Died: 01/22/2021

ID: 0979796
Sex: M
Age: 74
State: TX

Vax Date: 01/08/2021
Onset Date: 01/10/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies: none

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

Other Meds: 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.

Died: Y

Date Died: 01/26/2021

ID: 0979818
Sex: M
Age: 77
State: TX

Vax Date: 01/25/2021
Onset Date: 01/26/2021
Rec V Date: 01/27/2021

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.

Allergies: None

Symptoms: 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

Other Meds: 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

Died: Y

Date Died: 01/27/2021

ID: 0979837
Sex: M
Age: 76
State: NV

Vax Date: 01/25/2021
Onset Date: 01/27/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies: No known allergies

Symptoms: 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.

Other Meds:

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.

Died: Y

Date Died: 01/15/2021

ID: 0979841
Sex: M
Age: 64
State: MT

Vax Date: 01/07/2021
Onset Date: 01/09/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies:

Symptoms: 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.

Other Meds:

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.

Died: Y

Date Died: 01/02/2021

ID: 0979926
Sex: F
Age: 81
State: CA

Vax Date: 12/30/2020
Onset Date: 01/02/2021
Rec V Date: 01/27/2021

Lab Data: Pt was covid positive from 12/7-12/17

Allergies: N/A

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

Other Meds: 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

Died: Y

Date Died: 01/09/2021

ID: 0979990
Sex: M
Age: 63
State: OH

Vax Date: 01/07/2021
Onset Date: 01/09/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies: NKDA

Symptoms: sudden cardiac arrest

Other Meds:

Current Illness: none

Died: Y

Date Died: 01/14/2021

ID: 0980107
Sex: F
Age: 90
State: AL

Vax Date: 01/12/2021
Onset Date: 01/12/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies:

Symptoms: 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.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/23/2021

ID: 0981938
Sex: M
Age: 68
State:

Vax Date: 01/22/2021
Onset Date: 01/23/2021
Rec V Date: 01/27/2021

Lab Data: Covid negative: 12/27/20, 1/20/21, 1/25/21 Covid Negative 1/11/21

Allergies:

Symptoms: 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 >10 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.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/17/2021

ID: 0981945
Sex: M
Age: 95
State:

Vax Date: 01/08/2021
Onset Date: 01/13/2021
Rec V Date: 01/27/2021

Lab Data: COVID positive on 01/13/21

Allergies:

Symptoms: 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).

Other Meds:

Current Illness:

Died: Y

Date Died: 01/20/2021

ID: 0983720
Sex: M
Age: 75
State:

Vax Date: 12/30/2020
Onset Date: 01/20/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/23/2021

ID: 0983721
Sex: M
Age: 71
State:

Vax Date: 01/13/2021
Onset Date: 01/23/2021
Rec V Date: 01/27/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0981061
Sex: F
Age: 87
State: TN

Vax Date: 01/22/2021
Onset Date: 01/25/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: Unsure

Symptoms: Patient died 3 days post Moderna vaccine.

Other Meds: Unsure

Current Illness: None

Died: Y

Date Died: 01/27/2021

ID: 0981225
Sex: F
Age: 59
State: MD

Vax Date: 01/27/2021
Onset Date: 01/27/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: Imipenem, Penicillins, Peanut

Symptoms: 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.

Other Meds: 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:

Died: Y

Date Died:

ID: 0981303
Sex: M
Age:
State:

Vax Date:
Onset Date:
Rec V Date: 01/28/2021

Lab Data:

Allergies:

Symptoms: pneumonia; Initial information was received on 21-Jan-2021 regarding an unsolicited valid serious case from a consumer/non-health care professional. This case involves an 87 years old male patient who had a fatal pneumonia, while he received INFLUENZA VACCINE. It is unknown if the patient had any medical history, concomitant disease or risk factor. Medical treatment(s), past vaccination(s) and family history were not provided. On an unknown date, the patient received a dose of suspect INFLUENZA VACCINE produced by unknown manufacturer (batch number and expiry date not reported) via unknown route in unknown administration site for prophylactic vaccination On an unknown date, the patient developed a serious pneumonia (unknown latency) following the administration of INFLUENZA VACCINE. This event was assessed as medically significant and was leading to death. The patient was full of hair, most of his teeth and healthy to his last year with no flu shot ever until the last year. It is unknown if the patient experienced any additional symptoms/events There were no laboratory data/results available. It was not reported if the patient received a corrective treatment before death. At the time of report, the outcome of event was fatal It is unknown if an autopsy was done. The cause of death was Pneumonia. Information on batch number was requested for this case; Sender's Comments: This poorly documented case, involves an 87 years old male patient who had a fatal pneumonia following the administration of INFLUENZA VACCINE (unknown manufacturer). The time to onset was unknown. Additional information regarding patient's medical history, condition at the time of vaccination, concomitant medications, lab /radiological investigation excluding other etiologies and detailed autopsy report would be needed for complete assessment of the case. Based upon the reported information, the role of vaccine cannot be assessed; Reported Cause(s) of Death: pneumonia

Other Meds:

Current Illness:

Died: Y

Date Died: 01/19/2021

ID: 0981315
Sex: M
Age: 41
State: VA

Vax Date: 01/13/2021
Onset Date: 01/13/2021
Rec V Date: 01/28/2021

Lab Data: Patient recovered from event but passed 1/19/2021 - Primary cause of death per records - acute decompensated cirrhosis.

Allergies: NKDA

Symptoms: After vaccine was given, patient was cleaned up after having a bowel movement and shortly after, patient became tachypneic with nasal flaring and verbalized the words "can't breathe." Dr. was notified and came to the bedside to assess. Patient had audible upper airway wheezes and orders obtained for Epi, benadryl and solumedrol. RT also came to bedside to assist. 1mg Epi x2 given 25mg Benadryl given 125mg Solumedrol given Anesthesia was called for intubation due to continuing low sats. -7.5 ETT noted at 22@lip -OG@60 Both were cleared via CXR. -0307: patient sedated and resting comfortably.

Other Meds: Hospital meds the day of the event: furosemide, KCL, albumin, ceftriaxone, dexmedetomodine, lactulose, midodrine, octreotide, pantoprazole, and rifaximin

Current Illness: alcoholic cirrhosis and esophageal varices

Died: Y

Date Died: 01/18/2021

ID: 0981406
Sex: F
Age: 71
State: TN

Vax Date: 01/15/2021
Onset Date: 01/18/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: unknown

Symptoms: Stroke, death

Other Meds: multiple, unknown

Current Illness:

Died: Y

Date Died: 01/24/2021

ID: 0981407
Sex: F
Age: 48
State: MO

Vax Date: 01/06/2021
Onset Date: 01/24/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies:

Symptoms: Expired in sleep on 1/24/21

Other Meds:

Current Illness:

Died: Y

Date Died:

ID: 0981790
Sex: M
Age: 82
State: NC

Vax Date: 01/26/2021
Onset Date: 01/26/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: NKA listed on form

Symptoms: Systemic: Other- Death

Other Meds:

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0981849
Sex: M
Age: 92
State: IN

Vax Date: 01/13/2021
Onset Date: 01/16/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: unknown

Symptoms: died 01/16/2021

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/27/2021

ID: 0981912
Sex: F
Age: 67
State: CA

Vax Date: 01/23/2021
Onset Date: 01/23/2021
Rec V Date: 01/28/2021

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.

Allergies: none

Symptoms: 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.

Other Meds: albuterol, fluticasone nasal spray, hydrochlorothiazide, losartan

Current Illness:

Died: Y

Date Died: 01/13/2021

ID: 0982218
Sex: M
Age: 63
State: MO

Vax Date: 01/08/2021
Onset Date: 01/13/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: aspirin: severe unknown reaction

Symptoms: 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.

Other Meds: On hospice: morphine, ativan, trazodone, tylenol

Current Illness: failure to thrive, pressure ulcer, pneumonitis d/t aspiration, dementia, COPD, alzheimer's disease,

Died: Y

Date Died: 01/23/2021

ID: 0982354
Sex: M
Age: 91
State:

Vax Date: 12/29/2020
Onset Date: 01/23/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0982370
Sex: M
Age: 93
State: KY

Vax Date: 01/14/2021
Onset Date: 01/16/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies:

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

Other Meds:

Current Illness: Patient fell at home night before vaccination.

Died: Y

Date Died: 01/14/2021

ID: 0982417
Sex: F
Age: 89
State: KS

Vax Date: 12/30/2020
Onset Date: 01/07/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies:

Symptoms: Resident tested positive for COVID on 1/7/2021.

Other Meds:

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.

Died: Y

Date Died: 01/27/2021

ID: 0982472
Sex: M
Age: 72
State: NJ

Vax Date: 01/19/2021
Onset Date: 01/20/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: None

Symptoms: Worsening respiratory failure 1/20/2021 death 1/27/2021

Other Meds: Eliquis, Lasix, metoprolol

Current Illness: Chf, CKD

Died: Y

Date Died: 01/27/2021

ID: 0982495
Sex: M
Age: 65
State: OK

Vax Date: 01/15/2021
Onset Date: 01/19/2021
Rec V Date: 01/28/2021

Lab Data: none

Allergies: NKDA

Symptoms: 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.

Other Meds: diclofenac

Current Illness: none

Died: Y

Date Died: 01/25/2021

ID: 0982517
Sex: M
Age: 66
State:

Vax Date: 01/11/2021
Onset Date: 01/25/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies:

Symptoms: patient received COVID vaccine on 1/11/2021 and passed away on 1/25/2021

Other Meds:

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0982541
Sex: M
Age: 81
State: IL

Vax Date: 01/22/2021
Onset Date: 01/24/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies:

Symptoms: 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.

Other Meds:

Current Illness: COVID pneumonia 12/2020

Died: Y

Date Died: 01/26/2021

ID: 0982826
Sex: M
Age: 40
State: NV

Vax Date: 01/21/2021
Onset Date: 01/26/2021
Rec V Date: 01/28/2021

Lab Data: not available

Allergies: unknown

Symptoms: 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

Other Meds: unknown

Current Illness: immunocompromised with reportable conditions

Died: Y

Date Died: 01/25/2021

ID: 0982890
Sex: M
Age: 67
State: MS

Vax Date: 01/22/2021
Onset Date: 01/25/2021
Rec V Date: 01/28/2021

Lab Data: 1/25/2021- Troponin 3.010; WBC 19.6

Allergies: No Known Drug Allergies

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 01/16/2021

ID: 0982891
Sex: M
Age: 61
State: KS

Vax Date: 12/30/2020
Onset Date: 12/30/2020
Rec V Date: 01/28/2021

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.

Allergies: NKDA

Symptoms: 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.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/27/2021

ID: 0982929
Sex: F
Age: 61
State: MD

Vax Date: 12/30/2020
Onset Date: 01/27/2021
Rec V Date: 01/28/2021

Lab Data: N/A

Allergies: Quetiapine, Zyprexa

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 01/22/2021

ID: 0982942
Sex: M
Age: 57
State: AZ

Vax Date: 01/21/2021
Onset Date: 01/21/2021
Rec V Date: 01/28/2021

Lab Data: unknown

Allergies: peanuts

Symptoms: 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.

Other Meds: unknown

Current Illness: unknown

Died: Y

Date Died: 01/10/2021

ID: 0983169
Sex: M
Age: 83
State: KY

Vax Date: 01/05/2021
Onset Date: 01/08/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: Olanzapine, Risperidone, Aggrenox

Symptoms: 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.

Other Meds: Clopidogrel, Lexapro, Gabapentin, Synthroid, Prilosec, Zinc, Vitamin C, Vitamin D, Tuberculin Skin Test

Current Illness: COVID-19

Died: Y

Date Died: 01/24/2021

ID: 0983173
Sex: F
Age: 86
State: KY

Vax Date: 01/05/2021
Onset Date: 01/21/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: Avandia

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 01/15/2021

ID: 0983184
Sex: F
Age: 87
State: KY

Vax Date: 01/05/2021
Onset Date: 01/11/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: NKA

Symptoms: 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.

Other Meds: Norco, Morphine Sulfate, Levsin

Current Illness: COVID-19

Died: Y

Date Died: 01/15/2021

ID: 0983187
Sex: M
Age: 92
State: KY

Vax Date: 01/05/2021
Onset Date: 01/09/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: Risperidone, Memantine, Haldol

Symptoms: 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.

Other Meds: Allopurinol, Eliquis, Allegra, Synthroid, Sodium Chloride, Trazadone, Zinc, Vitamin C, Vitamin D, Dexamethasone, Tylenol

Current Illness: COVID-19

Died: Y

Date Died: 01/19/2021

ID: 0983189
Sex: F
Age: 92
State: KY

Vax Date: 01/05/2021
Onset Date: 01/11/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: Fosomax

Symptoms: 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.

Other Meds: Alprazolam, Amlodipine, Lexapro, Cozaar, Metoprolol, Tylenol

Current Illness: COVID-19

Died: Y

Date Died: 01/22/2021

ID: 0983192
Sex: F
Age: 89
State: KY

Vax Date: 01/05/2021
Onset Date: 01/06/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: NKA

Symptoms: 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.

Other Meds: None

Current Illness: COVID-19

Died: Y

Date Died: 01/19/2021

ID: 0983193
Sex: F
Age: 96
State: KY

Vax Date: 01/05/2021
Onset Date: 01/05/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies: Atorvastatin, Donepezil, Corticosteroids

Symptoms: 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.

Other Meds: Citalopram, Divalproex, Levothyroxine

Current Illness: COVID-19

Died: Y

Date Died: 01/18/2021

ID: 0983428
Sex: F
Age: 68
State: NE

Vax Date: 12/24/2020
Onset Date: 01/06/2021
Rec V Date: 01/28/2021

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.

Allergies: NKA to medications

Symptoms: 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.

Other Meds: 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.

Died: Y

Date Died: 01/24/2021

ID: 0983766
Sex: F
Age: 90
State: NC

Vax Date: 01/16/2021
Onset Date: 01/21/2021
Rec V Date: 01/28/2021

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

Allergies: No known allergies to drugs or food

Symptoms: 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.

Other Meds: 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.

Died: Y

Date Died:

ID: 0983919
Sex: M
Age: 69
State: FL

Vax Date: 01/21/2021
Onset Date: 01/01/2021
Rec V Date: 01/28/2021

Lab Data:

Allergies:

Symptoms: death

Other Meds:

Current Illness:

Died: Y

Date Died: 01/27/2021

ID: 1296823
Sex: F
Age: 50
State: IL

Vax Date: 01/26/2021
Onset Date: 01/27/2021
Rec V Date: 01/28/2021

Lab Data: NOT APPLICABLE

Allergies:

Symptoms: 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.

Other Meds: UNKNOWN

Current Illness: UNKNOWN

Died: Y

Date Died: 01/23/2021

ID: 0984617
Sex: F
Age:
State: FL

Vax Date: 01/16/2021
Onset Date: 01/17/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies:

Symptoms: 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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/27/2021

ID: 0985004
Sex: F
Age: 58
State: MI

Vax Date: 01/08/2021
Onset Date: 01/27/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies: Codeine Penicillin V

Symptoms: 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.

Other Meds: None

Current Illness: none

Died: Y

Date Died: 01/26/2021

ID: 0985205
Sex: M
Age: 75
State: OH

Vax Date: 01/25/2021
Onset Date: 01/26/2021
Rec V Date: 01/29/2021

Lab Data: None

Allergies: No

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

Other Meds: Yes, but caller does not know what they are.

Current Illness: No

Died: Y

Date Died: 01/25/2021

ID: 0985367
Sex: M
Age: 83
State: KY

Vax Date: 01/06/2021
Onset Date: 01/18/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies: ATIVAN GEODON

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 01/28/2021

ID: 0985449
Sex: F
Age: 87
State:

Vax Date: 01/27/2021
Onset Date: 01/28/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies:

Symptoms: 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

Other Meds:

Current Illness: colonic obstruction with dilatation of large and small bowel

Died: Y

Date Died: 01/24/2021

ID: 0985451
Sex: F
Age: 101
State: KY

Vax Date: 01/06/2021
Onset Date: 01/24/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies: NKA

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

Other Meds: 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:

Died: Y

Date Died: 01/27/2021

ID: 0985501
Sex: F
Age: 89
State: OH

Vax Date: 01/18/2021
Onset Date: 01/22/2021
Rec V Date: 01/29/2021

Lab Data: none, no autopsy

Allergies: none

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 02/04/2021

ID: 0985527
Sex: M
Age: 96
State: KY

Vax Date: 01/06/2021
Onset Date: 01/23/2021
Rec V Date: 01/29/2021

Lab Data: CBC, BMP 1-23-2021

Allergies: ROCEPHIN

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

Other Meds: ALLOPURINOL CHOLECALCIFEROL DEBROX DOCUSATE SODIUM FLOMAX FLONASE GABAPENTIN KONSYL PACKET LASIX LORATIDINE MELATONIN MIRALAX SENNA

Current Illness:

Died: Y

Date Died: 01/02/2021

ID: 0985715
Sex: M
Age: 80
State: FL

Vax Date: 12/29/2020
Onset Date: 01/02/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies: no known allergies

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 01/26/2021

ID: 0985814
Sex: M
Age: 94
State: OH

Vax Date: 01/20/2021
Onset Date: 01/21/2021
Rec V Date: 01/29/2021

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

Allergies: morphine, oxycodone, hydrocodone, hydromorphone, coumadin

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 01/01/2021

ID: 0985933
Sex: F
Age:
State:

Vax Date: 12/29/2020
Onset Date: 12/30/2020
Rec V Date: 01/29/2021

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

Allergies:

Symptoms: 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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/16/2021

ID: 0986063
Sex: F
Age: 83
State: UT

Vax Date: 01/12/2021
Onset Date: 01/16/2021
Rec V Date: 01/29/2021

Lab Data: No tests/results pertaining to this incident.

Allergies: No Known Allergies

Symptoms: Resident was vaccinated on 1/13/21. Resident passed away on 1/16/21

Other Meds: 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

Died: Y

Date Died: 01/24/2021

ID: 0986123
Sex: M
Age:
State: AZ

Vax Date: 01/19/2021
Onset Date: 01/24/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies:

Symptoms: 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

Other Meds:

Current Illness:

Died: Y

Date Died: 01/15/2021

ID: 0986200
Sex: F
Age: 82
State: NM

Vax Date: 12/30/2020
Onset Date: 01/15/2021
Rec V Date: 01/29/2021

Lab Data: None

Allergies: NKA.

Symptoms: Death

Other Meds: Atorvastatin, Metformin and Atenolol.

Current Illness: None.

Died: Y

Date Died:

ID: 0986631
Sex: F
Age: 87
State: MI

Vax Date: 01/14/2021
Onset Date: 01/15/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies: No known allergies.

Symptoms: Suspected myocardial infarction on 01/15/2021. Patient passed away on 01/15/2021.

Other Meds:

Current Illness:

Died: Y

Date Died: 01/28/2021

ID: 0986672
Sex: M
Age: 77
State: AZ

Vax Date: 01/01/2021
Onset Date: 01/15/2021
Rec V Date: 01/29/2021

Lab Data: Covid-19 nasal swab

Allergies: iodine topical betadine

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

Other Meds: 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

Died: Y

Date Died: 01/18/2021

ID: 0986773
Sex: M
Age: 67
State: VA

Vax Date: 12/31/2020
Onset Date: 01/14/2021
Rec V Date: 01/29/2021

Lab Data: Nasal swab sample obtained 1/14/21 and sent for PCR testing was positive for SARS-CoV-2.

Allergies: Quinolones, Latex, Natural rubber

Symptoms: 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.

Other Meds: 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.

Died: Y

Date Died: 01/04/2021

ID: 0986857
Sex: M
Age: 66
State: TX

Vax Date: 12/28/2020
Onset Date: 12/28/2020
Rec V Date: 01/29/2021

Lab Data:

Allergies: Fish / seafood

Symptoms: 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.

Other Meds: 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)

Died: Y

Date Died: 01/01/2021

ID: 0986869
Sex: F
Age: 79
State: NY

Vax Date: 01/03/2021
Onset Date: 01/10/2021
Rec V Date: 01/29/2021

Lab Data: NA

Allergies: NKA

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

Other Meds: Prednisone, Miralax, Labetalol, Gas-X, Gabapentin, Folic Acid, Fluconazole, Famotidine, Eliquis, Crestor, Bactrim

Current Illness: Pembro associated pneumonitis and nuronal inflammation, Candida Esophagitis

Died: Y

Date Died: 01/29/2021

ID: 0986901
Sex: F
Age: 33
State: NC

Vax Date: 01/28/2021
Onset Date: 01/28/2021
Rec V Date: 01/29/2021

Lab Data: Autopsy pending

Allergies: None

Symptoms: 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

Other Meds: Copaxone

Current Illness:

Died: Y

Date Died: 01/25/2021

ID: 0986948
Sex: F
Age: 80
State: GA

Vax Date: 01/22/2021
Onset Date: 01/24/2021
Rec V Date: 01/29/2021

Lab Data:

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

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

Other Meds: Diltiazem CD, Gabapentin, Hydroxychloroquine, Levothyroxine, Omeprazole, Oritavancin, Potassium Chloride, Propylene Glycol Eye Drops, Sertraline

Current Illness: alcoholic cirrhosis, thrombocytopenia, anemia, lymphedema

Died: Y

Date Died: 01/28/2021

ID: 0987029
Sex: M
Age: 86
State: NC

Vax Date: 01/27/2021
Onset Date: 01/28/2021
Rec V Date: 01/29/2021

Lab Data: N/A

Allergies: Penicillins Green Food Dye Dust Mites Aricept Namenda

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

Other Meds: 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

Died: Y

Date Died: 01/29/2021

ID: 0987126
Sex: F
Age: 90
State: IA

Vax Date: 01/29/2021
Onset Date: 01/29/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies:

Symptoms: Patient died. Patient had been declining in health rapidly prior to receiving the vaccine

Other Meds:

Current Illness:

Died: Y

Date Died: 01/04/2021

ID: 0987301
Sex: F
Age: 87
State: NC

Vax Date: 12/28/2020
Onset Date: 12/28/2020
Rec V Date: 01/29/2021

Lab Data: Don't Know

Allergies: Not aware

Symptoms: 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

Other Meds: Not Sure! Vaccine was given in a Nursing Facility

Current Illness: Previous Stroke

Died: Y

Date Died: 01/28/2021

ID: 0987469
Sex: M
Age: 89
State: PA

Vax Date: 01/26/2021
Onset Date: 01/27/2021
Rec V Date: 01/29/2021

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.

Allergies:

Symptoms: emesis bright yellow in color, liquid BM, increased respirations

Other Meds:

Current Illness: was being treated with antibiotic prednisone for hand swelling day prior

Died: Y

Date Died: 01/28/2021

ID: 0987513
Sex: M
Age: 64
State: VA

Vax Date: 01/27/2021
Onset Date: 01/27/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies: NKA

Symptoms: 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.

Other Meds: None

Current Illness: UTI And PNA

Died: Y

Date Died: 01/29/2021

ID: 0987533
Sex: M
Age: 91
State: CA

Vax Date: 01/28/2021
Onset Date: 01/29/2021
Rec V Date: 01/29/2021

Lab Data: Stat CBC & CMP ordered. Labs were drawn but the patient expired before the facility received the results.

Allergies: Dexamethasone, Versed

Symptoms: 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.

Other Meds: 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

Died: Y

Date Died: 01/17/2021

ID: 0988245
Sex: M
Age: 93
State:

Vax Date: 01/16/2021
Onset Date: 01/17/2021
Rec V Date: 01/29/2021

Lab Data:

Allergies:

Symptoms: 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:

Other Meds:

Current Illness:

Died: Y

Date Died: 01/26/2021

ID: 0988246
Sex: M
Age: 77
State: FL

Vax Date: 12/22/2020
Onset Date: 01/26/2021
Rec V Date: 01/29/2021

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

Allergies:

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

Other Meds: 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:

Died: Y

Date Died: 01/28/2021

ID: 0987636
Sex: M
Age: 78
State: GA

Vax Date: 01/18/2021
Onset Date: 01/21/2021
Rec V Date: 01/30/2021

Lab Data:

Allergies: None

Symptoms: 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

Other Meds: Insulin, blood pressure medication

Current Illness: Diabetes