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Vaccine Vaccine VAERS Event

Symptoms Type Manufacturer ID Category


Adverse Event Description

COVID19 Abdominal pain, Headaches, chest pain, loss of


ABDOMINAL PAIN VACCINE MODERNA 0948164-1 Death appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
ABDOMINAL PAIN VACCINE MODERNA 0948164-1 Hospitalized appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
Emergency
ABDOMINAL PAIN VACCINE MODERNA 0948164-1 appetite, confusion, elevated liver enzymes 1/8-
Room *
(COVID19) 1/15/21
Feeling sick after the Modena vaccine;
Stomachache; This spontaneous case was reported
by a consumer (subsequently medically confirmed)
and describes the occurrence of ABDOMINAL PAIN
UPPER (Stomachache) and MALAISE (Feeling sick
after the Modena vaccine) in a 53-year-old male
patient who received mRNA-1273 (Moderna COVID-
19 Vaccine) (batch no. 028A21A) for COVID-19
vaccination. Concurrent medical conditions included
Heart disorder. On 25-Mar-2021, the patient
received first dose of mRNA-1273 (Moderna
COVID-19 Vaccine) (Intramuscular) 1 dosage form.
In April 2021, after starting mRNA-1273 (Moderna
COVID-19 Vaccine), the patient experienced
COVID19 ABDOMINAL PAIN UPPER (Stomachache). On an
ABDOMINAL PAIN UPPER VACCINE MODERNA 1622381-1 Death unknown date, the patient experienced MALAISE
(COVID19) (Feeling sick after the Modena vaccine). At the time
of the report, ABDOMINAL PAIN UPPER
(Stomachache) and MALAISE (Feeling sick after the
Modena vaccine) outcome was unknown.
Concomitant product use was not provided by the
reporter. After 2-3 weeks of vaccination patient
experienced stomachache, patient thought this was
indigestion or pancreatitis. Patient contacted doctor
online. Patient's condition aggravated after second
dose and died on 05-Jun-2021. No treatment was
provided. Action taken with mRNA-1273 in
response to the events was not Applicable. This
case was linked to MOD-2021-211616 (Patient
Link). Most recent FOLLOW-UP information
incorporated above includes: On 07-Jun-2021:
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Follow up information received on 07-May-2021


had a new event feeling sick after the Modena
vaccine was added to the case.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
ABSENCE OF IMMEDIATE TREATMENT but the patient continued to go into PEA. The
VACCINE MODERNA 1002931-1 Death
RESPONSE patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
ABSENCE OF IMMEDIATE TREATMENT Emergency but the patient continued to go into PEA. The
VACCINE MODERNA 1002931-1
RESPONSE Room * patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
COVID19 arrival. The Combi tube was removed and an
ABSENCE OF IMMEDIATE TREATMENT
VACCINE MODERNA 1002931-1 Office Visit * endotracheal tube was placed without
RESPONSE
(COVID19) complications. ROSC was obtained multiple times
but the patient continued to go into PEA. The
patient was seen in the emergency department by
both critical care and Cardiology. EKG shows ST
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

elevations, but the patient was unstable to go to


catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
Patient entered Drug store to get his second
Moderna COVID shot on 4/8/2021 at approx.
12:30pm. (First dose was 3/11/2021) He filled out
his Pre-Vaccination Checklist for COVID-19
Vaccines and signed the consent. His form was
COVID19 reviewed and he was given his vaccine in his left
ACCIDENT VACCINE MODERNA 1181914-1 Death deltoid. He then was given his CDC card and waited
(COVID19) at least 15 minutes and then exited the building. At
1p.m he was in an accident on the main highway.
He was conscious after the accident, but later did
pass away. This information came from a Police
Officer as no one at the pharmacy witnessed the
accident.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
AKI requiring dialysis and ultimately became
ACUTE KIDNEY INJURY VACCINE MODERNA 1213571-1 Death
oliguric. He required epinephrine, dobutamine,
(COVID19)
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
Emergency AKI requiring dialysis and ultimately became
ACUTE KIDNEY INJURY VACCINE MODERNA 1213571-1
Room * oliguric. He required epinephrine, dobutamine,
(COVID19)
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Death. Narrative: Patient received Moderna COVID


vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
AKI requiring dialysis and ultimately became
ACUTE KIDNEY INJURY VACCINE MODERNA 1213571-1 Office Visit *
oliguric. He required epinephrine, dobutamine,
(COVID19)
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ACUTE KIDNEY INJURY VACCINE MODERNA 1236416-1 Death
(COVID19) new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID19
Emergency COVID PCR test on 3/4/21. He has a noted history
ACUTE KIDNEY INJURY VACCINE MODERNA 1236416-1
(COVID19)
Room * of COPD, CHF and OSA. On 3/6/21, he underwent a
new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

available. 38 days from time of second vaccine to


date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ACUTE KIDNEY INJURY VACCINE MODERNA 1236416-1 Office Visit *
new pacemaker placement. His course was
(COVID19)
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
ACUTE KIDNEY INJURY VACCINE PFIZER\BIONTECH 1109552-1 Death
hypoxemic/hypercarbic respiratory failure,
(COVID19)
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Family call Clinical Lead to car for elderly woman in


backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
ACUTE KIDNEY INJURY VACCINE PFIZER\BIONTECH 1109552-1 Hospitalized
hypoxemic/hypercarbic respiratory failure,
(COVID19)
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
COVID19
Pt transported by AMR/Fire to hospital. Pt was a full
ACUTE LEFT VENTRICULAR FAILURE VACCINE PFIZER\BIONTECH 1109552-1 Death
code on Hospice - she passed away 3/11/21 with
(COVID19)
the following cause of death: 1.Acute-on-chronic
hypoxemic/hypercarbic respiratory failure,
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Hyperkalemia. 7. Cardiogenic shock. 8. Acute


kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
ACUTE LEFT VENTRICULAR FAILURE VACCINE PFIZER\BIONTECH 1109552-1 Hospitalized
hypoxemic/hypercarbic respiratory failure,
(COVID19)
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Hospitalized and died due to COVID-19 after being
COVID19
fully vaccinated. From vital records: ACUTE
ACUTE RESPIRATORY FAILURE VACCINE MODERNA 1307516-1 Death
RESPIRATORY FAILURE WITH HYPOXIA,
(COVID19)
PNEUMONIA DUE TO COVID-19
Hospitalized and died due to COVID-19 after being
COVID19
fully vaccinated. From vital records: ACUTE
ACUTE RESPIRATORY FAILURE VACCINE MODERNA 1307516-1 Hospitalized
RESPIRATORY FAILURE WITH HYPOXIA,
(COVID19)
PNEUMONIA DUE TO COVID-19
8/14/2021 Admit Hospital. Patient presented to
COVID19 emergency room with shortness of breath for the
ACUTE RESPIRATORY FAILURE VACCINE MODERNA 1684819-1 Death last 4 days with weakness and decline in status and
(COVID19) diarrhea. Her oxygen saturation was low in the low
90s. home oxygen dependent. Tested positive for
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID-19 from PCR on 8/15/21. Diagnosed with:


COVID-19 pneumonia, acute on chronic hypoxic
respiratory failure. Transferred to Hospice 8/20/21.
patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Number 025A21A; Second dose: 04/14/21 Lot
Number 030B21A
8/14/2021 Admit Hospital. Patient presented to
emergency room with shortness of breath for the
last 4 days with weakness and decline in status and
diarrhea. Her oxygen saturation was low in the low
90s. home oxygen dependent. Tested positive for
COVID19
COVID-19 from PCR on 8/15/21. Diagnosed with:
ACUTE RESPIRATORY FAILURE VACCINE MODERNA 1684819-1 Hospitalized
COVID-19 pneumonia, acute on chronic hypoxic
(COVID19)
respiratory failure. Transferred to Hospice 8/20/21.
patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Number 025A21A; Second dose: 04/14/21 Lot
Number 030B21A
COVID19
Patient with failure to thrive symptoms prior to 2nd
ADULT FAILURE TO THRIVE VACCINE PFIZER\BIONTECH 1009266-1 Death
dose, not eating, not taking medications.
(COVID19)
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ANTICOAGULANT THERAPY VACCINE MODERNA 1236416-1 Death
new pacemaker placement. His course was
(COVID19)
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

death Narrative: Patient received Moderna covid


vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
Emergency of COPD, CHF and OSA. On 3/6/21, he underwent a
ANTICOAGULANT THERAPY VACCINE MODERNA 1236416-1
Room * new pacemaker placement. His course was
(COVID19)
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ANTICOAGULANT THERAPY VACCINE MODERNA 1236416-1 Office Visit *
new pacemaker placement. His course was
(COVID19)
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
started experiencing after receiving 2nd dose of
COVID19
Covid vaccine. Found to have a positive troponin,
ANTICOAGULANT THERAPY VACCINE PFIZER\BIONTECH 1350545-1 Death
hyponatremia. Stress test revealed reversible
(COVID19)
myocardial ischemia of the inferior and lateral walls
of left ventricle with a large defect size but mild
defect severity. Patient underwent PCI with DES
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

placement and was placed on triple therapy with


aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
episodes of vomiting, leading to terminal events:
brainstem compression and rapid deterioration and
CS of 2T preclude meaningful survival
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
started experiencing after receiving 2nd dose of
Covid vaccine. Found to have a positive troponin,
hyponatremia. Stress test revealed reversible
myocardial ischemia of the inferior and lateral walls
of left ventricle with a large defect size but mild
COVID19
defect severity. Patient underwent PCI with DES
ANTICOAGULANT THERAPY VACCINE PFIZER\BIONTECH 1350545-1 Hospitalized
placement and was placed on triple therapy with
(COVID19)
aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
episodes of vomiting, leading to terminal events:
brainstem compression and rapid deterioration and
CS of 2T preclude meaningful survival
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
COVID19
atrial fibrillation on apixaban, cardiomyopathy with
ANXIETY VACCINE PFIZER\BIONTECH 1020134-1 Death
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
(COVID19)
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

There is no diaphoresis, palpitations or


lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

see pt. Will continue to monitor closely.


01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
COVID19
Emergency presents to E.R. with CC of chest pain/sob, with
ANXIETY VACCINE PFIZER\BIONTECH 1020134-1
Room * multiple medical conditions including hypertension,
(COVID19)
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

breath. He has been having worsening shortness of


breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

he's handing off to oncoming MOD and they will


come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
COVID19
pulse. Narrative: Patient was first vaccinated for
ANXIETY VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
(COVID19) COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

poor EF, dyslipidemia, COPD, CVA, lung CA s/p


radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

receive 2nd dose of COVID vaccine 1/29 at 1530.


Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"Patient was vaccinated in her home (COVID J&J)
COVID19
on 3/8. Vaccinator obtained consent and confirmed
APHASIA VACCINE JANSSEN 1126863-1 Death
throughout the process that patient as at baseline
(COVID19)
since patient was nonverbal and bedbound. Later
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

that same day she experienced an emergency and


was take to the hospital and subsequently admitted
to ICU. She died on 3/10, family present, on
comfort care. Per HPI, ""Patient is a 85 y.o. female
with advanced dementia (non verbal, wheelchair
bound at baseline), chronic aspiration, recurrent
UTIs, voiding dysfunction currently self-straight
cathing, has suspicious bladder and gallbladder
masses (being worked up), has right sided
hydronephrosis, BIBEMS for acute hypoxemia,
difficult to bag en route, ED had difficulty intubating
and so performed cricothroidotomy. Patient had
brief PEA arrest due to hypoxia. ED provider noted
""excessive pulmonary edema in airway,
unfavorable anatomy, and airway swelling.""
Suspected insult stemming from J&J COVID
vaccination reaction."
As per patient daughter - patient had some minor
chills on the day of the vaccination - Friday
COVID19
1/15/21; felt well next day -Saturday, than she was
ARTERIOSCLEROSIS VACCINE PFIZER\BIONTECH 1041789-1 Death
found slumped and lifeless on the couch on Sunday
(COVID19)
1/17. Cause of death on death certificate was
reportedly put as COPD, Lung Ca and ASHD.
As per patient daughter - patient had some minor
chills on the day of the vaccination - Friday
COVID19
ARTERIOSCLEROSIS CORONARY 1/15/21; felt well next day -Saturday, than she was
VACCINE PFIZER\BIONTECH 1041789-1 Death
ARTERY
(COVID19) found slumped and lifeless on the couch on Sunday
1/17. Cause of death on death certificate was
reportedly put as COPD, Lung Ca and ASHD.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
COVID19 resps. Called AMR to car side who called 911.
ASBESTOSIS VACCINE PFIZER\BIONTECH 1109552-1 Death Transferred patient to a gurney and began CPR as
(COVID19) we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
the following cause of death: 1.Acute-on-chronic
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

hypoxemic/hypercarbic respiratory failure,


multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
ASBESTOSIS VACCINE PFIZER\BIONTECH 1109552-1 Hospitalized
hypoxemic/hypercarbic respiratory failure,
(COVID19)
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
COVID19 she couldn't walk, dry cough. Per daughter not
ASPARTATE AMINOTRANSFERASE
VACCINE PFIZER\BIONTECH 1255836-1 Death acting herself and more confused. Clinical
INCREASED
(COVID19) impressions included hypoxia, COVID-19. Pt is s/p
her first dose of vaccine and this precludes plasma.
Supportive care steroids and doxy. Family faxed
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

DNR on 1/12/21 at 2225. Remdesivir given 1/13/21


at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
"Information here obtained from daughter: on
Thursday patient had an uneventful fistulagram
with angioplasty. Patient got vaccine at end of
usual Friday am dialysis treatment. He was
observed for about 30"" and no untoward event
noted, vitals usual. At home on Saturday morning,
seemed not quite himself by wife as reported by
daughter, from whom i got his information. He gets
COVID19
up late as hemodialysis starts at 515 am. No
ASTHENIA VACCINE MODERNA 1106667-1 Death
(COVID19) reported problems on Friday. On Saturday morning,
he seemed not himself but sat down and ate
breakfast around 9 am. On getting up from table he
got suddenly weak, his head rolled back and his
eyes rolled up. 911 called and he was given
resuscitation efforts of unknown duration which
were unsuccessful. He was pronounced dead at 11
am and the mortuary was called. No premortem
labs, et al."
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
ASTHENIA VACCINE MODERNA 1228019-1 Death staphylococcus, MRSA infection-discharged to
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
Emergency
ASTHENIA VACCINE MODERNA 1228019-1 staphylococcus, MRSA infection-discharged to
Room *
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
ASTHENIA VACCINE MODERNA 1228019-1 Office Visit * staphylococcus, MRSA infection-discharged to
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
8/14/2021 Admit Hospital. Patient presented to
emergency room with shortness of breath for the
COVID19 last 4 days with weakness and decline in status and
ASTHENIA VACCINE MODERNA 1684819-1 Death diarrhea. Her oxygen saturation was low in the low
(COVID19) 90s. home oxygen dependent. Tested positive for
COVID-19 from PCR on 8/15/21. Diagnosed with:
COVID-19 pneumonia, acute on chronic hypoxic
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

respiratory failure. Transferred to Hospice 8/20/21.


patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Number 025A21A; Second dose: 04/14/21 Lot
Number 030B21A
8/14/2021 Admit Hospital. Patient presented to
emergency room with shortness of breath for the
last 4 days with weakness and decline in status and
diarrhea. Her oxygen saturation was low in the low
90s. home oxygen dependent. Tested positive for
COVID19
COVID-19 from PCR on 8/15/21. Diagnosed with:
ASTHENIA VACCINE MODERNA 1684819-1 Hospitalized
(COVID19) COVID-19 pneumonia, acute on chronic hypoxic
respiratory failure. Transferred to Hospice 8/20/21.
patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Number 025A21A; Second dose: 04/14/21 Lot
Number 030B21A
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
COVID19 Syndrome, Sjogren's syndrome presented with
ASTHENIA VACCINE PFIZER\BIONTECH 1020134-1 Death chief complaint of chest pain or shortness of
(COVID19) breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

time of CP. Pt CP improved w/ prn NTG. Pt HR


improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

bed with 3 staff assist. Pt stopped breathing and


lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
COVID19 poor EF, dyslipidemia, COPD, CVA, lung CA s/p
Emergency
ASTHENIA VACCINE PFIZER\BIONTECH 1020134-1 radiotherapy, PTSD, depression, Churg Strauss
Room *
(COVID19) Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

thus he passed out. Could not say if there were


seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

BM. Assisted x2 to BSC. While sitting on BSC pt's


eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
COVID19 multiple medical conditions including hypertension,
ASTHENIA VACCINE PFIZER\BIONTECH 1020134-1 Office Visit * atrial fibrillation on apixaban, cardiomyopathy with
(COVID19) poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

complains of left upper chest pain with no radiation.


There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

discussed Around 2310 MOD came to bedside to


see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
presented to Emergency room with complaints of
approximately 5 days of progressively worsening
shortness of breath with a dry nonproductive
cough, increased weakness, and wheezing.
COVID19 Symptoms not controlled with increased use of
ASTHENIA VACCINE PFIZER\BIONTECH 1227451-1 Death rescue inhaler albuterol. Patient's daughter reached
(COVID19) out and spoke with patient's pulmonologist Dr.
today who ordered oral steroids however patient
reports she had not started taking them yet.
Patient was initiated on 15 L non-rebreather and
received 2 duo nebs EN route to the hospital. It
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

was reported she did have some intermittent chest


tightness although on my review, she denied this.
Upon arrival to the emergency room, patient was
initiated on BiPAP and receive 40 mg of IV Lasix at
125 mg of IV Solu-Medrol. Patient expired
4/19/2021
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
impressions included hypoxia, COVID-19. Pt is s/p
COVID19
her first dose of vaccine and this precludes plasma.
ASTHENIA VACCINE PFIZER\BIONTECH 1255836-1 Death
Supportive care steroids and doxy. Family faxed
(COVID19)
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
started experiencing after receiving 2nd dose of
Covid vaccine. Found to have a positive troponin,
hyponatremia. Stress test revealed reversible
myocardial ischemia of the inferior and lateral walls
of left ventricle with a large defect size but mild
COVID19
defect severity. Patient underwent PCI with DES
ASTHENIA VACCINE PFIZER\BIONTECH 1350545-1 Death
(COVID19) placement and was placed on triple therapy with
aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
episodes of vomiting, leading to terminal events:
brainstem compression and rapid deterioration and
CS of 2T preclude meaningful survival
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
COVID19
started experiencing after receiving 2nd dose of
ASTHENIA VACCINE PFIZER\BIONTECH 1350545-1 Hospitalized
Covid vaccine. Found to have a positive troponin,
(COVID19)
hyponatremia. Stress test revealed reversible
myocardial ischemia of the inferior and lateral walls
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

of left ventricle with a large defect size but mild


defect severity. Patient underwent PCI with DES
placement and was placed on triple therapy with
aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
episodes of vomiting, leading to terminal events:
brainstem compression and rapid deterioration and
CS of 2T preclude meaningful survival
Atrial fibrillation; Feeling fluttery; Heart rate was
racing and was increasing, went up to 175 just
sitting; A spontaneous report was received from a
consumer concerning a 64-year-old female patient
who received Moderna's COVID-19 vaccine (mRNA-
1273) and experienced atrial fibrillation, feeling
fluttery, and heart rate was racing and was
increasing, went up to 175 just sitting. The
patient's medical history was not provided.
Concomitant medications included Travatan for
glaucoma. On 12 Feb 2021, prior to the onset of
the events, the patient received the first of two
planned doses of mRNA-1273 (lot/batch: 030M20A)
intramuscularly in the left arm for prophylaxis of
COVID19
COVID-19 infection. On 12 Feb 2021, five hours
ATRIAL FIBRILLATION VACCINE MODERNA 1071120-1 Death
(COVID19) after vaccination, the patient experienced a fluttery
feeling, heart rate was racing and was increasing,
heart rate went up to 175 just sitting. She took an
EKG on her watch and it was atrial fibrillation.
When she was sleeping, her heart rate was at 102
or the 90s, normally it would be in the 60s. No
treatment information was provided. Action taken
with mRNA-1273 in response to the events was not
reported. At the time of this report, the outcome of
the events, atrial fibrillation, feeling fluttery, and
heart rate was racing and was increasing, went up
to 175 just sitting, was unknown.; Reporter's
Comments: This case concerns a 64 year old
female patient, who was on hospice care
experienced a fatal event of death, 1 day after
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

receiving second dose of mRNA- 1273 (Lot#


030M20A). Very limited information regarding this
event has been provided at this time. Further
information has been requested.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
COVID19
lightheadedness. He denies fever or chills. He
ATRIAL FIBRILLATION VACCINE PFIZER\BIONTECH 1020134-1 Death
complains of having fallen a few times recently,
(COVID19)
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Consider underlying lung disease vs acute


pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

pulmonary edema Lasix ordered. Hid lactic acid is


elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
COVID19
Emergency complains of left upper chest pain with no radiation.
ATRIAL FIBRILLATION VACCINE PFIZER\BIONTECH 1020134-1
Room * There is no diaphoresis, palpitations or
(COVID19)
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

about 08:00, Cardiology sees patient and signs off,


""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

He got a total of 9 amps of epi, 3 amps od Bicarb


and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
COVID19
breath the past few days, also complains of cough
ATRIAL FIBRILLATION VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
productive of yellowish sputum, no hemoptysis. He
(COVID19)
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

He does have intermittent chest pain. Patient


having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

patient went into Asystole and code called second


time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Atrial fibrillation; Feeling fluttery; Heart rate was
racing and was increasing, went up to 175 just
sitting; A spontaneous report was received from a
consumer concerning a 64-year-old female patient
who received Moderna's COVID-19 vaccine (mRNA-
1273) and experienced atrial fibrillation, feeling
fluttery, and heart rate was racing and was
increasing, went up to 175 just sitting. The
patient's medical history was not provided.
Concomitant medications included Travatan for
glaucoma. On 12 Feb 2021, prior to the onset of
COVID19
the events, the patient received the first of two
ATRIAL FLUTTER VACCINE MODERNA 1071120-1 Death
planned doses of mRNA-1273 (lot/batch: 030M20A)
(COVID19)
intramuscularly in the left arm for prophylaxis of
COVID-19 infection. On 12 Feb 2021, five hours
after vaccination, the patient experienced a fluttery
feeling, heart rate was racing and was increasing,
heart rate went up to 175 just sitting. She took an
EKG on her watch and it was atrial fibrillation.
When she was sleeping, her heart rate was at 102
or the 90s, normally it would be in the 60s. No
treatment information was provided. Action taken
with mRNA-1273 in response to the events was not
reported. At the time of this report, the outcome of
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

the events, atrial fibrillation, feeling fluttery, and


heart rate was racing and was increasing, went up
to 175 just sitting, was unknown.; Reporter's
Comments: This case concerns a 64 year old
female patient, who was on hospice care
experienced a fatal event of death, 1 day after
receiving second dose of mRNA- 1273 (Lot#
030M20A). Very limited information regarding this
event has been provided at this time. Further
information has been requested.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ATRIAL FLUTTER VACCINE MODERNA 1236416-1 Death
(COVID19) new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID19
Emergency COVID PCR test on 3/4/21. He has a noted history
ATRIAL FLUTTER VACCINE MODERNA 1236416-1
(COVID19)
Room * of COPD, CHF and OSA. On 3/6/21, he underwent a
new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

available. 38 days from time of second vaccine to


date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ATRIAL FLUTTER VACCINE MODERNA 1236416-1 Office Visit *
new pacemaker placement. His course was
(COVID19)
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ATRIOVENTRICULAR BLOCK VACCINE MODERNA 1236416-1 Death
(COVID19) new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
COVID19
Emergency 3/4/21, he was admitted to a facility for shortness
ATRIOVENTRICULAR BLOCK VACCINE MODERNA 1236416-1
Room * of breath x 1 week. Upon admission, he was found
(COVID19)
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID PCR test on 3/4/21. He has a noted history


of COPD, CHF and OSA. On 3/6/21, he underwent a
new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
ATRIOVENTRICULAR BLOCK VACCINE MODERNA 1236416-1 Office Visit *
(COVID19) new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
On 1/23/21 the patient had a single-car accident,
slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
AUTOPSY VACCINE MODERNA 1004811-1 Death and released. On 1/31/21 the patient had a
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
COVID19 On 1/23/21 the patient had a single-car accident,
Emergency
AUTOPSY VACCINE MODERNA 1004811-1 slid off icy road into snowbank. She was seen in our
Room *
(COVID19) ER, diagnosed w/ trauma and L4 compression
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

fracture. She was transported to Hospital for


further trauma workup. We believe she was treated
and released. On 1/31/21 the patient had a
headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
"Patient and her husband are elderly, but healthy
and live independently. Patient took blood pressure
medicine 'off and on' according to family. She was
5'2"", 120 pounds and slim and healthy and active,
so was her husband, though he had pulmonary
fibrosis so they had been staying home and not
attending church etc, and masking when they did
go out to protect against covid disease. They were
both vaccinated with covid Pfizer vaccine (dose #1)
on Thursday Feb 11. (02/11/2021) Thursday night
COVID19 as they went to bed they checked in with each
AUTOPSY VACCINE PFIZER\BIONTECH 1031846-1 Death other on how they each felt. Patient said she felt
(COVID19) totally fine, and her husband said his arm was a bit
sore. Patient woke before her husband on Friday
Feb 12, went downstairs and, from what the family
can tell, fixed herself a snack, then sat on the sofa.
Patient's husband found her deceased on the sofa.
He called 911 and they asked him to do CPR until
the paramedics arrived. Because of proximity to
covid vaccine, the ME wanted to examine the body
in the home and also ordered an autopsy. Autopsy
was completed on the same day as death, Feb 12,
2021"
presented to Emergency room with complaints of
approximately 5 days of progressively worsening
shortness of breath with a dry nonproductive
COVID19 cough, increased weakness, and wheezing.
BILEVEL POSITIVE AIRWAY PRESSURE VACCINE PFIZER\BIONTECH 1227451-1 Death Symptoms not controlled with increased use of
(COVID19) rescue inhaler albuterol. Patient's daughter reached
out and spoke with patient's pulmonologist Dr.
today who ordered oral steroids however patient
reports she had not started taking them yet.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Patient was initiated on 15 L non-rebreather and


received 2 duo nebs EN route to the hospital. It
was reported she did have some intermittent chest
tightness although on my review, she denied this.
Upon arrival to the emergency room, patient was
initiated on BiPAP and receive 40 mg of IV Lasix at
125 mg of IV Solu-Medrol. Patient expired
4/19/2021
"Patient was vaccinated in her home (COVID J&J)
on 3/8. Vaccinator obtained consent and confirmed
throughout the process that patient as at baseline
since patient was nonverbal and bedbound. Later
that same day she experienced an emergency and
was take to the hospital and subsequently admitted
to ICU. She died on 3/10, family present, on
comfort care. Per HPI, ""Patient is a 85 y.o. female
with advanced dementia (non verbal, wheelchair
COVID19 bound at baseline), chronic aspiration, recurrent
BLADDER MASS VACCINE JANSSEN 1126863-1 Death UTIs, voiding dysfunction currently self-straight
(COVID19) cathing, has suspicious bladder and gallbladder
masses (being worked up), has right sided
hydronephrosis, BIBEMS for acute hypoxemia,
difficult to bag en route, ED had difficulty intubating
and so performed cricothroidotomy. Patient had
brief PEA arrest due to hypoxia. ED provider noted
""excessive pulmonary edema in airway,
unfavorable anatomy, and airway swelling.""
Suspected insult stemming from J&J COVID
vaccination reaction."
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
COVID19
impressions included hypoxia, COVID-19. Pt is s/p
BLOOD ALBUMIN DECREASED VACCINE PFIZER\BIONTECH 1255836-1 Death
her first dose of vaccine and this precludes plasma.
(COVID19)
Supportive care steroids and doxy. Family faxed
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

O2 sat continues to decrease. NRB 15L in place O2


Sat 90%. Pt became pulseless and expired at 0451.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
COVID19
complains of having fallen a few times recently,
BLOOD CALCIUM DECREASED VACCINE PFIZER\BIONTECH 1020134-1 Death
thus he passed out. Could not say if there were
(COVID19)
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

1/29 Patient received 2nd dose COVID19 vaccine at


about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

and is on Levophed. Continue to monitor. Updated


patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
COVID19
Emergency There is no diaphoresis, palpitations or
BLOOD CALCIUM DECREASED VACCINE PFIZER\BIONTECH 1020134-1
Room * lightheadedness. He denies fever or chills. He
(COVID19)
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

failure as evidenced by orthostatic hypotension and


no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

prior to this he already was on ASA, Apixiban for


afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
COVID19
productive of yellowish sputum, no hemoptysis. He
BLOOD CALCIUM DECREASED VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
(COVID19) complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

rates of 140's-150's 1/29 more chest pain at 04:00,


relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

called off at 5:17 but he started having pulse and


agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
COVID19
breath. He has been having worsening shortness of
BLOOD CHLORIDE NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Death
breath the past few days, also complains of cough
(COVID19)
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Increased trop, transferred. 1/28, struggling with


orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

note: Called for CODE BLUE AGAIN AT 4:53. While


on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
COVID19
Emergency Syndrome, Sjogren's syndrome presented with
BLOOD CHLORIDE NORMAL VACCINE PFIZER\BIONTECH 1020134-1
(COVID19)
Room * chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

RN advises pt was in afib w/ RVR at a rate >140 at


time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

unresponsive still with pulse. Lifted patient back to


bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
COVID19
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
BLOOD CHLORIDE NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
radiotherapy, PTSD, depression, Churg Strauss
(COVID19)
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

complains of having fallen a few times recently,


thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

help to use bedside commode to urinate and have


BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
COVID19
multiple medical conditions including hypertension,
BLOOD CREATININE INCREASED VACCINE PFIZER\BIONTECH 1020134-1 Death
atrial fibrillation on apixaban, cardiomyopathy with
(COVID19)
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

productive of yellowish sputum, no hemoptysis. He


complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

MOD called and all above and previous information


discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID19
Emergency COVID 19 on 1/8/21. On 1/24/21: 61 year old
BLOOD CREATININE INCREASED VACCINE PFIZER\BIONTECH 1020134-1
Room * presents to E.R. with CC of chest pain/sob, with
(COVID19)
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Syndrome, Sjogren's syndrome presented with


chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

information and overall concern for pt, asked for


MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
COVID19
consciousness , then stopped breathing and lost
BLOOD CREATININE INCREASED VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
pulse. Narrative: Patient was first vaccinated for
(COVID19)
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

multiple medical conditions including hypertension,


atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

since he got ""that shot"" he hasn't felt well. When


asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
COVID19
Presented to ED on 1/12/21 slowly worsening
BLOOD CREATININE NORMAL VACCINE PFIZER\BIONTECH 1255836-1 Death
constant myalgias, generalized weakness where
(COVID19)
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

she couldn't walk, dry cough. Per daughter not


acting herself and more confused. Clinical
impressions included hypoxia, COVID-19. Pt is s/p
her first dose of vaccine and this precludes plasma.
Supportive care steroids and doxy. Family faxed
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
COVID19
productive of yellowish sputum, no hemoptysis. He
BLOOD CULTURE VACCINE PFIZER\BIONTECH 1020134-1 Death
(COVID19) complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

rates of 140's-150's 1/29 more chest pain at 04:00,


relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

called off at 5:17 but he started having pulse and


agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
COVID19
Emergency breath. He has been having worsening shortness of
BLOOD CULTURE VACCINE PFIZER\BIONTECH 1020134-1
Room * breath the past few days, also complains of cough
(COVID19)
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Increased trop, transferred. 1/28, struggling with


orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

note: Called for CODE BLUE AGAIN AT 4:53. While


on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
COVID19
Syndrome, Sjogren's syndrome presented with
BLOOD CULTURE VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
(COVID19) chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

RN advises pt was in afib w/ RVR at a rate >140 at


time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

unresponsive still with pulse. Lifted patient back to


bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
presented to Emergency room with complaints of
approximately 5 days of progressively worsening
shortness of breath with a dry nonproductive
cough, increased weakness, and wheezing.
Symptoms not controlled with increased use of
rescue inhaler albuterol. Patient's daughter reached
out and spoke with patient's pulmonologist Dr.
COVID19 today who ordered oral steroids however patient
BLOOD CULTURE VACCINE PFIZER\BIONTECH 1227451-1 Death reports she had not started taking them yet.
(COVID19) Patient was initiated on 15 L non-rebreather and
received 2 duo nebs EN route to the hospital. It
was reported she did have some intermittent chest
tightness although on my review, she denied this.
Upon arrival to the emergency room, patient was
initiated on BiPAP and receive 40 mg of IV Lasix at
125 mg of IV Solu-Medrol. Patient expired
4/19/2021
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

presented to Emergency room with complaints of


approximately 5 days of progressively worsening
shortness of breath with a dry nonproductive
cough, increased weakness, and wheezing.
Symptoms not controlled with increased use of
rescue inhaler albuterol. Patient's daughter reached
out and spoke with patient's pulmonologist Dr.
COVID19 today who ordered oral steroids however patient
BLOOD LACTIC ACID VACCINE PFIZER\BIONTECH 1227451-1 Death reports she had not started taking them yet.
(COVID19) Patient was initiated on 15 L non-rebreather and
received 2 duo nebs EN route to the hospital. It
was reported she did have some intermittent chest
tightness although on my review, she denied this.
Upon arrival to the emergency room, patient was
initiated on BiPAP and receive 40 mg of IV Lasix at
125 mg of IV Solu-Medrol. Patient expired
4/19/2021
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
COVID19 Syndrome, Sjogren's syndrome presented with
BLOOD LACTIC ACID INCREASED VACCINE PFIZER\BIONTECH 1020134-1 Death chief complaint of chest pain or shortness of
(COVID19) breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

time of CP. Pt CP improved w/ prn NTG. Pt HR


improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

bed with 3 staff assist. Pt stopped breathing and


lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
COVID19 poor EF, dyslipidemia, COPD, CVA, lung CA s/p
Emergency
BLOOD LACTIC ACID INCREASED VACCINE PFIZER\BIONTECH 1020134-1 radiotherapy, PTSD, depression, Churg Strauss
Room *
(COVID19) Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

thus he passed out. Could not say if there were


seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

BM. Assisted x2 to BSC. While sitting on BSC pt's


eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
COVID19 multiple medical conditions including hypertension,
BLOOD LACTIC ACID INCREASED VACCINE PFIZER\BIONTECH 1020134-1 Office Visit * atrial fibrillation on apixaban, cardiomyopathy with
(COVID19) poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

complains of left upper chest pain with no radiation.


There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

discussed Around 2310 MOD came to bedside to


see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
COVID19
impressions included hypoxia, COVID-19. Pt is s/p
BLOOD LACTIC ACID INCREASED VACCINE PFIZER\BIONTECH 1255836-1 Death
her first dose of vaccine and this precludes plasma.
(COVID19)
Supportive care steroids and doxy. Family faxed
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

O2 sat continues to decrease. NRB 15L in place O2


Sat 90%. Pt became pulseless and expired at 0451.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
COVID19
complains of having fallen a few times recently,
BLOOD POTASSIUM NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Death
thus he passed out. Could not say if there were
(COVID19)
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

1/29 Patient received 2nd dose COVID19 vaccine at


about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

and is on Levophed. Continue to monitor. Updated


patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
COVID19
Emergency There is no diaphoresis, palpitations or
BLOOD POTASSIUM NORMAL VACCINE PFIZER\BIONTECH 1020134-1
Room * lightheadedness. He denies fever or chills. He
(COVID19)
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

failure as evidenced by orthostatic hypotension and


no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

prior to this he already was on ASA, Apixiban for


afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
COVID19
productive of yellowish sputum, no hemoptysis. He
BLOOD POTASSIUM NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
(COVID19) complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

rates of 140's-150's 1/29 more chest pain at 04:00,


relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

called off at 5:17 but he started having pulse and


agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
impressions included hypoxia, COVID-19. Pt is s/p
COVID19
her first dose of vaccine and this precludes plasma.
BLOOD SODIUM DECREASED VACCINE PFIZER\BIONTECH 1255836-1 Death
Supportive care steroids and doxy. Family faxed
(COVID19)
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
COVID19
multiple medical conditions including hypertension,
BLOOD SODIUM NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Death
(COVID19) atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

productive of yellowish sputum, no hemoptysis. He


complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

MOD called and all above and previous information


discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID19
Emergency COVID 19 on 1/8/21. On 1/24/21: 61 year old
BLOOD SODIUM NORMAL VACCINE PFIZER\BIONTECH 1020134-1
Room * presents to E.R. with CC of chest pain/sob, with
(COVID19)
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Syndrome, Sjogren's syndrome presented with


chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

information and overall concern for pt, asked for


MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
COVID19
consciousness , then stopped breathing and lost
BLOOD SODIUM NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
pulse. Narrative: Patient was first vaccinated for
(COVID19)
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

multiple medical conditions including hypertension,


atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

since he got ""that shot"" he hasn't felt well. When


asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID19 Receiver of vaccine was reported dead on 04-22-


BLOOD TEST VACCINE MODERNA 1242950-1 Death 2021 TOD 0809 to Medical Examiner's Office Report
(COVID19) # 052-EMF-79-21
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
COVID19 lightheadedness. He denies fever or chills. He
BLOOD UREA INCREASED VACCINE PFIZER\BIONTECH 1020134-1 Death complains of having fallen a few times recently,
(COVID19) thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

pulmonary disease."" No pulmonary consult noted.


1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

elevated. Blood cultures pending. Started Zosyn


and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
COVID19 complains of left upper chest pain with no radiation.
Emergency
BLOOD UREA INCREASED VACCINE PFIZER\BIONTECH 1020134-1 There is no diaphoresis, palpitations or
Room *
(COVID19) lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

""shortness of breath and cough not due to heart


failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

and 1amp of D50. Trope bumped from 0.12 to 0.43


prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
COVID19 breath the past few days, also complains of cough
BLOOD UREA INCREASED VACCINE PFIZER\BIONTECH 1020134-1 Office Visit * productive of yellowish sputum, no hemoptysis. He
(COVID19) complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

having periods of A-Fib RVR with non-sustained


rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

time. Patient had a prolonged CPR and was actually


called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
impressions included hypoxia, COVID-19. Pt is s/p
COVID19
her first dose of vaccine and this precludes plasma.
BLOOD UREA INCREASED VACCINE PFIZER\BIONTECH 1255836-1 Death
Supportive care steroids and doxy. Family faxed
(COVID19)
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
On 1/23/21 the patient had a single-car accident,
slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
BONE FRAGMENTATION VACCINE MODERNA 1004811-1 Death and released. On 1/31/21 the patient had a
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

On 1/23/21 the patient had a single-car accident,


slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
Emergency
BONE FRAGMENTATION VACCINE MODERNA 1004811-1 and released. On 1/31/21 the patient had a
Room *
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
started experiencing after receiving 2nd dose of
Covid vaccine. Found to have a positive troponin,
hyponatremia. Stress test revealed reversible
myocardial ischemia of the inferior and lateral walls
of left ventricle with a large defect size but mild
COVID19
defect severity. Patient underwent PCI with DES
BRAIN COMPRESSION VACCINE PFIZER\BIONTECH 1350545-1 Death
placement and was placed on triple therapy with
(COVID19)
aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
episodes of vomiting, leading to terminal events:
brainstem compression and rapid deterioration and
CS of 2T preclude meaningful survival
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
started experiencing after receiving 2nd dose of
Covid vaccine. Found to have a positive troponin,
hyponatremia. Stress test revealed reversible
COVID19 myocardial ischemia of the inferior and lateral walls
BRAIN COMPRESSION VACCINE PFIZER\BIONTECH 1350545-1 Hospitalized of left ventricle with a large defect size but mild
(COVID19) defect severity. Patient underwent PCI with DES
placement and was placed on triple therapy with
aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

episodes of vomiting, leading to terminal events:


brainstem compression and rapid deterioration and
CS of 2T preclude meaningful survival
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
BRONCHIECTASIS VACCINE PFIZER\BIONTECH 1109552-1 Death
(COVID19) hypoxemic/hypercarbic respiratory failure,
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
COVID19 we transferred to AMR rig. EKG - showed PEA - CPR
BRONCHIECTASIS VACCINE PFIZER\BIONTECH 1109552-1 Hospitalized continued - patient intubated by AMR - epi is given.
(COVID19) Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
the following cause of death: 1.Acute-on-chronic
hypoxemic/hypercarbic respiratory failure,
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Acute combined metabolic and toxic


encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
COVID19 complains of left upper chest pain with no radiation.
CARBON DIOXIDE NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Death There is no diaphoresis, palpitations or
(COVID19) lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

""shortness of breath and cough not due to heart


failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

and 1amp of D50. Trope bumped from 0.12 to 0.43


prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
COVID19 breath the past few days, also complains of cough
Emergency
CARBON DIOXIDE NORMAL VACCINE PFIZER\BIONTECH 1020134-1 productive of yellowish sputum, no hemoptysis. He
Room *
(COVID19) complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

having periods of A-Fib RVR with non-sustained


rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

time. Patient had a prolonged CPR and was actually


called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
COVID19 chief complaint of chest pain or shortness of
CARBON DIOXIDE NORMAL VACCINE PFIZER\BIONTECH 1020134-1 Office Visit * breath. He has been having worsening shortness of
(COVID19) breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

resolved. Pt admits to continued dyspnea.


Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

and Code Blue called at 0120. 1/30 Hospitalist


note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
COVID19
CARDIAC ARREST VACCINE MODERNA 0965564-1 Death Cardiac arrest Narrative:
(COVID19)
COVID19
Emergency
CARDIAC ARREST VACCINE MODERNA 0965564-1 Cardiac arrest Narrative:
Room *
(COVID19)
COVID19
CARDIAC ARREST VACCINE MODERNA 0965564-1 Office Visit * Cardiac arrest Narrative:
(COVID19)
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
COVID19
complications. ROSC was obtained multiple times
CARDIAC ARREST VACCINE MODERNA 1002931-1 Death
but the patient continued to go into PEA. The
(COVID19)
patient was seen in the emergency department by
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

we were unable to resuscitate the patient. Time of


death 1253 on 1/24/21.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
Emergency but the patient continued to go into PEA. The
CARDIAC ARREST VACCINE MODERNA 1002931-1
Room * patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
but the patient continued to go into PEA. The
CARDIAC ARREST VACCINE MODERNA 1002931-1 Office Visit *
patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID19
COVID 19 on 1/8/21. On 1/24/21: 61 year old
CARDIAC ARREST VACCINE PFIZER\BIONTECH 1020134-1 Death
presents to E.R. with CC of chest pain/sob, with
(COVID19)
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Syndrome, Sjogren's syndrome presented with


chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

information and overall concern for pt, asked for


MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
COVID19
Emergency consciousness , then stopped breathing and lost
CARDIAC ARREST VACCINE PFIZER\BIONTECH 1020134-1
Room * pulse. Narrative: Patient was first vaccinated for
(COVID19)
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

multiple medical conditions including hypertension,


atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

since he got ""that shot"" he hasn't felt well. When


asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
COVID19
"anxious, restless, weak, dizzy, felt ""horrible"".
CARDIAC ARREST VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
Continued to C/O symptoms,. At 01:15, patient lost
(COVID19)
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

consciousness , then stopped breathing and lost


pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

anxious again. Tachypneic, stating he feels so weak


and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

at 08:18. Family at beside, Mother asks for code to


be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
COVID19
complains of having fallen a few times recently,
CARDIAC FAILURE CONGESTIVE VACCINE PFIZER\BIONTECH 1020134-1 Death
thus he passed out. Could not say if there were
(COVID19)
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

1/29 Patient received 2nd dose COVID19 vaccine at


about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

and is on Levophed. Continue to monitor. Updated


patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
COVID19
Emergency There is no diaphoresis, palpitations or
CARDIAC FAILURE CONGESTIVE VACCINE PFIZER\BIONTECH 1020134-1
Room * lightheadedness. He denies fever or chills. He
(COVID19)
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

failure as evidenced by orthostatic hypotension and


no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

prior to this he already was on ASA, Apixiban for


afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
COVID19
productive of yellowish sputum, no hemoptysis. He
CARDIAC FAILURE CONGESTIVE VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
(COVID19) complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

rates of 140's-150's 1/29 more chest pain at 04:00,


relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

called off at 5:17 but he started having pulse and


agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
CARDIAC FAILURE CONGESTIVE VACCINE PFIZER\BIONTECH 1109552-1 Death
(COVID19) hypoxemic/hypercarbic respiratory failure,
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
COVID19
backseat of car who had become unresponsive.
CARDIAC FAILURE CONGESTIVE VACCINE PFIZER\BIONTECH 1109552-1 Hospitalized
Patient lying on side. Wearing portable NC o2.
(COVID19)
Unresponsive to verbal/sternal rub. No pulse, No
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

resps. Called AMR to car side who called 911.


Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
the following cause of death: 1.Acute-on-chronic
hypoxemic/hypercarbic respiratory failure,
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
CARDIAC PACEMAKER INSERTION VACCINE MODERNA 1236416-1 Death
new pacemaker placement. His course was
(COVID19)
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
COVID19
Emergency 3/4/21, he was admitted to a facility for shortness
CARDIAC PACEMAKER INSERTION VACCINE MODERNA 1236416-1
(COVID19)
Room * of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID PCR test on 3/4/21. He has a noted history


of COPD, CHF and OSA. On 3/6/21, he underwent a
new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
death Narrative: Patient received Moderna covid
vaccine #1 on 1/22/21 and #2 on 2/24/21. On
3/4/21, he was admitted to a facility for shortness
of breath x 1 week. Upon admission, he was found
to be in heart block and was admitted to the ICU
and placed on pressors. He did have a negative
COVID PCR test on 3/4/21. He has a noted history
COVID19
of COPD, CHF and OSA. On 3/6/21, he underwent a
CARDIAC PACEMAKER INSERTION VACCINE MODERNA 1236416-1 Office Visit *
(COVID19) new pacemaker placement. His course was
complicated by the development of AKI,
paroxysmal V tach and new aflutter and was
initiated on apixaban. He was discharged on
3/18/21. No further records available and a date of
death was recorded as 4/3/21. No autopsy results
available. 38 days from time of second vaccine to
date of death.
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
started experiencing after receiving 2nd dose of
Covid vaccine. Found to have a positive troponin,
hyponatremia. Stress test revealed reversible
myocardial ischemia of the inferior and lateral walls
COVID19
of left ventricle with a large defect size but mild
CARDIAC STRESS TEST ABNORMAL VACCINE PFIZER\BIONTECH 1350545-1 Death
(COVID19) defect severity. Patient underwent PCI with DES
placement and was placed on triple therapy with
aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
episodes of vomiting, leading to terminal events:
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

brainstem compression and rapid deterioration and


CS of 2T preclude meaningful survival
Patient brought to the ED with generalized
weakness worsening over prior 2-3 days, states she
started experiencing after receiving 2nd dose of
Covid vaccine. Found to have a positive troponin,
hyponatremia. Stress test revealed reversible
myocardial ischemia of the inferior and lateral walls
of left ventricle with a large defect size but mild
COVID19
defect severity. Patient underwent PCI with DES
CARDIAC STRESS TEST ABNORMAL VACCINE PFIZER\BIONTECH 1350545-1 Hospitalized
placement and was placed on triple therapy with
(COVID19)
aspirin, clopidogrel and eliquis. Patient presented to
ED again on 5/23/21 outcome: patient is brought
to ED after a fall and loss of unconsciousness, hit
her head with large laceration at back of head, 2
episodes of vomiting, leading to terminal events:
brainstem compression and rapid deterioration and
CS of 2T preclude meaningful survival
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
but the patient continued to go into PEA. The
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1002931-1 Death
patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
COVID19
Emergency arrival. The Combi tube was removed and an
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1002931-1
Room * endotracheal tube was placed without
(COVID19)
complications. ROSC was obtained multiple times
but the patient continued to go into PEA. The
patient was seen in the emergency department by
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

both critical care and Cardiology. EKG shows ST


elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
but the patient continued to go into PEA. The
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1002931-1 Office Visit *
patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/3/21. He is noted to be a dialysis
patient. On 3/24/21, his wife took him to a facility
ER due to intermittent shortness of breath over the
previous week. He was admitted for fluid overload.
COVID19 On 3/27/21, he was found unresponsive and CPR
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1213287-1 Death was initiated and a code blue was called. He
(COVID19) received defibrillation, epinephrine, IV calcium,
sodium bicarb and amiodarone and was intubated;
however he did not survive and time of death is
recorded as 3/27/21 at 0138. No autopsy results
available. 24 days from time of vaccine to date of
death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/3/21. He is noted to be a dialysis
COVID19 patient. On 3/24/21, his wife took him to a facility
Emergency
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1213287-1 ER due to intermittent shortness of breath over the
Room *
(COVID19) previous week. He was admitted for fluid overload.
On 3/27/21, he was found unresponsive and CPR
was initiated and a code blue was called. He
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

received defibrillation, epinephrine, IV calcium,


sodium bicarb and amiodarone and was intubated;
however he did not survive and time of death is
recorded as 3/27/21 at 0138. No autopsy results
available. 24 days from time of vaccine to date of
death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/3/21. He is noted to be a dialysis
patient. On 3/24/21, his wife took him to a facility
ER due to intermittent shortness of breath over the
previous week. He was admitted for fluid overload.
COVID19 On 3/27/21, he was found unresponsive and CPR
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1213287-1 Office Visit * was initiated and a code blue was called. He
(COVID19) received defibrillation, epinephrine, IV calcium,
sodium bicarb and amiodarone and was intubated;
however he did not survive and time of death is
recorded as 3/27/21 at 0138. No autopsy results
available. 24 days from time of vaccine to date of
death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
AKI requiring dialysis and ultimately became
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1213571-1 Death
oliguric. He required epinephrine, dobutamine,
(COVID19)
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
Emergency AKI requiring dialysis and ultimately became
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1213571-1
(COVID19)
Room * oliguric. He required epinephrine, dobutamine,
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Death. Narrative: Patient received Moderna COVID


vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
AKI requiring dialysis and ultimately became
CARDIO-RESPIRATORY ARREST VACCINE MODERNA 1213571-1 Office Visit *
oliguric. He required epinephrine, dobutamine,
(COVID19)
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
COVID19
productive of yellowish sputum, no hemoptysis. He
CARDIO-RESPIRATORY ARREST VACCINE PFIZER\BIONTECH 1020134-1 Death
(COVID19) complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

rates of 140's-150's 1/29 more chest pain at 04:00,


relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

called off at 5:17 but he started having pulse and


agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
COVID19
Emergency breath. He has been having worsening shortness of
CARDIO-RESPIRATORY ARREST VACCINE PFIZER\BIONTECH 1020134-1
Room * breath the past few days, also complains of cough
(COVID19)
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Increased trop, transferred. 1/28, struggling with


orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

note: Called for CODE BLUE AGAIN AT 4:53. While


on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
COVID19
Syndrome, Sjogren's syndrome presented with
CARDIO-RESPIRATORY ARREST VACCINE PFIZER\BIONTECH 1020134-1 Office Visit *
(COVID19) chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

RN advises pt was in afib w/ RVR at a rate >140 at


time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

unresponsive still with pulse. Lifted patient back to


bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
COVID19
Pt transported by AMR/Fire to hospital. Pt was a full
CARDIO-RESPIRATORY ARREST VACCINE PFIZER\BIONTECH 1109552-1 Death
code on Hospice - she passed away 3/11/21 with
(COVID19)
the following cause of death: 1.Acute-on-chronic
hypoxemic/hypercarbic respiratory failure,
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Hyperkalemia. 7. Cardiogenic shock. 8. Acute


kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
CARDIO-RESPIRATORY ARREST VACCINE PFIZER\BIONTECH 1109552-1 Hospitalized
hypoxemic/hypercarbic respiratory failure,
(COVID19)
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
COVID19
we transferred to AMR rig. EKG - showed PEA - CPR
CARDIOGENIC SHOCK VACCINE PFIZER\BIONTECH 1109552-1 Death
(COVID19) continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
the following cause of death: 1.Acute-on-chronic
hypoxemic/hypercarbic respiratory failure,
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Bronchiectasis, chronic, secondary to asbestosis. 4.


Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
Family call Clinical Lead to car for elderly woman in
backseat of car who had become unresponsive.
Patient lying on side. Wearing portable NC o2.
Unresponsive to verbal/sternal rub. No pulse, No
resps. Called AMR to car side who called 911.
Transferred patient to a gurney and began CPR as
we transferred to AMR rig. EKG - showed PEA - CPR
continued - patient intubated by AMR - epi is given.
Pt transported by AMR/Fire to hospital. Pt was a full
code on Hospice - she passed away 3/11/21 with
COVID19
the following cause of death: 1.Acute-on-chronic
CARDIOGENIC SHOCK VACCINE PFIZER\BIONTECH 1109552-1 Hospitalized
hypoxemic/hypercarbic respiratory failure,
(COVID19)
multifactorial in origin. 2. Possible aspiration
pneumonia, present on admission. 3.
Bronchiectasis, chronic, secondary to asbestosis. 4.
Acute combined metabolic and toxic
encephalopathy, present on admission. 5. Out of
hospital pulseless electrical activity arrest. 6.
Hyperkalemia. 7. Cardiogenic shock. 8. Acute
kidney injury. 9. Lactic acidosis. 10. Acute diastolic
congestive heart failure. 11. Severe protein-calorie
malnutrition.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
CARDIOMEGALY VACCINE MODERNA 1228019-1 Death staphylococcus, MRSA infection-discharged to
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
Emergency
CARDIOMEGALY VACCINE MODERNA 1228019-1 staphylococcus, MRSA infection-discharged to
Room *
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
CARDIOMEGALY VACCINE MODERNA 1228019-1 Office Visit * staphylococcus, MRSA infection-discharged to
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Death. Narrative: Patient received Moderna COVID


vaccine #1 on 3/3/21. He is noted to be a dialysis
patient. On 3/24/21, his wife took him to a facility
ER due to intermittent shortness of breath over the
previous week. He was admitted for fluid overload.
COVID19 On 3/27/21, he was found unresponsive and CPR
CARDIOVERSION VACCINE MODERNA 1213287-1 Death was initiated and a code blue was called. He
(COVID19) received defibrillation, epinephrine, IV calcium,
sodium bicarb and amiodarone and was intubated;
however he did not survive and time of death is
recorded as 3/27/21 at 0138. No autopsy results
available. 24 days from time of vaccine to date of
death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/3/21. He is noted to be a dialysis
patient. On 3/24/21, his wife took him to a facility
ER due to intermittent shortness of breath over the
previous week. He was admitted for fluid overload.
COVID19 On 3/27/21, he was found unresponsive and CPR
Emergency
CARDIOVERSION VACCINE MODERNA 1213287-1 was initiated and a code blue was called. He
Room *
(COVID19) received defibrillation, epinephrine, IV calcium,
sodium bicarb and amiodarone and was intubated;
however he did not survive and time of death is
recorded as 3/27/21 at 0138. No autopsy results
available. 24 days from time of vaccine to date of
death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/3/21. He is noted to be a dialysis
patient. On 3/24/21, his wife took him to a facility
ER due to intermittent shortness of breath over the
previous week. He was admitted for fluid overload.
COVID19 On 3/27/21, he was found unresponsive and CPR
CARDIOVERSION VACCINE MODERNA 1213287-1 Office Visit * was initiated and a code blue was called. He
(COVID19) received defibrillation, epinephrine, IV calcium,
sodium bicarb and amiodarone and was intubated;
however he did not survive and time of death is
recorded as 3/27/21 at 0138. No autopsy results
available. 24 days from time of vaccine to date of
death.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

"Patient and her husband are elderly, but healthy


and live independently. Patient took blood pressure
medicine 'off and on' according to family. She was
5'2"", 120 pounds and slim and healthy and active,
so was her husband, though he had pulmonary
fibrosis so they had been staying home and not
attending church etc, and masking when they did
go out to protect against covid disease. They were
both vaccinated with covid Pfizer vaccine (dose #1)
on Thursday Feb 11. (02/11/2021) Thursday night
COVID19 as they went to bed they checked in with each
CEREBRAL HAEMORRHAGE VACCINE PFIZER\BIONTECH 1031846-1 Death other on how they each felt. Patient said she felt
(COVID19) totally fine, and her husband said his arm was a bit
sore. Patient woke before her husband on Friday
Feb 12, went downstairs and, from what the family
can tell, fixed herself a snack, then sat on the sofa.
Patient's husband found her deceased on the sofa.
He called 911 and they asked him to do CPR until
the paramedics arrived. Because of proximity to
covid vaccine, the ME wanted to examine the body
in the home and also ordered an autopsy. Autopsy
was completed on the same day as death, Feb 12,
2021"
Patient admitted to hospital evening of 2/7/21 with
COVID19 acute ischemic stroke and received tenectaplase.
CEREBROVASCULAR ACCIDENT VACCINE PFIZER\BIONTECH 1019661-1 Death Diagnosis Left MCA stroke. Reporting event given
(COVID19) was just over 24 hours after first COVID vaccine
dose.
Patient admitted to hospital evening of 2/7/21 with
COVID19 acute ischemic stroke and received tenectaplase.
Life
CEREBROVASCULAR ACCIDENT VACCINE PFIZER\BIONTECH 1019661-1 Diagnosis Left MCA stroke. Reporting event given
Threatening
(COVID19) was just over 24 hours after first COVID vaccine
dose.
Patient admitted to hospital evening of 2/7/21 with
COVID19 acute ischemic stroke and received tenectaplase.
CEREBROVASCULAR ACCIDENT VACCINE PFIZER\BIONTECH 1019661-1 Hospitalized Diagnosis Left MCA stroke. Reporting event given
(COVID19) was just over 24 hours after first COVID vaccine
dose.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

presented to Emergency room with complaints of


approximately 5 days of progressively worsening
shortness of breath with a dry nonproductive
cough, increased weakness, and wheezing.
Symptoms not controlled with increased use of
rescue inhaler albuterol. Patient's daughter reached
out and spoke with patient's pulmonologist Dr.
COVID19 today who ordered oral steroids however patient
CHEST DISCOMFORT VACCINE PFIZER\BIONTECH 1227451-1 Death reports she had not started taking them yet.
(COVID19) Patient was initiated on 15 L non-rebreather and
received 2 duo nebs EN route to the hospital. It
was reported she did have some intermittent chest
tightness although on my review, she denied this.
Upon arrival to the emergency room, patient was
initiated on BiPAP and receive 40 mg of IV Lasix at
125 mg of IV Solu-Medrol. Patient expired
4/19/2021
COVID19 Abdominal pain, Headaches, chest pain, loss of
CHEST PAIN VACCINE MODERNA 0948164-1 Death appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
CHEST PAIN VACCINE MODERNA 0948164-1 Hospitalized appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
Emergency
CHEST PAIN VACCINE MODERNA 0948164-1 appetite, confusion, elevated liver enzymes 1/8-
Room *
(COVID19) 1/15/21
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
COVID19 presents to E.R. with CC of chest pain/sob, with
CHEST PAIN VACCINE PFIZER\BIONTECH 1020134-1 Death multiple medical conditions including hypertension,
(COVID19) atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

breath the past few days, also complains of cough


productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

come to bedside to see pt. Around 2300 oncoming


MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
Continued to C/O symptoms,. At 01:15, patient lost
consciousness , then stopped breathing and lost
COVID19 pulse. Narrative: Patient was first vaccinated for
Emergency
CHEST PAIN VACCINE PFIZER\BIONTECH 1020134-1 COVID 19 on 1/8/21. On 1/24/21: 61 year old
Room *
(COVID19) presents to E.R. with CC of chest pain/sob, with
multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

radiotherapy, PTSD, depression, Churg Strauss


Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
movements with assistance. Pt also stated ever
since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Around 2250 Spoke w MOD to relay above


information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
"anxious, restless, weak, dizzy, felt ""horrible"".
COVID19 Continued to C/O symptoms,. At 01:15, patient lost
CHEST PAIN VACCINE PFIZER\BIONTECH 1020134-1 Office Visit * consciousness , then stopped breathing and lost
(COVID19) pulse. Narrative: Patient was first vaccinated for
COVID 19 on 1/8/21. On 1/24/21: 61 year old
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

presents to E.R. with CC of chest pain/sob, with


multiple medical conditions including hypertension,
atrial fibrillation on apixaban, cardiomyopathy with
poor EF, dyslipidemia, COPD, CVA, lung CA s/p
radiotherapy, PTSD, depression, Churg Strauss
Syndrome, Sjogren's syndrome presented with
chief complaint of chest pain or shortness of
breath. He has been having worsening shortness of
breath the past few days, also complains of cough
productive of yellowish sputum, no hemoptysis. He
complains of left upper chest pain with no radiation.
There is no diaphoresis, palpitations or
lightheadedness. He denies fever or chills. He
complains of having fallen a few times recently,
thus he passed out. Could not say if there were
seizures activity. Admitted to 3D Tele. On 1/27, Pt
advises he had episode of substernal CP this am.
RN advises pt was in afib w/ RVR at a rate >140 at
time of CP. Pt CP improved w/ prn NTG. Pt HR
improved after daily medications. Pt sts his CP has
resolved. Pt admits to continued dyspnea.
Increased trop, transferred. 1/28, struggling with
orthopnea and cough. He has no peripheral edema.
He does have intermittent chest pain. Patient
having periods of A-Fib RVR with non-sustained
rates of 140's-150's 1/29 more chest pain at 04:00,
relieved with NTG. HR = AF, with RVR 145. At
about 08:00, Cardiology sees patient and signs off,
""shortness of breath and cough not due to heart
failure as evidenced by orthostatic hypotension and
no improvement in symptoms with diuresis.
Consider underlying lung disease vs acute
pulmonary disease."" No pulmonary consult noted.
1/29 Patient received 2nd dose COVID19 vaccine at
about 3:30-4p. No notes from staff on this event.
No notes from MD that this was discussed and still
part of the plan. 1/29 nurse's note: At around 2240
Pt was able to rest briefly but is now restless and
anxious again. Tachypneic, stating he feels so weak
and dizzy and overall just feel horrible. Continuing
to get up frequently to have small soft bowel
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

movements with assistance. Pt also stated ever


since he got ""that shot"" he hasn't felt well. When
asked what shot pt replied ""COVID shot."" Pt did
receive 2nd dose of COVID vaccine 1/29 at 1530.
Around 2250 Spoke w MOD to relay above
information and overall concern for pt, asked for
MOD to come to bedside to evaluate pt. MOD states
he's handing off to oncoming MOD and they will
come to bedside to see pt. Around 2300 oncoming
MOD called and all above and previous information
discussed Around 2310 MOD came to bedside to
see pt. Will continue to monitor closely.
01/30/2021 ADDENDUM Around 0115 pt called for
help to use bedside commode to urinate and have
BM. Assisted x2 to BSC. While sitting on BSC pt's
eyes rolled back and pt made postures consistent
with a seizure, body became very rigid. Pt was
unresponsive still with pulse. Lifted patient back to
bed with 3 staff assist. Pt stopped breathing and
lost pulse. Chest compressions started immediately
and Code Blue called at 0120. 1/30 Hospitalist
note: Called for CODE BLUE AGAIN AT 4:53. While
on Vent after s/p Code blue for reasons not clear
patient went into Asystole and code called second
time. Patient had a prolonged CPR and was actually
called off at 5:17 but he started having pulse and
agonal resp. he was placed on Levophed and D5NS.
He got a total of 9 amps of epi, 3 amps od Bicarb
and 1amp of D50. Trope bumped from 0.12 to 0.43
prior to this he already was on ASA, Apixiban for
afib. Cards are on board for his CHF for his
pulmonary edema Lasix ordered. Hid lactic acid is
elevated. Blood cultures pending. Started Zosyn
and is on Levophed. Continue to monitor. Updated
patients Mom and she requested to do everything
at this point. Coded again at 5:40, survived, but
AOD writes a death note(?) Coded for the 4th time
at 08:18. Family at beside, Mother asks for code to
be stopped."
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID19 Abdominal pain, Headaches, chest pain, loss of


CHEST X-RAY VACCINE MODERNA 0948164-1 Death appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
CHEST X-RAY VACCINE MODERNA 0948164-1 Hospitalized appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
Emergency
CHEST X-RAY VACCINE MODERNA 0948164-1 appetite, confusion, elevated liver enzymes 1/8-
Room *
(COVID19) 1/15/21
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
CHEST X-RAY ABNORMAL VACCINE MODERNA 1228019-1 Death staphylococcus, MRSA infection-discharged to
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
Emergency
CHEST X-RAY ABNORMAL VACCINE MODERNA 1228019-1 staphylococcus, MRSA infection-discharged to
Room *
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
CHEST X-RAY ABNORMAL VACCINE MODERNA 1228019-1 Office Visit * staphylococcus, MRSA infection-discharged to
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
COVID19
that his test is positive. As per the protocol, all
CHILLS VACCINE JANSSEN 1266936-1 Death
COVID-19 positive individuals must report to the
(COVID19)
Health Center within 24 hours of notification and
complete 10 days home isolation. During isolation,
on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

tachypneic and was subsequently sedated and


intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
COVID19 Health Center within 24 hours of notification and
Life
CHILLS VACCINE JANSSEN 1266936-1 complete 10 days home isolation. During isolation,
Threatening
(COVID19) on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
COVID19
Apr-21 he developed a cough and requested a day
CHILLS VACCINE JANSSEN 1266936-1 Hospitalized
to rest. On 11-Apr-21, he went to Hospital to be
(COVID19)
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID-19 positive individuals must report to the


Health Center within 24 hours of notification and
complete 10 days home isolation. During isolation,
on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
As per patient daughter - patient had some minor
chills on the day of the vaccination - Friday
COVID19
1/15/21; felt well next day -Saturday, than she was
CHILLS VACCINE PFIZER\BIONTECH 1041789-1 Death
(COVID19) found slumped and lifeless on the couch on Sunday
1/17. Cause of death on death certificate was
reportedly put as COPD, Lung Ca and ASHD.
As per patient daughter - patient had some minor
chills on the day of the vaccination - Friday
COVID19
CHRONIC OBSTRUCTIVE PULMONARY 1/15/21; felt well next day -Saturday, than she was
VACCINE PFIZER\BIONTECH 1041789-1 Death
DISEASE found slumped and lifeless on the couch on Sunday
(COVID19)
1/17. Cause of death on death certificate was
reportedly put as COPD, Lung Ca and ASHD.
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
COGNITIVE DISORDER VACCINE MODERNA 1005533-1 Death administration of 2nd Covid vaccine, patient began
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
Life
COGNITIVE DISORDER VACCINE MODERNA 1005533-1 administration of 2nd Covid vaccine, patient began
Threatening
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Narrative: 89yo with type 2 DM, HT, pacemaker


COVID19 and prior COVID+ in Nov 2020. Shortly after
COGNITIVE DISORDER VACCINE MODERNA 1005533-1 Hospitalized administration of 2nd Covid vaccine, patient began
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
Emergency
COGNITIVE DISORDER VACCINE MODERNA 1005533-1 administration of 2nd Covid vaccine, patient began
Room *
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
COGNITIVE DISORDER VACCINE MODERNA 1005533-1 Office Visit * administration of 2nd Covid vaccine, patient began
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
COVID19 Abdominal pain, Headaches, chest pain, loss of
COMPUTERISED TOMOGRAM VACCINE MODERNA 0948164-1 Death appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
COMPUTERISED TOMOGRAM VACCINE MODERNA 0948164-1 Hospitalized appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
Emergency
COMPUTERISED TOMOGRAM VACCINE MODERNA 0948164-1 appetite, confusion, elevated liver enzymes 1/8-
Room *
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
COMPUTERISED TOMOGRAM ABDOMEN VACCINE MODERNA 0948164-1 Death appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
COMPUTERISED TOMOGRAM ABDOMEN VACCINE MODERNA 0948164-1 Hospitalized appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
Emergency
COMPUTERISED TOMOGRAM ABDOMEN VACCINE MODERNA 0948164-1 appetite, confusion, elevated liver enzymes 1/8-
Room *
(COVID19) 1/15/21
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
COMPUTERISED TOMOGRAM ABDOMEN
VACCINE MODERNA 1228019-1 Death staphylococcus, MRSA infection-discharged to
ABNORMAL
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,


COMPUTERISED TOMOGRAM ABDOMEN Emergency
VACCINE MODERNA 1228019-1 staphylococcus, MRSA infection-discharged to
ABNORMAL Room *
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
COMPUTERISED TOMOGRAM ABDOMEN
VACCINE MODERNA 1228019-1 Office Visit * staphylococcus, MRSA infection-discharged to
ABNORMAL
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
On 1/23/21 the patient had a single-car accident,
slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
COMPUTERISED TOMOGRAM ABNORMAL VACCINE MODERNA 1004811-1 Death and released. On 1/31/21 the patient had a
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
On 1/23/21 the patient had a single-car accident,
slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
Emergency
COMPUTERISED TOMOGRAM ABNORMAL VACCINE MODERNA 1004811-1 and released. On 1/31/21 the patient had a
Room *
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
Patients First dose 01/13/2021 and second dose of
Moderna Covid 19 vaccine was administered on
COVID19
February 11th. Patient developed pulmonary
COMPUTERISED TOMOGRAM ABNORMAL VACCINE MODERNA 1223371-1 Death
(COVID19) embolism in both lungs and hospitalized February
25th. Patient later developed PCP Pneumonia and
died March 23rd.
Patients First dose 01/13/2021 and second dose of
COVID19
Moderna Covid 19 vaccine was administered on
COMPUTERISED TOMOGRAM ABNORMAL VACCINE MODERNA 1223371-1 Hospitalized
(COVID19) February 11th. Patient developed pulmonary
embolism in both lungs and hospitalized February
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

25th. Patient later developed PCP Pneumonia and


died March 23rd.
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
COVID19
COMPUTERISED TOMOGRAM HEAD observed face down beside bed, resident sustained
VACCINE PFIZER\BIONTECH 0961010-1 Death
NORMAL a 1inX1in eccyhmotic/hematoma to the forehead.
(COVID19)
Neuro Checks with in normal limes Vital signs:
100/52, 100, 97.2, 28. Resident sent to ED for
further medical evaluation via EMS.
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
COVID19
COMPUTERISED TOMOGRAM HEAD observed face down beside bed, resident sustained
VACCINE PFIZER\BIONTECH 0961010-1 Hospitalized
NORMAL a 1inX1in eccyhmotic/hematoma to the forehead.
(COVID19)
Neuro Checks with in normal limes Vital signs:
100/52, 100, 97.2, 28. Resident sent to ED for
further medical evaluation via EMS.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
COMPUTERISED TOMOGRAM PELVIS
VACCINE MODERNA 1228019-1 Death staphylococcus, MRSA infection-discharged to
ABNORMAL
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
COMPUTERISED TOMOGRAM PELVIS Emergency
VACCINE MODERNA 1228019-1 staphylococcus, MRSA infection-discharged to
ABNORMAL Room *
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
COVID19 Narrative: 2/8/2021 UTI, sepsis, hyperglycemia,
COMPUTERISED TOMOGRAM PELVIS
VACCINE MODERNA 1228019-1 Office Visit * staphylococcus, MRSA infection-discharged to
ABNORMAL
(COVID19) hospice care from Medical Center 2/9, passed 2/11.
On 1/23/21 the patient had a single-car accident,
slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
COMPUTERISED TOMOGRAM SPINE VACCINE MODERNA 1004811-1 Death and released. On 1/31/21 the patient had a
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

On 1/23/21 the patient had a single-car accident,


slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
Emergency
COMPUTERISED TOMOGRAM SPINE VACCINE MODERNA 1004811-1 and released. On 1/31/21 the patient had a
Room *
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
Per the patient's husband, on 03/26/2021, the day
after vaccination, the decedent complained of
nausea with vomiting, and had difficulty driving. On
03/27/2021, her nausea continued and she
complained of shortness of breath while walking.
COVID19 On 03/28/2021, she was short of breath before
CONDITION AGGRAVATED VACCINE MODERNA 1209422-1 Death vomiting a small amount. She then became
(COVID19) unresponsive. Death was pronounced a short time
later. Per her treating physician who signed the
death certificate, the cause of death is felt to be
probable myocardial infarction due to electrolyte
abnormalities due to complications of her diabetes
mellitus.
"Patient and her husband are elderly, but healthy
and live independently. Patient took blood pressure
medicine 'off and on' according to family. She was
5'2"", 120 pounds and slim and healthy and active,
so was her husband, though he had pulmonary
fibrosis so they had been staying home and not
attending church etc, and masking when they did
COVID19
go out to protect against covid disease. They were
CONDITION AGGRAVATED VACCINE PFIZER\BIONTECH 1031846-1 Death
both vaccinated with covid Pfizer vaccine (dose #1)
(COVID19)
on Thursday Feb 11. (02/11/2021) Thursday night
as they went to bed they checked in with each
other on how they each felt. Patient said she felt
totally fine, and her husband said his arm was a bit
sore. Patient woke before her husband on Friday
Feb 12, went downstairs and, from what the family
can tell, fixed herself a snack, then sat on the sofa.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Patient's husband found her deceased on the sofa.


He called 911 and they asked him to do CPR until
the paramedics arrived. Because of proximity to
covid vaccine, the ME wanted to examine the body
in the home and also ordered an autopsy. Autopsy
was completed on the same day as death, Feb 12,
2021"
Pt. did not die from COVID vaccine. He was
COVID19
diagnosed with COVID19 on 06/04/2021. He had
CONDITION AGGRAVATED VACCINE PFIZER\BIONTECH 1407048-1 Death
an extensive past medical history with several
(COVID19)
preexisting conditions which COVID exacerbated.
COVID19 Abdominal pain, Headaches, chest pain, loss of
CONFUSIONAL STATE VACCINE MODERNA 0948164-1 Death appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
CONFUSIONAL STATE VACCINE MODERNA 0948164-1 Hospitalized appetite, confusion, elevated liver enzymes 1/8-
(COVID19) 1/15/21
COVID19 Abdominal pain, Headaches, chest pain, loss of
Emergency
CONFUSIONAL STATE VACCINE MODERNA 0948164-1 appetite, confusion, elevated liver enzymes 1/8-
Room *
(COVID19) 1/15/21
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
impressions included hypoxia, COVID-19. Pt is s/p
COVID19
her first dose of vaccine and this precludes plasma.
CONFUSIONAL STATE VACCINE PFIZER\BIONTECH 1255836-1 Death
Supportive care steroids and doxy. Family faxed
(COVID19)
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
7/30/21: admitted for multiple falls 8/5/21:
Transitioned to Inpatient Rehab. 8/13/21: He
COVID19
became altered and hypoxic, prompting testing for
CONFUSIONAL STATE VACCINE PFIZER\BIONTECH 1641551-1 Death
COVID-19. Resulted positive COVID PCR on
(COVID19)
8/13/21; breathing comfortably on 2L nasal
cannula 8/17/21: completed remdesivir course,
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

worsening confusion and altered mentation; using


heated-high flow at 35L, non-rebreather 8/19/21:
patient discharged to hospice. 8/22/21: patient
passed. Time of death 0508.
7/30/21: admitted for multiple falls 8/5/21:
Transitioned to Inpatient Rehab. 8/13/21: He
became altered and hypoxic, prompting testing for
COVID-19. Resulted positive COVID PCR on
COVID19
8/13/21; breathing comfortably on 2L nasal
CONFUSIONAL STATE VACCINE PFIZER\BIONTECH 1641551-1 Hospitalized
cannula 8/17/21: completed remdesivir course,
(COVID19)
worsening confusion and altered mentation; using
heated-high flow at 35L, non-rebreather 8/19/21:
patient discharged to hospice. 8/22/21: patient
passed. Time of death 0508.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
AKI requiring dialysis and ultimately became
CORONARY ARTERY BYPASS VACCINE MODERNA 1213571-1 Death
(COVID19) oliguric. He required epinephrine, dobutamine,
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
Death. Narrative: Patient received Moderna COVID
vaccine #1 on 3/1/21. On 3/17/21, he was
admitted to a facility for a CABG. Per notes, after
his CABG, he developed Pseudomonas pneumonia,
COVID19
Emergency AKI requiring dialysis and ultimately became
CORONARY ARTERY BYPASS VACCINE MODERNA 1213571-1
Room * oliguric. He required epinephrine, dobutamine,
(COVID19)
dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
Death. Narrative: Patient received Moderna COVID
COVID19 vaccine #1 on 3/1/21. On 3/17/21, he was
CORONARY ARTERY BYPASS VACCINE MODERNA 1213571-1 Office Visit * admitted to a facility for a CABG. Per notes, after
(COVID19) his CABG, he developed Pseudomonas pneumonia,
AKI requiring dialysis and ultimately became
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

oliguric. He required epinephrine, dobutamine,


dopamine, amiodarone and went through two code
blues prior to pronouncement of death on 3/25/21
at 2305. No autopsy reports available. 24 days
from time of vaccine to date of death.
"Patient and her husband are elderly, but healthy
and live independently. Patient took blood pressure
medicine 'off and on' according to family. She was
5'2"", 120 pounds and slim and healthy and active,
so was her husband, though he had pulmonary
fibrosis so they had been staying home and not
attending church etc, and masking when they did
go out to protect against covid disease. They were
both vaccinated with covid Pfizer vaccine (dose #1)
on Thursday Feb 11. (02/11/2021) Thursday night
COVID19 as they went to bed they checked in with each
CORONARY ARTERY OCCLUSION VACCINE PFIZER\BIONTECH 1031846-1 Death other on how they each felt. Patient said she felt
(COVID19) totally fine, and her husband said his arm was a bit
sore. Patient woke before her husband on Friday
Feb 12, went downstairs and, from what the family
can tell, fixed herself a snack, then sat on the sofa.
Patient's husband found her deceased on the sofa.
He called 911 and they asked him to do CPR until
the paramedics arrived. Because of proximity to
covid vaccine, the ME wanted to examine the body
in the home and also ordered an autopsy. Autopsy
was completed on the same day as death, Feb 12,
2021"
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
COVID19
to rest. On 11-Apr-21, he went to Hospital to be
COUGH VACCINE JANSSEN 1266936-1 Death
evaluated by the physician who ordered some labs
(COVID19)
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
Health Center within 24 hours of notification and
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

complete 10 days home isolation. During isolation,


on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
COVID19 Health Center within 24 hours of notification and
Life
COUGH VACCINE JANSSEN 1266936-1 complete 10 days home isolation. During isolation,
Threatening
(COVID19) on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Employee developed a fever and chills on 01-Apr-


21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
COVID19 Health Center within 24 hours of notification and
COUGH VACCINE JANSSEN 1266936-1 Hospitalized complete 10 days home isolation. During isolation,
(COVID19) on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
presented to Emergency room with complaints of
approximately 5 days of progressively worsening
shortness of breath with a dry nonproductive
cough, increased weakness, and wheezing.
Symptoms not controlled with increased use of
rescue inhaler albuterol. Patient's daughter reached
COVID19 out and spoke with patient's pulmonologist Dr.
COUGH VACCINE PFIZER\BIONTECH 1227451-1 Death today who ordered oral steroids however patient
(COVID19) reports she had not started taking them yet.
Patient was initiated on 15 L non-rebreather and
received 2 duo nebs EN route to the hospital. It
was reported she did have some intermittent chest
tightness although on my review, she denied this.
Upon arrival to the emergency room, patient was
initiated on BiPAP and receive 40 mg of IV Lasix at
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

125 mg of IV Solu-Medrol. Patient expired


4/19/2021
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
impressions included hypoxia, COVID-19. Pt is s/p
COVID19
her first dose of vaccine and this precludes plasma.
COUGH VACCINE PFIZER\BIONTECH 1255836-1 Death
Supportive care steroids and doxy. Family faxed
(COVID19)
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
COVID19 Health Center within 24 hours of notification and
COVID-19 VACCINE JANSSEN 1266936-1 Death complete 10 days home isolation. During isolation,
(COVID19) on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Employee developed a fever and chills on 01-Apr-


21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
COVID19 Health Center within 24 hours of notification and
Life
COVID-19 VACCINE JANSSEN 1266936-1 complete 10 days home isolation. During isolation,
Threatening
(COVID19) on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
COVID19 evaluated by the physician who ordered some labs
COVID-19 VACCINE JANSSEN 1266936-1 Hospitalized which were normal. He was then advised to
(COVID19) complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
Health Center within 24 hours of notification and
complete 10 days home isolation. During isolation,
on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

supervisor who called 112 for an ambulance. He


was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Hospitalized and died due to COVID-19 after being
COVID19
fully vaccinated. From vital records: ACUTE
COVID-19 VACCINE MODERNA 1307516-1 Death
RESPIRATORY FAILURE WITH HYPOXIA,
(COVID19)
PNEUMONIA DUE TO COVID-19
Hospitalized and died due to COVID-19 after being
COVID19
fully vaccinated. From vital records: ACUTE
COVID-19 VACCINE MODERNA 1307516-1 Hospitalized
RESPIRATORY FAILURE WITH HYPOXIA,
(COVID19)
PNEUMONIA DUE TO COVID-19
Patient received second COVId 19 vaccine on
4/9/21 @ Health Department. Was admitted to
COVID19
hospital on 5/18/2021 with SOB, Nausea, Vomiting,
COVID-19 VACCINE MODERNA 1364724-1 Death
and Headache. Diagnosed with COVID 19 infection
(COVID19)
and COVID 19 Pneumonia. Patient expired on
5/19/2021 at hospital.
8/14/2021 Admit Hospital. Patient presented to
emergency room with shortness of breath for the
last 4 days with weakness and decline in status and
diarrhea. Her oxygen saturation was low in the low
90s. home oxygen dependent. Tested positive for
COVID19
COVID-19 from PCR on 8/15/21. Diagnosed with:
COVID-19 VACCINE MODERNA 1684819-1 Death
COVID-19 pneumonia, acute on chronic hypoxic
(COVID19)
respiratory failure. Transferred to Hospice 8/20/21.
patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Number 025A21A; Second dose: 04/14/21 Lot
Number 030B21A
COVID19 8/14/2021 Admit Hospital. Patient presented to
COVID-19 VACCINE MODERNA 1684819-1 Hospitalized emergency room with shortness of breath for the
(COVID19) last 4 days with weakness and decline in status and
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

diarrhea. Her oxygen saturation was low in the low


90s. home oxygen dependent. Tested positive for
COVID-19 from PCR on 8/15/21. Diagnosed with:
COVID-19 pneumonia, acute on chronic hypoxic
respiratory failure. Transferred to Hospice 8/20/21.
patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Number 025A21A; Second dose: 04/14/21 Lot
Number 030B21A
Presented to ED on 1/12/21 slowly worsening
constant myalgias, generalized weakness where
she couldn't walk, dry cough. Per daughter not
acting herself and more confused. Clinical
impressions included hypoxia, COVID-19. Pt is s/p
COVID19
her first dose of vaccine and this precludes plasma.
COVID-19 VACCINE PFIZER\BIONTECH 1255836-1 Death
Supportive care steroids and doxy. Family faxed
(COVID19)
DNR on 1/12/21 at 2225. Remdesivir given 1/13/21
at 1am. 1/13/21 note at 1:30am: Pt's O2 sat
fluctuating btw 80%-90%. Increased NC success pt
O2 sat continues to decrease. NRB 15L in place O2
Sat 90%. Pt became pulseless and expired at 0451.
COVID19
Patient hospitalized and died of pneumonia caused
COVID-19 VACCINE PFIZER\BIONTECH 1289390-1 Death
by COVID-19 after being fully vaccinated.
(COVID19)
COVID19
Patient hospitalized and died of pneumonia caused
COVID-19 VACCINE PFIZER\BIONTECH 1289390-1 Hospitalized
by COVID-19 after being fully vaccinated.
(COVID19)
Patient received second COVID 19 vaccine on
4/13/21 at Site. Patient tested positive for COVID
COVID19
on 5/16/2021. Patient had worsened short of
COVID-19 VACCINE PFIZER\BIONTECH 1354193-1 Death
(COVID19) breath on 5/25/2021 and was admitted to Medical
and placed on a vent. Patient expired on
5/26/2021.
Pt. did not die from COVID vaccine. He was
COVID19
diagnosed with COVID19 on 06/04/2021. He had
COVID-19 VACCINE PFIZER\BIONTECH 1407048-1 Death
(COVID19) an extensive past medical history with several
preexisting conditions which COVID exacerbated.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID19
COVID-19 VACCINE PFIZER\BIONTECH 1433899-1 Death Died of COVID-19 illness on 02/26/2021
(COVID19)
Case had covid vaccines x 2 with last dose
administered on 2/17/2021. Developed symptoms
COVID19
of Covid 19 on 8/17/2021. Case had a positive
COVID-19 VACCINE PFIZER\BIONTECH 1641014-1 Death
COVID 19 lab test on 8/18/2021 was admitted to
(COVID19)
Medical Center. Case Expired while still hospitalized
on 8/21/2021.
Patient received COvid vaccine x2 with last dose
administered on 2/5/2021. Patient developed
COVID19
symptoms of Covid 19 Case tested positive for
COVID-19 VACCINE PFIZER\BIONTECH 1641295-1 Death
COvid 19 on 7/30/2021 and was admitted to
(COVID19)
Medical Center on 8/11/2021. Patient expired while
still hospitalized on 8/19/2021.
7/30/21: admitted for multiple falls 8/5/21:
Transitioned to Inpatient Rehab. 8/13/21: He
became altered and hypoxic, prompting testing for
COVID-19. Resulted positive COVID PCR on
COVID19
8/13/21; breathing comfortably on 2L nasal
COVID-19 VACCINE PFIZER\BIONTECH 1641551-1 Death
cannula 8/17/21: completed remdesivir course,
(COVID19)
worsening confusion and altered mentation; using
heated-high flow at 35L, non-rebreather 8/19/21:
patient discharged to hospice. 8/22/21: patient
passed. Time of death 0508.
7/30/21: admitted for multiple falls 8/5/21:
Transitioned to Inpatient Rehab. 8/13/21: He
became altered and hypoxic, prompting testing for
COVID-19. Resulted positive COVID PCR on
COVID19
8/13/21; breathing comfortably on 2L nasal
COVID-19 VACCINE PFIZER\BIONTECH 1641551-1 Hospitalized
cannula 8/17/21: completed remdesivir course,
(COVID19)
worsening confusion and altered mentation; using
heated-high flow at 35L, non-rebreather 8/19/21:
patient discharged to hospice. 8/22/21: patient
passed. Time of death 0508.
Case was fully vaccinated with COVID 19 vaccine.
COVID19
Last dose administered on 2/5/21. Case tested
COVID-19 VACCINE PFIZER\BIONTECH 1656270-1 Death
(COVID19) positive for COVID 19 on 8/4/2021. and was
admitted to Medical Center with covid signs and
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

symptoms on 8/11/2021. Case expired while still


hospitalized on 8/26/2021.
Hospitalized and died due to COVID-19 after being
COVID19
fully vaccinated. From vital records: ACUTE
COVID-19 PNEUMONIA VACCINE MODERNA 1307516-1 Death
RESPIRATORY FAILURE WITH HYPOXIA,
(COVID19)
PNEUMONIA DUE TO COVID-19
Hospitalized and died due to COVID-19 after being
COVID19
fully vaccinated. From vital records: ACUTE
COVID-19 PNEUMONIA VACCINE MODERNA 1307516-1 Hospitalized
(COVID19) RESPIRATORY FAILURE WITH HYPOXIA,
PNEUMONIA DUE TO COVID-19
Patient received second COVId 19 vaccine on
4/9/21 @ Health Department. Was admitted to
COVID19
hospital on 5/18/2021 with SOB, Nausea, Vomiting,
COVID-19 PNEUMONIA VACCINE MODERNA 1364724-1 Death
and Headache. Diagnosed with COVID 19 infection
(COVID19)
and COVID 19 Pneumonia. Patient expired on
5/19/2021 at hospital.
8/14/2021 Admit Hospital. Patient presented to
emergency room with shortness of breath for the
last 4 days with weakness and decline in status and
diarrhea. Her oxygen saturation was low in the low
90s. home oxygen dependent. Tested positive for
COVID19
COVID-19 from PCR on 8/15/21. Diagnosed with:
COVID-19 PNEUMONIA VACCINE MODERNA 1684819-1 Death
COVID-19 pneumonia, acute on chronic hypoxic
(COVID19)
respiratory failure. Transferred to Hospice 8/20/21.
patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Number 025A21A; Second dose: 04/14/21 Lot
Number 030B21A
8/14/2021 Admit Hospital. Patient presented to
emergency room with shortness of breath for the
last 4 days with weakness and decline in status and
diarrhea. Her oxygen saturation was low in the low
COVID19
90s. home oxygen dependent. Tested positive for
COVID-19 PNEUMONIA VACCINE MODERNA 1684819-1 Hospitalized
COVID-19 from PCR on 8/15/21. Diagnosed with:
(COVID19)
COVID-19 pneumonia, acute on chronic hypoxic
respiratory failure. Transferred to Hospice 8/20/21.
patient died on 8/25/21. Note: COVID-19 Moderna
vaccine previously given: First dose: 03/08/21 Lot
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Number 025A21A; Second dose: 04/14/21 Lot


Number 030B21A
COVID19
Patient hospitalized and died of pneumonia caused
COVID-19 PNEUMONIA VACCINE PFIZER\BIONTECH 1289390-1 Death
by COVID-19 after being fully vaccinated.
(COVID19)
COVID19
Patient hospitalized and died of pneumonia caused
COVID-19 PNEUMONIA VACCINE PFIZER\BIONTECH 1289390-1 Hospitalized
by COVID-19 after being fully vaccinated.
(COVID19)
presented to Emergency room with complaints of
approximately 5 days of progressively worsening
shortness of breath with a dry nonproductive
cough, increased weakness, and wheezing.
Symptoms not controlled with increased use of
rescue inhaler albuterol. Patient's daughter reached
out and spoke with patient's pulmonologist Dr.
COVID19 today who ordered oral steroids however patient
CULTURE URINE POSITIVE VACCINE PFIZER\BIONTECH 1227451-1 Death reports she had not started taking them yet.
(COVID19) Patient was initiated on 15 L non-rebreather and
received 2 duo nebs EN route to the hospital. It
was reported she did have some intermittent chest
tightness although on my review, she denied this.
Upon arrival to the emergency room, patient was
initiated on BiPAP and receive 40 mg of IV Lasix at
125 mg of IV Solu-Medrol. Patient expired
4/19/2021
"Patient was vaccinated in her home (COVID J&J)
on 3/8. Vaccinator obtained consent and confirmed
throughout the process that patient as at baseline
since patient was nonverbal and bedbound. Later
that same day she experienced an emergency and
was take to the hospital and subsequently admitted
COVID19
to ICU. She died on 3/10, family present, on
DEATH VACCINE JANSSEN 1126863-1 Death
comfort care. Per HPI, ""Patient is a 85 y.o. female
(COVID19)
with advanced dementia (non verbal, wheelchair
bound at baseline), chronic aspiration, recurrent
UTIs, voiding dysfunction currently self-straight
cathing, has suspicious bladder and gallbladder
masses (being worked up), has right sided
hydronephrosis, BIBEMS for acute hypoxemia,
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

difficult to bag en route, ED had difficulty intubating


and so performed cricothroidotomy. Patient had
brief PEA arrest due to hypoxia. ED provider noted
""excessive pulmonary edema in airway,
unfavorable anatomy, and airway swelling.""
Suspected insult stemming from J&J COVID
vaccination reaction."
Patient was found deceased in her home by her
COVID19
daughter 9+ hours after receiving the vaccine. The
DEATH VACCINE JANSSEN 1144617-1 Death
was no indication of how long the patient had been
(COVID19)
deceased prior to being discovered.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
COVID19 Health Center within 24 hours of notification and
DEATH VACCINE JANSSEN 1266936-1 Death complete 10 days home isolation. During isolation,
(COVID19) on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Employee developed a fever and chills on 01-Apr-
COVID19
Life 21 which he managed with Tylenol. Symptoms
DEATH VACCINE JANSSEN 1266936-1
(COVID19)
Threatening resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

Apr-21 he developed a cough and requested a day


to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
complete PCR swab and was notified on 12-Apri-21
that his test is positive. As per the protocol, all
COVID-19 positive individuals must report to the
Health Center within 24 hours of notification and
complete 10 days home isolation. During isolation,
on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
declining on 21-Apr-21 as he became hypoxic and
tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
Employee developed a fever and chills on 01-Apr-
21 which he managed with Tylenol. Symptoms
resolved as per patient who contributed the
symptoms as a result of the J&J vaccine. On 10-
Apr-21 he developed a cough and requested a day
to rest. On 11-Apr-21, he went to Hospital to be
evaluated by the physician who ordered some labs
which were normal. He was then advised to
COVID19 complete PCR swab and was notified on 12-Apri-21
DEATH VACCINE JANSSEN 1266936-1 Hospitalized that his test is positive. As per the protocol, all
(COVID19) COVID-19 positive individuals must report to the
Health Center within 24 hours of notification and
complete 10 days home isolation. During isolation,
on 17-Apr-21, patient developed hemoptysis and
difficulty breathing a breathing and notified his
supervisor who called 112 for an ambulance. He
was transferred to Hospital. Evaluated and started
treatment for pneumonia and was transferred to
Hospital on 18-Apr-21. His condition started
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

declining on 21-Apr-21 as he became hypoxic and


tachypneic and was subsequently sedated and
intubated. As he became HD unstable, Levophed
and Vasopressin were started and reached maxed
doses. On 25-Apr-21 Dr. from the hospital called
and stated that patient expired at 0830.
COVID19
DEATH VACCINE JANSSEN 1478327-1 Death PE diagnosed 6/11/21 death 7/4/21
(COVID19)
COVID19
Life
DEATH VACCINE JANSSEN 1478327-1 PE diagnosed 6/11/21 death 7/4/21
Threatening
(COVID19)
COVID19
DEATH VACCINE JANSSEN 1478327-1 Hospitalized PE diagnosed 6/11/21 death 7/4/21
(COVID19)
Cause of death not documented. The ADR did not
occur at the time of the administration of the
COVID19 vaccine nor was there an ADR that occurred
DEATH VACCINE JANSSEN 1591271-1 Death between the observation period and the date of
(COVID19) death. Significant comorbidities include HTN,
hyperlipidemia, COPD, GERD, prolonged QT
interval, and history of polypectomy.
Patient received her vaccination on 1/12/21
COVID19 administered by pharmacy*+. She expired on
DEATH VACCINE MODERNA 0940855-1 Death 1/12/21 an approximately 7:30pm. Resident did
(COVID19) not have any adverse reactions and was a hospice
patient.
Patient received her vaccination on 1/12/21
COVID19 administered by pharmacy*+. She expired on
DEATH VACCINE MODERNA 0940855-1 Office Visit * 1/12/21 an approximately 7:30pm. Resident did
(COVID19) not have any adverse reactions and was a hospice
patient.
COVID19
DEATH VACCINE MODERNA 0961845-1 Death Narrative:
(COVID19)
COVID19
Emergency
DEATH VACCINE MODERNA 0961845-1 Narrative:
Room *
(COVID19)
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID19
DEATH VACCINE MODERNA 0961845-1 Office Visit * Narrative:
(COVID19)
COVID19
DEATH VACCINE MODERNA 0963163-1 Death Narrative:
(COVID19)
COVID19
Emergency
DEATH VACCINE MODERNA 0963163-1 Narrative:
Room *
(COVID19)
COVID19
DEATH VACCINE MODERNA 0963163-1 Office Visit * Narrative:
(COVID19)
COVID19
Pt passed away evening of 1/13 - unknown reason
DEATH VACCINE MODERNA 0967747-1 Death
(COVID19) currently Narrative:

COVID19
Emergency Pt passed away evening of 1/13 - unknown reason
DEATH VACCINE MODERNA 0967747-1
Room * currently Narrative:
(COVID19)
COVID19
Pt passed away evening of 1/13 - unknown reason
DEATH VACCINE MODERNA 0967747-1 Office Visit *
currently Narrative:
(COVID19)
COVID19
DEATH VACCINE MODERNA 0975918-1 Death death Narrative:
(COVID19)
COVID19
Emergency
DEATH VACCINE MODERNA 0975918-1 death Narrative:
Room *
(COVID19)
COVID19
DEATH VACCINE MODERNA 0975918-1 Office Visit * death Narrative:
(COVID19)
COVID19
Death Narrative: Patient with Severe Dementia and
DEATH VACCINE MODERNA 0983721-1 Death
on Hospice for end of life care.
(COVID19)
COVID19
Emergency Death Narrative: Patient with Severe Dementia and
DEATH VACCINE MODERNA 0983721-1
Room * on Hospice for end of life care.
(COVID19)
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

COVID19
Death Narrative: Patient with Severe Dementia and
DEATH VACCINE MODERNA 0983721-1 Office Visit *
(COVID19) on Hospice for end of life care.

REC'D CALL FROM PT'S SON, PT HAS BEEN ON


COVID19 HOSPICE CARE AND PASSED 1/26/21. DOES NOT
DEATH VACCINE MODERNA 0987877-1 Death BELIEVE THIS IS RELATED TO VACCINE
(COVID19) ADMINISTRATION, BUT WANTED TO REPORT TO
US.
COVID19 No adverse events reported post vaccine. 1 st dose
DEATH VACCINE MODERNA 0992154-1 Death on 1/11/21 by public health. Death 1/31/21 Patient
(COVID19) was on hospice for gradual decline.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
but the patient continued to go into PEA. The
DEATH VACCINE MODERNA 1002931-1 Death
patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
CARDIAC ARREST, DEATH Narrative: The patient
presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
Emergency but the patient continued to go into PEA. The
DEATH VACCINE MODERNA 1002931-1
Room * patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

CARDIAC ARREST, DEATH Narrative: The patient


presents to the emergency department in
cardiopulmonary arrest. CPR was continued upon
arrival. The Combi tube was removed and an
endotracheal tube was placed without
complications. ROSC was obtained multiple times
COVID19
but the patient continued to go into PEA. The
DEATH VACCINE MODERNA 1002931-1 Office Visit *
patient was seen in the emergency department by
(COVID19)
both critical care and Cardiology. EKG shows ST
elevations, but the patient was unstable to go to
catheterization. The patient had 1 episode of
asystole. Despite best efforts and multiple attempts
we were unable to resuscitate the patient. Time of
death 1253 on 1/24/21.
On 1/23/21 the patient had a single-car accident,
slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
DEATH VACCINE MODERNA 1004811-1 Death and released. On 1/31/21 the patient had a
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
On 1/23/21 the patient had a single-car accident,
slid off icy road into snowbank. She was seen in our
ER, diagnosed w/ trauma and L4 compression
fracture. She was transported to Hospital for
COVID19 further trauma workup. We believe she was treated
Emergency
DEATH VACCINE MODERNA 1004811-1 and released. On 1/31/21 the patient had a
Room *
(COVID19) headache but did not seek medical attention. In the
morning of 2/1 she became unresponsive and was
pronounced dead on the scene when EMS arrived.
Autopsy showed a left temporal subdural
hematoma.
COVID19 Narrative: 89yo with type 2 DM, HT, pacemaker
DEATH VACCINE MODERNA 1005533-1 Death and prior COVID+ in Nov 2020. Shortly after
(COVID19) administration of 2nd Covid vaccine, patient began
Vaccine Vaccine VAERS Event
Symptoms Type Manufacturer ID Category
Adverse Event Description

to have increased cognitive decline and 2 days after


he expired at the facility
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
Life
DEATH VACCINE MODERNA 1005533-1 administration of 2nd Covid vaccine, patient began
Threatening
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
DEATH VACCINE MODERNA 1005533-1 Hospitalized administration of 2nd Covid vaccine, patient began
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
Emergency
DEATH VACCINE MODERNA 1005533-1 administration of 2nd Covid vaccine, patient began
Room *
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
Narrative: 89yo with type 2 DM, HT, pacemaker
COVID19 and prior COVID+ in Nov 2020. Shortly after
DEATH VACCINE MODERNA 1005533-1 Office Visit * administration of 2nd Covid vaccine, patient began
(COVID19) to have increased cognitive decline and 2 days after
he expired at the facility
COVID19
Pt was deceased when we came for second dose.
DEATH VACCINE MODERNA 1017960-1 Death
(COVID19) COD unknown to pharmacy.

COVID19
Moderna administered 02/01/21. Patient expired
DEATH VACCINE MODERNA 1023979-1 Death
(COVID19) 02/10/2020 unexpectedly

Within 10 minutes following the second vaccination,


patient reported dizziness and nausea, had an
COVID19 episode of vomiting but recovered within 30
DEATH VACCINE MODERNA 1069118-1 Death minutes. It was reported to our clinic that the
(COVID19) patient was found deceased on March 1, 2021 at
approximately 10 pm. Cause of death is not
determined at this time.
COVID19 NO IMMEDIATE ADVERSE EVENTS PRESENT
DEATH VACCINE MODERNA 1081547-1 Death FOLLOWING IMMUNIZATION. RESIDENT WAS
(COVID19)