Sunday, August 8, 2021

Wisconsin: 743 Series Adverse Reactions To The Jab, And They Are All Listed Here, Adverse Events Are More Common, Went Up 10% if One Week, Even Though Less Are Getting VXX

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From the 7/30/2021 release of VAERS data:

Found 743 cases where Location is Wisconsin and Vaccine is COVID19 and Serious

Table


Age	Count	Percent
< 3 Years	1	0.13%
12-17 Years	7	0.94%
17-44 Years	130	17.5%
44-65 Years	208	27.99%
65-75 Years	137	18.44%
75+ Years	247	33.24%
Unknown	13	1.75%
TOTAL	743	100%

Case Details

VAERS ID:	905345 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2020-12-17
Onset:	2020-12-20
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2020-12-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Haemorrhage, Platelet count decreased, SARS-CoV-2 test negative, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Write-up: Patient received Pfizer COVID 19 vaccine last Thursday 12/17. Admitted today (12/21) with bleeding and low platelet count - working up for ITP, TTP. Given recency of vaccination and no known contributory allergy or medical history, physician thought potentially associated with vaccination.

VAERS ID:	910316 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2020-12-17
Onset:	2020-12-21
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2020-12-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / OT

Administered by: Private Purchased by: ?
Symptoms: Laboratory test, Platelet transfusion, SARS-CoV-2 test negative, Thrombotic thrombocytopenic purpura
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Embolic and thrombotic events, arterial (narrow), Renovascular disorders (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (broad)

Write-up: TTP; This is a spontaneous report from a non-contactable pharmacist. A 22-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE), intramuscular on 17Dec2020 as a single dose for COVID-19 immunization. The patient did not have any known relevant medical history. The patient had no allergies to medications, food or other products. Prior to the vaccination, the patient was not diagnosed with COVID-19. The patient''s concomitant medications were not reported. It was unknown if the patient received any other vaccines within four weeks prior to the vaccination. On 21Dec2020, the patient experienced thrombotic thrombocytopenic purpura (TTP); which was serious for hospitalization. The clinical course was as follows: The patient went to the emergency room/urgent care and was admitted in the early morning of 21Dec2020 due to TTP. Work-up was ongoing with no known results. On 21Dec2020, the patient also had a COVID-19 test which was negative. The patient was treated with unspecified corticosteroids and platelets. The clinical outcome of the TTP was unknown. The reporter assessed that it was unknown if the TTP was related to the vaccination. The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.; Sender''s Comments: Current limited information does not allow a full medically meaningful assessment, especially lack of medical history, concomitant medications, concurrent illness and diagnostic workups such as coagulation test, Combs test, bacterial/virologic/immunological biomarkers to identify the etiology. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.

VAERS ID:	916414 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-31
Onset:	2020-12-31
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2020-12-31

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EJ1685 / UNK	LA / IM

Administered by: Work Purchased by: ?
Symptoms: Dysphagia, Dyspnoea, Electrocardiogram, Lip swelling, Swollen tongue
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Anticholinergic syndrome (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: erythromycin, synthroid, vitamins b complex,c and vitamin d
Current Illness: none
Preexisting Conditions: hypothyroidism
Allergies: quinolones - rash
Diagnostic Lab Data: ekg / vital sign monitoring, iv fluids along with iv solu-medrol, benadryl and pepcid
CDC Split Type:

Write-up: approximately 30 minutes after receiving vaccination i began to develop tongue and lip swelling as well as difficulty swallowing and breathing , i then proceeded immediately to the nearest er

VAERS ID:	921188 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2020-12-17
Onset:	2020-12-21
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-01-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Platelet count decreased, Thrombotic thrombocytopenic purpura
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Embolic and thrombotic events, arterial (narrow), Renovascular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: 22 year old patient with no known allergies or medical history admitted 12/21 with TTP and currently being worked up. Currently unclear if related or unrelated to COVID vaccination, but received Pfizer vaccine Thursday 12/17.

VAERS ID:	920879 (history)
Form:	Version 2.0
Age:	36.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-23
Onset:	2020-12-28
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-01-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1284 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal pain, Appendicectomy, Appendicitis, Appendicolith, Computerised tomogram abdomen abnormal, Laboratory test, Ultrasound abdomen abnormal
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal obstruction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Write-up: Abdominal pain that proceeded to get worse into the next day. Connected with PCP, had labs drawn and ultrasound ordered. Ended up going to ER. Determined to have Appendicitis, needed and had appendectomy on 12/29/2020.

VAERS ID:	921572 (history)
Form:	Version 2.0
Age:	87.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2020-12-29
Onset:	2020-12-30
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Chills, Death, Fall, Hip fracture, Oxygen saturation decreased, Pain, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-02
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl
Current Illness: Heart Failure
Preexisting Conditions: Chronic Kidney Disease, Atherosclerotic Heart Disease
Allergies: Lisinopril, Losartan
Diagnostic Lab Data:
CDC Split Type:

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

VAERS ID:	923901 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-05
Onset:	2021-01-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Feeling hot, Flushing
SMQs:, Anaphylactic reaction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypersensitivity (broad)

Write-up: LEFT SIDED CHEST PAIN, SHORTNESS OF BREATH, FELT WARM AND FLUSHED

VAERS ID:	927260 (history)
Form:	Version 2.0
Age:	87.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-28
Onset:	2021-01-06
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-01-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	037K20A / 1	AR / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Blood lactic acid increased, Bradycardia, Cardiac arrest, Computerised tomogram head normal, Death, Heart sounds abnormal, Pulse absent, Respiration abnormal, Resuscitation, SARS-CoV-2 test negative, Unresponsive to stimuli, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vit D3, Miralax, Spironolactone, Tramadol, Metoprolol Succinate, MOM, Ferrous Gluconate, Ondansetron, Nitroglycerin Sublingual PRN, PreserVision AREDS, Fluticasone Propionate Suspension, Lisinopril, Clopidogrel Bisulfate, Campor-Methol-Met
Current Illness: Digestive Surgery for bowel obstruction
Preexisting Conditions: HTN, AAA, Chronic Diastolic Heart Failure, Diabetes Type 2, Paroxysmal atrial fibrillation, bradycardia, Hx of STEMI, Hx of CVA, HX of uterine cancer,
Allergies: Codeine, Meperidine, Morphine, Estrogens, Penicillins, Tetanus Toxoids
Diagnostic Lab Data: Brain CT negative WBC and lactic acid increased. COVID 19 on 1/4/21 negative
CDC Split Type:

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

VAERS ID:	928291 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-04
Onset:	2021-01-05
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	RA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Abdominal pain upper, Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood alkaline phosphatase increased, Blood bilirubin increased, Chest pain, Hepatic enzyme increased, Liver function test increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (narrow), Biliary system related investigations, signs and symptoms (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: symptoms:chest and stomach pain Has markedly elevated liver function tests that were normal 2 weeks prior to immunization Is being admitted the hospital to monitor liver function test.

VAERS ID:	929997 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-04
Onset:	2021-01-05
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011L20A / 1	AR / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Death, Dysphagia, Feeding disorder, Lethargy, Mobility decreased, Speech disorder
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-07
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg daily, Dexamethasone 4 mg daily (for itching related to renal failure), Isosorbide dinitrate 30 mg daily, Levothyroxine 0.075 mg daily, Bisoprolol 5 mg BID, Furosemide 80 mg BID, saline nasal spray, Tylenol 1000 mg PO TID
Current Illness: none acute
Preexisting Conditions: He was on hospice for about the last 1 month for CHF (EF 20-25%) and renal failure (creat 3-4). He was on hospice but was up and around and able to eat and take pills. The day after he had his injection, he was very lethargic and only mumbled. Was not able to take meds or eat. He was on hospice, so did not want work-up or treatment. He passed away on 1/7 am. We don''t know if it was a coincidence that he died or if the vaccine caused him to deteriorate more quickly.
Allergies: Losartan, lisinopril, metoprolol
Diagnostic Lab Data: He did not have testing at that point because he was on Hospice.
CDC Split Type:

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

VAERS ID:	935266 (history)
Form:	Version 2.0
Age:	41.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-06
Onset:	2021-01-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011L20A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal discomfort, Abdominal distension, Abdominal pain, Bowel movement irregularity, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (broad)

Write-up: Patient presents with abdominal pain that started in the middle of the night. Had first COVID vaccine the previous day. Patient states the pain is intermittent "comes and goes" "cramping" "pressure and bloating" feeling. Patient states her normal bowel movements are 12 times per day. The last time she went was this morning. She is concerned about an "obstruction" Patient states she has "some nausea" She states she has ate and drank normally today. Patient has a history of ulcerative colitis and a complete colectomy with a ileal rectal pouch. She has had abdominal pain since this morning which is crampy, associated with nausea and recurrent vomiting. She normally has 6-12 bowel movements a day, but none since this morning. She does feel her abdomen is distended as well. The last time she had anything like this was when she developed pouch itis last spring, but that was much less painful than this. Her appendix is gone, but she believes she still has her gallbladder.

VAERS ID:	944732 (history)
Form:	Version 2.0
Age:	92.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-13
Onset:	2021-01-14
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	037K2OA / 1	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Pulse absent, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-14
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cholecalciferol, furosemide, metoprolol tartrate, tamsulosin, amlodipine, finasteride
Current Illness: Covid-19 infection from 12/31-01/10/2021
Preexisting Conditions: CHF, atrial fibrilation, Dysphagia, macular degeneration, Vitamin D deficiency, impaired fasting glucose, benign prostatic hyperplasia, osteoporosis, retention of urine, anemia
Allergies: hydrocodone
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Resident found unresponsive and without pulse at 05:45am.

VAERS ID:	945038 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-14
Onset:	2021-01-14
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	041L20A / 1	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Pharyngeal swelling, Pruritus
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: birth control
Current Illness: no
Preexisting Conditions: no
Allergies: Bee and cat- swelling only to bees, no anaphylaxis,
Diagnostic Lab Data: Vitals
CDC Split Type:

Write-up: Vaccination given 1314 and sent to waiting room for monitoring. Began to have itching at 1325. PO benadryl administered. Then with throat swelling. Epinephrine administered by EMS/Fire at 1:32pm: 0.5mg IM right arm. 1342 improving 1350 itching/throat swelling returning while EMS/Fire on phone with medical director. 1352 second dose of epinephrine administered by De Pere EMS/Fire: 0.5mg IM left arm Medical Director on site for evaluation. Client given option to transport to hospital or stay for monitoring with EMS/Dr. Condition improving, chose to stay for monitoring. Client improved and up walking halls 1513 Client cleared to be released home via private transport

VAERS ID:	945336 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-05
Onset:	2021-01-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Senior Living Purchased by: ?
Symptoms: Abnormal behaviour, Cerebral ventricle dilatation, Computerised tomogram abnormal, Eyelid ptosis, Facial paralysis, Laboratory test, Posture abnormal, Sinusitis
SMQs:, Dementia (broad), Dystonia (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hearing impairment (broad), Periorbital and eyelid disorders (narrow), Ocular motility disorders (narrow)

Write-up: Staff reported that he wasn''t being himself. He was leaning more towards the right. Had symptoms similar to Bell''s Palsy, some right sided facial droop, right eyelid drooping. On CT right maxillary sinusitis, ventriculomegaly.

VAERS ID:	949724 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-08
Onset:	2021-01-09
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EK5730 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Cardiogenic shock, Chest pain, Coronary artery bypass, Critical illness, Haemorrhage
SMQs:, Cardiac failure (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow)

Write-up: Pt had 3 vessel CABG on 1/14/21 after presenting to ED with chest pain on 1/9/21. Pt is critically ill following OR after cardiogenic shock, bleeding. Requiring inotropes and Impella.

VAERS ID:	950073 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-15
Onset:	2021-01-15
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025L20A / 1	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Body temperature increased, Death, Headache, Lethargy, Mycobacterium tuberculosis complex test negative, Neck pain, Respiration abnormal, Tremor, Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Arthritis (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-16
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC Split Type:

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

VAERS ID:	951482 (history)
Form:	Version 2.0
Age:	23.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-13
Onset:	2021-01-13
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025CZ0A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Anion gap, Basophil count decreased, Basophil percentage decreased, Blood calcium normal, Blood chloride increased, Blood creatinine normal, Blood glucose normal, Blood potassium decreased, Blood sodium normal, Blood urea nitrogen/creatinine ratio, Blood urea normal, Calcium ionised normal, Carbon dioxide normal, Dysphagia, Electrocardiogram normal, Eosinophil count decreased, Eosinophil percentage decreased, Glomerular filtration rate normal, Granulocyte count decreased, Granulocyte percentage, Haematocrit increased, Haemoglobin normal, Human chorionic gonadotropin negative, Injection site urticaria, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Monocyte count normal, Monocyte percentage decreased, Neutrophil count normal, Neutrophil percentage increased, Palpitations, Platelet count normal, Red blood cell count normal, Red cell distribution width normal, Sensation of foreign body, Sinus tachycardia, Swollen tongue, Throat tightness, Urticaria, White blood cell count normal
SMQs:, Anaphylactic reaction (narrow), Agranulocytosis (broad), Angioedema (narrow), Haematopoietic leukopenia (narrow), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (narrow)

Write-up: I received the dose at 1:45 pm on 1/13/2021 at Medical Center. Almost 1 hour post vaccine I started to feel a lump in my throat, as the minutes passed my throat started to feel tighter and fight and flight mode kicked in. It was hard to swallow, my tongue was swelling and I called EMS at 2:40 pm 1/13/2021. EMS noticed hives on my chest and left arm where I got the first dose of Moderna. I received epinephrine IM and IV benadryl in the ambulance. I was sinus tachycardic with heart rate in the 140s oxygen was 99% room air, lungs clear.. I was taken to ER where I was on observation for 2 hours. I was discharged around 5:10 pm on 1/13/2021. On my car ride home around 5:40pm I again started to feel my throat tighten, tongue swell, and heart race. I called EMS again, and was treated with IV benadryl, and epinephrine IM. I was taken to Medical Center where I was given IV solu-medrol and got blood taken and a pregnancy test done. My potassium was 3.1 and I took 2 potassium tablets to supplement. My EKG was normal sinus tach, oxygen 100% room air, blood pressure 140s/90s and got down to 120/80s. I was transported to another Medical Center for overnight observation because first Medical Center was full.

VAERS ID:	953201 (history)
Form:	Version 2.0
Age:	33.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2020-12-31
Onset:	2021-01-01
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Lethargy, Myalgia
SMQs:, Rhabdomyolysis/myopathy (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Famotidine 40 mg daily, TUMS 1-2 tablets daily prn, APAP 500 mg daily prn, Magnesium tablets 500 mg daily, Voltaren OTC gel apply to affected area daily prn
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: I was diagnosed with COVID-19 on 12/7/2020. My course of symptoms lasted 16 days, meaning I started feeling healthy again on 12/23/20. I am a pharmacist with a healthcare system and they have been offering the Pfizer/Biontech COVID-19 vaccine for essential associates. I received by first dose of vaccine on 12/31/20. On 1/1/20 I woke up with very noticeable muscle aches and fairly profound lethargy, which last 18-20 hours. I was not able to do much on 1/1/21 because of the way I was feeling. I''m not sure if this reaction is normal for patients who receive their COVID-19 vaccine close to their illness/infection with COVID-19, which is why I''m reporting this to the FDA.

VAERS ID:	955516 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-29
Onset:	2020-12-30
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	037K20A / UNK	- / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Body temperature increased
SMQs:, Neuroleptic malignant syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Temp of 104.5, hospitalization

VAERS ID:	955871 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-06
Onset:	2021-01-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EJ1686 / 1	LA / OT

Administered by: Private Purchased by: ?
Symptoms: Chills, Decreased appetite, Fatigue, Headache, Influenza like illness, Loss of personal independence in daily activities, Nausea, Pain, Pyrexia
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Tenderness (usual)
Allergies:
Diagnostic Lab Data: Test Date: 20210107; Test Name: Temperature; Result Unstructured Data: Test Result:high; Comments: at 2:00; Test Date: 20210108; Test Name: Temperature; Result Unstructured Data: Test Result:low grade; Comments: at about 4:30 in the afternoon; Test Date: 202101; Test Name: Temperature; Result Unstructured Data: Test Result:102; Comments: went above 102 degrees
CDC Split Type: USPFIZER INC2021026419

Write-up: Doesn''t feel like eating; Fever; Chills/ Chilled; Nausea; Severe Headache/Dull headache/Frontal headache; Fatigue; Body aches; This is a spontaneous report from a contactable Nurse (patient). This 61-year-old female patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number EJ1686), via intramuscular, on 06Jan2021 (at 14:30) at single dose at left deltoid for COVID-19 immunisation, administered at hospital. Age at vaccination is 61-year-old. Historical vaccine included Diphtheria and Tetanus vaccine (intramuscular, at single dose) on 15Dec2020 for immunization; and Shingles vaccine (intramuscular, at single dose) on 15Dec2020 for varicella immunization. Relevant medical history included usual tenderness. No relevant concomitant medications were provided. On 07Jan2021, she woke up at 2:00 in the morning, she had a high temperature, she was chilled, she had a severe headache, nausea, fatigue, and body aches. She got up and took ibuprofen (ADVIL). She was basically in bed, she had to cancel all her appointments in the morning, she just laid in bed and the following afternoon her fever broke at about 4:30 in the afternoon then she just had a low grade temperature and a dull headache, nausea through the next day, Friday the 08Jan2021. She still has a very dull headache and just not right, kind of like a flu bug. She had no fever; she had not had any fever after Friday afternoon or Saturday. Fever started at 2 in the morning 07Jan2021 and she experienced the chills until after fever broke. Fever went above 102 degrees. She still had a little of the nausea, she just didn''t feel like eating. She still had the dull headache. The nausea and headache have improved when compared to how it was on the 07Jan2021. She was back to work now she just has a dull frontal headache. The reporting nurse assessed all the events, except of ''Doesn''t feel like eating'', serious for disability. She stated she may have had usual tenderness but nothing like this. The patient had recovered from the event fever on 08Jan2021 and from the event ''chills/chilled'' on 07Jan2021; the patient was recovering from ''nausea'' and ''severe Headache/Dull headache/Frontal headache'', while the outcome of the remaining events was unknown.; Sender''s Comments: A possible contribution role of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) to the onset of the reported events cannot be excluded due to temporal relationship. It is worth noting that patient had other vaccines not far ago, including Diphtheria and Tetanus vaccine and Shingles vaccine on 15Dec2020 for immunization. The case will be reassessed should additional information become available. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics committees and Investigators, as appropriate.

VAERS ID:	960023 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-14
Onset:	2021-01-15
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Computerised tomogram head abnormal, Dialysis, Electroencephalogram normal, Lumbar puncture normal, Magnetic resonance imaging brain normal, Mental status changes, Pyrexia, SARS-CoV-2 test positive
SMQs:, Acute renal failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient was receiving dialysis and had low grade fevers on the morning on 1/15/2021. Patient was sent to the hospital''s emergency room and was found to have a temperature of 103. The patient also had mental status changes. It is unsure what caused the mental status changes and fevers.

VAERS ID:	962940 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-20
Onset:	2021-01-20
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011J20A / 2	UN / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Cold sweat, Crepitations, Death, Dyspnoea, Pallor, Productive cough
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-20
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin
Current Illness: Unknown
Preexisting Conditions: Dementia, Diabetes, Chronic A Fib, Dyslipidemia, Depression, Osteoarthritis
Allergies: Galantamine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt''s room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127.

VAERS ID:	966178 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-19
Onset:	2021-01-22
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-01-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-22
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen 600 mg every 4 hrs, albuterol 2 puffs every 6 hrs, Symbicort 2puffs 2 x days, vitamin D, B12, Prozac 20 mg once per day, Veramyst 1 spray once per day, Lisinopril 5 mg once per day, Prilosec 40 mg once per day, Probiotic daily
Current Illness: skin ulcer of lower right leg due to old gun shot wound
Preexisting Conditions: alcoholism in remission, aortic stenosis-mild, arthritis, blood loss anemia, carpel tunnel syndrome bilateral, cellulitis of right leg, chronic insomnia, COPD, diverticulosis of sigmoid and descending colon, eczema, gun shot wound of leg, heart murmur-right upper external border, hemorrhoids, history of blood transfusion, history of falling, lyme disease, osteoarthritis of left knee, pneumonia, polyp of colon flat, peripyloric ulcer, peptic ulcer disease, sleep apnea, unspecified essential hypertension, viral meningitis
Allergies: aminoglycosides and sulfa meds
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt called son to let him know he couldn''t breath around 2 AM. Pts son showed up at his house 10 minutes later and ambulance arrived with in 20 minutes at 2:15

VAERS ID:	966670 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-21
Onset:	2021-01-21
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025J20A CVS / 1	- / -

Administered by: Senior Living Purchased by: ?
Symptoms: Seizure, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Write-up: Moderna COVID-19 Vaccine EUA Pt found unresponsive with seizure at her skilled nursing facility. Pt had first dose of vaccine earlier in the afternoon prior to being found unresponsive and seizing.

VAERS ID:	967214 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-21
Onset:	2021-01-21
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027L20A / UNK	RA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Cerebrovascular accident, Depressed level of consciousness, Disorientation, Dizziness, Dysstasia, Intensive care
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Within 1/2 hour of vaccination the patient was dizzy and was having a hard time remaining upright, additionally the patient was less alert and oriented. Patient was observed for a few minutes and then ambulance was called. Patient was transported via EMS within an hour of being vaccinated to local hospital. Patient was found to have has had major stroke and is presently in ICU and not expected to make it.

VAERS ID:	968326 (history)
Form:	Version 2.0
Age:	84.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-21
Onset:	2021-01-21
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027L20A / 1	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Disorientation, Dizziness, Neurological symptom
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Vestibular disorders (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Patient was dizzy and slight disorientation after getting vaccine and was observed on site until 1/22 then she was sent to hospital for stroke like symptoms and is scheduled to return to facility on 1/23.

VAERS ID:	972545 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-13
Onset:	2021-01-21
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-01-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Hypoxia, SARS-CoV-2 test positive
SMQs:, Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Reporting per Pfizer that patient tested positive for COVID post-vaccination (1/21/2021) and was hospitalized (1/24/2021). Patient received Bamlanivimab treatment 1/22/2021, 2nd dose will be deferred 90 days per PCP. Patient admitted for hypoxia, improved SPO2 to $g95% on room air, and was discharged back to ALF 1/25/2021.

VAERS ID:	974095 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2020-12-30
Onset:	2021-01-16
Days after vaccination:	17
Submitted:	0000-00-00
Entered:	2021-01-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Blood lactic acid, Peptostreptococcus infection, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

Write-up: Inpatient admission for the treatment of sepsis (peptostreptococcus suspected) source of the infection unknown.

VAERS ID:	974118 (history)
Form:	Version 2.0
Age:
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-08
Onset:	2021-01-09
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026L20A / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Body temperature, Cardiac disorder, Chills, Disorientation, Dyspnoea, Fall, Fatigue, Gait disturbance, Myalgia, Pyrexia, Weight increased
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Disoriented; Couldn''t walk; Had difficulty breathing; Fever of 102; Heart problem got worse; Put on 10lbs; Fell once on the floor; chills; Fatigue; Muscle aches; A spontaneous report was received from a consumer concerning a 89-year old, male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and experienced disoriented, couldn''t walk, fell once on the floor, heart problem got worse, fever of 102, chills, fatigue, muscle aches, difficulty breathing, and put on 10lbs. The patient''s medical history, as provided by the reporter, included heart problems. Concomitant medications reported included blood thinners and diuretic. On 08 Jan 2021, approximately one day prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Batch number 026L20A) intramuscularly for prophylaxis of COVID-19 infection. On 09 Jan 2021, the patient was disoriented and couldn''t find his way to the bathroom, couldn''t walk and fell on the floor, had a fever of 102 degrees, chills, fatigue, and muscle aches. Per the patient''s wife, his heart problem got worse after receiving the vaccine as he also experienced difficulty breathing and gained 10 pounds. On 09 Jan 2021, the patient was taken to the hospital and remains hospitalized. Treatment for the event included antibiotics and diuretic. Action taken with mRNA-1273 in response to the events was not reported. The outcome of the events, disoriented, couldn''t walk, heart problem got worse, fever of 102, chills, fatigue, muscle aches, difficulty breathing, and put on 10lbs, was not resolved. The outcome of the event, fell once on the floor, was resolved on 09 Jan 2021.; Reporter''s Comments: This case concerns a 89-year-old male patient who received their first of two planned doses of mRNA-1273 (Lot 026L20A), and who experienced the serious listed event of fever, the serious unlisted events of Disorientation, Gait disturbance, and Dyspnoea, the non-serious listed events of chills, fatigue, and muscle aches, and the non-serious unlisted events of Cardiac disorder, Weight increased, and Fall. Very limited information regarding the events has been provided at this time. Based on the current available information and temporal association between the use of the vaccine and the onset of events on the day after vaccination, a causal relationship cannot be excluded and the events are considered possibly related to the vaccine.

VAERS ID:	974313 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-22
Onset:	2021-01-24
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-01-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Antiphospholipid antibodies, Brain stem infarction, Cerebrovascular accident, Coagulation test, Hypoaesthesia, Magnetic resonance imaging, Peripheral sensorimotor neuropathy
SMQs:, Peripheral neuropathy (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Cholecalciferol daily, fish oil daily, garlic capsule daily, glucosamine daily, losartan daily, zinc daily, metformin 500 mg po daily (most doses are unclear from her medication history)
Current Illness: Patient was confirmed to be COVID positive in early December (did not require hospitalization).
Preexisting Conditions: Hypertension, diabetes, morbid obesity
Allergies: None
Diagnostic Lab Data: MRI, antiphospholipid panel (results not returned yet).
CDC Split Type:

Write-up: Patient vaccinated on 1/22. The next morning (1/23), patient experienced diminished sensory and motor function in left arm and leg, as well as facial numbness. Presented to the hospital on 1/24, and was found to have a small stroke in pontine medullary junction. Discharged on 1/25. There is some suspicion that her COVID infection in December may have precipitated this, and patient is currently being evaluated for coagulation disorders, primarily antiphospholipid antibody testing. It is unlikely that the vaccine contributed to this, but given close timeline between the two, filing this report.

VAERS ID:	974424 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-01-25
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-01-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1283 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Paraesthesia oral
SMQs:, Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad)

Write-up: Patient reported her tongue felt tingly 5 minutes following the first dose. She reported this finding at today''s visit. She said she just took a Benadryl when she got home following her first dose. I did question if she has had anaphylaxis in the past to any meds, etc, and she said no, but reported having allergic symptoms with an antibiotic. No other allergic history to vaccines, meds, etc. Patient wanted to continue with second dose of vaccine today. Vaccinated at 1615. Patient reported tongue tingling at 1640. 25mg PO Benadryl given at 1640. Patient left the clinic at 1700 stating that she felt ok to leave. She had Benadryl at home and knew who to call if symptoms worsened. Writer called the patient back on 1/26/2021 at 1100. Patient stated that at 1900 last night (1/25/2021) she had to go to the Emergency room and received 2 doses of Epinephrine. She then had to stay the night to be observed. Patient stated that she was being discharged today.

VAERS ID:	975002 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-12
Onset:	2021-01-13
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027C20A / 1	LA / SYR

Administered by: Senior Living Purchased by: ?
Symptoms: Balance disorder, Computerised tomogram head abnormal, Death, Diarrhoea, Fall, Headache, Subdural haematoma, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations: Influenza vaccine 10/06/2020, age 88, fever, chills, vomiting, malaise
Other Medications: Cholecalciferol 1000 ius daily, Magnesium Oxide 400mg BID, Vi
Current Illness: Stable
Preexisting Conditions: Chronic atrial fibrillation (on warfarin), coronary artery disease, chronic heart failure with preserved ejection
Allergies: Bee venum, shellfish, adhesive tape, cardizem, primidone
Diagnostic Lab Data: 1/13/2021 CT scan head
CDC Split Type:

Write-up: on 1/13/2021 at 3:40am Cliff called for assistance. He lost his balance and had fallen. Cliff refused vitals, refused emergency department, denied hitting his head. As the day progressed patient developed a headache, diarrhea, and vomiting. He again declined the offer for the emergency room. At supper time wife and staff found Cliff unresponsive, 911 was called and he was taken to the emergency department. The ER did a CT scan and found an acute subdural hematoma. Patient was placed on comfort cares and expired at 3pm on 01/14/2021. Cliff did not have a history of falls.

VAERS ID:	977023 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-12
Onset:	2021-01-23
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-01-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / IM

Administered by: Other Purchased by: ?
Symptoms: Facial paralysis
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Hearing impairment (broad)

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

Write-up: Bell?s palsy on left side (onset 01/24) T/t Valacylovir 1000 mg PO TID x 1 week and prednisone 60 mg PO Daily x 1 week.

VAERS ID:	978998 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-21
Onset:	2021-01-22
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	042L20A / 1	LA / IM

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

Write-up: Day after receiving COVID 19 vaccine dose 1 admitted to hospital with fall and weakness, tested positive for COVID 19.

VAERS ID:	980352 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-05
Onset:	2021-01-08
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-01-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Acute kidney injury, Alanine aminotransferase, Alanine aminotransferase increased, Aspartate aminotransferase, Aspartate aminotransferase increased, Asthenia, Blood bilirubin, Blood bilirubin increased, Blood pressure measurement, Decreased appetite, Fatigue, Hypotension, Lipase, Lipase increased, Pancreatitis acute, Troponin, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad)

Write-up: Acute pancreatitis; Acute renal failure; Low blood pressure; Weakness; Decreased appetite; Fatigue; Alanine aminotransferase increased; Aspartate aminotransferase increased; Troponin increased; Lipase increased; Blood bilirubin increased; A spontaneous report was received from a physician concerning an 81-year-old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and developed an odd presentation of acute pancreatitis, acute renal failure, low blood pressure, weakness, decreased appetite and fatigue. The patient''s medical history included advanced dementia, heart disease, pulmonary embolism and possible leukemia. Concomitant product use was not provided by the reporter. On 05 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 for prophylaxis of COVID-19 infection. On 08 Jan 2021, three days after vaccination, the patient developed symptoms of weakness, decreased appetite, and fatigue. On 11 Jan 2021, the patient was admitted into the hospital with a diagnosis of low blood pressure,acute renal failure,acute pancreatitis,alanine aminotransferase increased,aspartate aminotransferase increased, troponin increased,lipase increased and blood bilirubin increased. Abnormal lab results included "significantly elevated" aspartate transaminase, alanine transaminase, bilirubin, lipase up to 1900, and "slightly elevated" troponin of 0.079. On 13 Jan 2021, the patient''s symptoms had improved, and he was discharged. Treatment for the event included two liters of intravenous fluid and supportive care. Action taken with the second dose of mRNA-1273 in response to the event was not provided. The events, acute pancreatitis, acute renal failure, low blood pressure, weakness, decreased appetite and fatigue, were considered resolved on 13 Jan 2021. The physician assessed the events, acute pancreatitis, acute renal failure, low blood pressure, weakness, decreased appetite and fatigue, as not related to mRNA-1273. The physician''s rationale was that the patient may have had a gallstone obstructing the pancreatic duct and once the stone passed, the patient got better with supportive care and slow administration of fluids.; Reporter''s Comments: This case concerns a 81-year-old male patient with medical history of dementia, heart disease, pulmonary embolism, and possible leukemia, who received their first of two planned doses of mRNA-1273 (Lot unknown), and who experienced the serious unlisted events of acute pancreatitis, acute renal failure, low blood pressure, the non-serious listed event of fatigue, and the non-serious unlisted events of weakness, decreased appetite, elevated aspartate transaminase, elevated alanine transaminase, elevated bilirubin, elevated lipase, and elevated troponin. Very limited information regarding these events has been provided at this time. Based on the current available information and in agreement with the physician reporter''s assessment, the events are assessed as unlikely related to mRNA-1273, noting the rapid improvement after administration of IV fluids.

VAERS ID:	981535 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-23
Onset:	2021-01-24
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-01-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	PFEL3429 / 1	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Anger, Blood test normal, Condition aggravated, Confusional state, Dementia, Disorientation, Emotional distress, Magnetic resonance imaging normal, Speech disorder, Urine analysis normal
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (narrow), Depression (excl suicide and self injury) (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: The next morning after receiving the vaccine I noticed that my mother she talking to me, as her primary giver she knows me and comfortable to me. She tells me the same story over the over with isn''t abnormal. It was every 3-4 words she was jumbling her words. I didn''t think anything of it at first. I just let it go. Early Wednesday morning 2:48am, I heard her in her bedroom. I went to check on her, I found at her dresser trying to put her watch on. She didn''t know who was I or didn''t know where she was. It took me about 40 minutes to calm her down. Now it was every 2 words that she was jumbling up. I finally got her back to bed. I went to send a message to her doctor. In the morning someone from the doctor''s office called back I explained what was going on and they said get her to an ER. I took her to the hospital 01/27/2021. She was admitted to hospital for overnight observation. Still not been discharged. Patient was still confused when I had to left last night, did not understand where she was at or why she had to stay there. My mother was very angry when she woke up early Wednesday is not my mom she is very lovely. One year or two years she did have a TA or mini stroke.

VAERS ID:	981787 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-19
Onset:	2021-01-28
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-01-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Chest pain, Computerised tomogram thorax abnormal, Fibrin D dimer increased, Hypopnoea, Lung opacity, Pleural effusion, Pulmonary embolism, SARS-CoV-2 test negative
SMQs:, Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Write-up: pulmonary embolism that presented with chest pain and inability to take a deep breath, admitted and started on Heparin drip. Patient transitioned to Apixiban.

VAERS ID:	981825 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-30
Onset:	2021-01-18
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-01-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EK5730 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Chest X-ray abnormal, Cough, Dyspnoea, Exposure to SARS-CoV-2, Hypoxia, Lung infiltration, Nausea, SARS-CoV-2 test positive, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient presented to the ED on 1/21/21 for evaluation of SOB stating her husband tested positive for COVID earlier that week and she has been around him. The patient states her symptoms started 3-4 days prior to presentation. She admits to cough, nausea, and an episode of vomiting the day of presentation. She had been intermittently using her husband''s oxygen prior to presentation which she says has helped with her symptoms, but does not use oxygen at baseline. Upon presentation the patient''s oxygen saturation rate on room air is 89%. Patient was placed on 2L oxygen via nasal cannula and then was saturating in the mid 90s. CXR demonstrated bilateral patchy infiltrates in the ED which the ED physician felt to be consistent with COVID infection. The patient''s rapid COVID test resulted as positive. The patient was admitted to the hospital for further management of hypoxia related to COVID infection. The patient remains hospitalized on the day of report submission (1/28/21)

VAERS ID:	988876 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-20
Onset:	2021-01-29
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-01-31

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Chills, Muscle fatigue, Pain in extremity
SMQs:, Rhabdomyolysis/myopathy (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluoxetine - 60mg daily Lorazepam - 1-2.5mg daily Orphenadrine - 100mg ER BID Zofran ODT 4mg PRN Zolpidem 10mg 1-1.5 tabs per evening
Current Illness:
Preexisting Conditions: POTS Vestibular/Hemiplegic Migraines
Allergies: Pertussis vaccine _ anaphylaxis
Diagnostic Lab Data:
CDC Split Type:

Write-up: sore left arm x 2 days, muscle fatigue, chills

VAERS ID:	992063 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-19
Onset:	2021-01-29
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-02-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / 1	- / -

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

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

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

VAERS ID:	997081 (history)
Form:	Version 1.0
Age:	91.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-21
Onset:	2021-01-23
Days after vaccination:	2
Submitted:	2021-02-01
Days after onset:	9
Entered:	2021-02-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	037K20A / 1	LA / IM

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

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

Write-up: Pt suffered stroke on 1-23-21, 2 days after getting vaccine.

VAERS ID:	997677 (history)
Form:	Version 2.0
Age:	94.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-01
Onset:	2021-02-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031L20A / 1	- / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood pressure increased, Cerebrovascular accident, Coma scale abnormal, Death, General physical health deterioration, Heart rate increased, Loss of consciousness, Posturing, Pulmonary embolism
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Dystonia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-03
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan, dilTIAZem, Omeprazole, Ipratropium-Albuterol Solution, Perforomist Nebulization Solution, Furosemide, Budesonide Suspension, Levothyroxine , PARoxetine, Melatonin, Ibuprofen, Aspirin, Cholecalciferol, Docusate Sodium Capsule, ARIP
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPOTHYROIDISM, HYPERTENSION, IRON DEFICIENCY ANEMIAS
Allergies: Amlodipine, Ciprofloxacin, Citalopram, Codeine, Penicillin, traMADol, Spiriva Respimat, Sulfa Antibiotics
Diagnostic Lab Data: Family declined treatment or diagnostic testing. Dr signed comfort orders, verbalized probable PE or stroke
CDC Split Type:

Write-up: Rapid decline in health status, Elevated BP&P, posturing, loss of consciousness, Glasgow coma Scale 4 starting 2/1/2021, Deceased 2/3/21

VAERS ID:	998887 (history)
Form:	Version 2.0
Age:	96.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-29
Onset:	2021-02-02
Days after vaccination:	35
Submitted:	0000-00-00
Entered:	2021-02-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Chest X-ray normal, Cough, Dyspnoea, Failure to thrive, General physical health deterioration, Hypophagia, Oropharyngeal pain, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Neonatal disorders (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt receieved her first dose of the Moderna COVID-19 on 12/29/2020. Lot number, route, and site not specified in medical record. No record of 2nd dose was found on medical record review. Pt was admitted to reporting hospital 2/2/2021 with an admitting diagnosis of failure to thrive/poor oral intake. Pt was reported in ER to have a sore throat, cough, shortness of breath, and general recent decline. Reported that pt and others in family had GI like illness about a week ago. Admission test for COVID was positive per PCR NP swab on 2/2/2021. Pt still currently admitted.

VAERS ID:	999146 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-01-27
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Acute myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Multiple vitamin, Aspirin 81mg daily, Glucosamine/Chondroitin 1 daily, Metformin ER 500mg twice daily
Current Illness: None
Preexisting Conditions: Coronary Atherosclerosis, Polymyalgia rheumatica, Type 2 diabetes Mellitus
Allergies: No known allergies
Diagnostic Lab Data: Available on request
CDC Split Type:

Write-up: The patient had an acute myocardial infarction of the anterolateral wall of the heart. He was brought to the emergency room . He arrived at the hospital at 1605, was stabilized and transferred at 1705 to a different hospital.

VAERS ID:	999192 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-02-03
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

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

Write-up: According to the staff at the Hospital, the patient was treated in their emergency room for a stroke this morning at approximately 730AM

VAERS ID:	1005663 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-26
Onset:	2021-01-27
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Blood culture positive, Chills, Condition aggravated, Illness, Laboratory test abnormal, Pneumonia, Pyrexia, Sepsis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Write-up: Per report from family member illness started with fever, chills and increasingly progressed to needing emergency care

VAERS ID:	1006921 (history)
Form:	Version 2.0
Age:	87.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-01-29
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-02-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9262 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Cerebellar infarction, Magnetic resonance imaging brain abnormal, Muscular weakness, Platelet count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Haematopoietic thrombocytopenia (narrow), Peripheral neuropathy (broad), Systemic lupus erythematosus (broad), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Began having leg weakness 4 days after the vaccine on the evening on 1/29/21. The next day the leg weakness was more significant and went to the emergency room where they found greater weakness in the left leg than the right leg. An MRI showed "Punctate focus of diffusion restriction within the left cerebellar vermis consistent with acute infarct." He was also found to have a critically low platelet level of 30 and then 27 while in the emergency room. He was then admitted to the hospital, placed on steroids to increase his platelet level and given physical therapy following the stroke. He was admitted to the hospital for a total of 3 nights. He was discharged home on Aspirin, Carvedilol, and Atorvastatin, has follow up with hematology to check platelets and physical therapy.

VAERS ID:	1008768 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-02-04
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Flushing, Headache, Swollen tongue, Throat tightness
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: AmLodPine, atorvastin, furosemide, calcium, gabapentin,levothyroxine, met form in, advair, albuterol, cetirizine, cymbalta, requip, famotidine, flax seed, losartan, montelukast, trazodone, vitamin D, humalog, Lantus, multivitamin, melatonin
Current Illness: Diabetes
Preexisting Conditions: Severe back problems, fibrou, GERD, restless legs, asthma
Allergies: Reglan, IVP dyes, penicillin, bethanechol, levequin, lisinopril, amoxicillin, augmentin, clindamycin, doxycycline, fish of any kind, sea food
Diagnostic Lab Data: 02/04/2021 gave me Benadryl, Pepsid, steroids, sole-medrol, epi in ER
CDC Split Type:

Write-up: Severe headache, face flushing, swollen tongue, throat closing off

VAERS ID:	1012831 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-02-05
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-02-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Abdominal pain upper, Cough, Exposure to SARS-CoV-2, Feeding disorder, Nausea, Pyrexia, SARS-CoV-2 test positive, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Records review utilized to obtain information: Pt recieved his first dose of the Pfizer COVID-19 vaccine on 1/27/2021, unable to determine location that administered vaccine. Pt called to his PCP and indicated he was experiencing "intense, but intermittent stomach pain in the LUQ since the day after receiving vaccine. He stated he was not eating due to the pain, and that nausea and vomiting would occur when eating. His wife and son both tested positive for COVID-19 per PCR on 1/29 (unknown what type of test). He was tested on 1/25 prior to vaccination and was negative at that time. He ended up going to the ER later that day and is recorded as having a fever and cough at that time, in addition to the pain as described above. Pt tested positive at this time on admission testing (2/5/2021). He is still currently inpatient at our facility.

VAERS ID:	1013270 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-02-03
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Erythema, External ear pain, Headache, Herpes zoster, Masticatory pain, Oropharyngeal pain, Pain, Pain in jaw, Rash, Rash vesicular, Tinnitus
SMQs:, Anaphylactic reaction (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hearing impairment (narrow), Osteonecrosis (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Opportunistic infections (broad)

Write-up: Pt developed Shingles after vaccination. Notes from call to PCP day after vaccination: "Since yesterday morning after vaccine after she received her covid vaccine, she noted that her right ear hurts. She says that the pain does not feel like it is in the ear but right around the ear, and the bones around the ear. She says it hurts to chew, and the area to the back of her ear has ringing sound. She does not note that the ear is red . When she rubs under the ear she says the area is painful is painful. She does not note a lump or bump under her ear.. She states that the jaw/bone area hurts with the vibration of the conversation." Sore throat and headache, only on right side. Pain progressed to the point of hospitalization, with vesicles erupting on right side of face/ear canal.

VAERS ID:	1015773 (history)
Form:	Version 2.0
Age:	99.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-01
Onset:	2021-02-02
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	004M20A / 2	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-02
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: aspirin 81 mg,
Current Illness: skin rash
Preexisting Conditions: Demenita, GERD, Heart failure, Kidney disease, stage 3,
Allergies: Lisinipril, Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away in her sleep. No s/s of adverse events leading up to the residents death. Resident was previously declining- MD stated the vaccine had nothing to do with the death.

VAERS ID:	1016827 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-01-27
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Alanine aminotransferase normal, Antinuclear antibody positive, Aspartate aminotransferase normal, Atelectasis, Back pain, Blood albumin normal, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood creatinine normal, Blood potassium normal, Blood sodium normal, Blood urea normal, Cardiomegaly, Catheterisation cardiac abnormal, Chest X-ray abnormal, Chest discomfort, Chest pain, Cough, Dizziness, Dyspnoea, Electrocardiogram ST-T change, Fibrin D dimer normal, Haematocrit normal, Haematoma, Haemoglobin normal, Hyperdynamic left ventricle, International normalised ratio normal, Pain, Pain in extremity, Platelet count normal, Protein total increased, Prothrombin level normal, Red blood cell count normal, Troponin increased, Ultrasound Doppler normal, White blood cell count increased
SMQs:, Cardiac failure (broad), Liver related investigations, signs and symptoms (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (narrow), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Tubulointerstitial diseases (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: History of Present Illness: Patient is a(n) 67 Y female with a PMH of asthma, HTN, HLD, GERD who arrived to the ED via rescue squad with complaints of sudden onset of squeezing chest pain/tightness that radiated to the back, associated dyspnea, lightheadedness and dizziness that began around 6:30PM. Pt reports she was feeling well prior to the episode and she had her COVID 19 vaccine at 4:30PM and had tolerated the vaccine well. She does report that she had atrial fibrillation before, about 5 years ago and she underwent a cardiac work up. She denied palpitations, fever, chills, body aches, nausea, or vomiting. She does have a non productive cough. Her BP normally runs 130/80''s at home and is controlled w amlodipine. She was given SL nitro and aspirin in the ambulance. EKG showed atrial fibrillation with RVR, HR 150''s. Reason for admission: Atrial fibrillation with rapid ventricular response (*) Atrial fibrillation with RVR (*) She was admitted for further evaluation and monitoring. Troponin level noted to be 0.79 and EKG with ST-T wave changes, cardiology was consulted and patient underwent cardiac cath who revealed no significant CAD hyperdynamic LVEF 70 %. She developed a small hematoma post catheterization which has resolved. Cardizem was switched to metoprolol and both BP and HR are improved and controlled with losartan. Pt without any adverse effects to losartan, no s/s angioedema. Afib with an abrupt onset and abrupt return to normal sinus rhythm. She complained of calf pain, US dopplers were obtained and were negative for DVT. Her D Dimer was also normal. Pt discharge to home in stable condition.

VAERS ID:	1017843 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-26
Onset:	2021-01-30
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-02-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Arthralgia, Asthenia, Blood urine present, Condition aggravated, Haematuria, Incontinence, Multiple sclerosis relapse, Muscle spasms, Pain, Pain in extremity
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Optic nerve disorders (broad), Demyelination (narrow), Arthritis (broad), Tubulointerstitial diseases (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Pt arrives to ED via EMS with c/o blood in the urine, pain, and weakness since this morning. Pt states the staff noticed the blood this morning in his urine; pt denies any pain while urinating. Pt is incontinent per his normal. Pt states he received is first covid vaccination about 4 days ago, and yesterday he received his biyearly MS treatment. Pt states that one doctor told him to wait a month in between the vaccine and treatment, another said 2 weeks, and one said he could get it right away. Pt states that this morning, his MS flared up worse than its ever been. Pt states he is having severe muscle spasms and pain in the bilateral shoulders and right leg. Pt states that he has also been weaker

VAERS ID:	1018278 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-02-09
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-02-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

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

Write-up: death- unexplained cause

VAERS ID:	1019911 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-02-09
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-02-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Dyspnoea, Exposure to SARS-CoV-2, Fatigue, Mechanical ventilation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Tested positive for COVID-19 on 01/26/2021 (Antigen positive) - presented to ED due to shortness of breath and fatigue
Preexisting Conditions: Active Problems Noted Date Hypokalemia 1/28/21 Pneumonia due to COVID-19 virus 1/28/21 Acute hypoxemic respiratory failure 1/28/21 Stone of salivary gland or duct 1/8/21 Recurrent major depressive disorder, in partial remission 1/7/21 Secondary hyperparathyroidism of renal origin 1/7/21 Abnormal blood smear 7/22/20 Alkaline reflux gastritis 1/2/20 Severe obesity (BMI 35.0-39.9) with comorbidity 12/20/18 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin 12/20/18 Morbid obesity due to excess calories 6/18/18 Psoriasis 12/13/17 Proteinuria 10/20/17 Bilateral leg edema 12/5/16 Hypertriglyceridemia 6/27/16 Essential hypertension with goal blood pressure less than 130/85 6/27/16 Anxiety, generalized 6/27/16 Hypothyroid 11/24/14 Aortic valve replaced 7/7/14 Pulmonary emphysema 1/22/09 Obstructive sleep apnea syndrome 8/4/1943 Resolved Problems Noted Date Resolved Date Other chest pain 10/29/19 10/30/19 Chest pain 10/29/19 10/30/19 Type 2 diabetes mellitus without complication, without long-term current use of insulin 6/24/19 7/6/20 Sialadenitis 1/4/19 1/2/20 Obesity (BMI 35.0-39.9 without comorbidity) 12/20/18 1/29/21 Abdominal pain 11/21/18 1/2/20 Type 1 diabetes mellitus with stage 3 chronic kidney disease 6/18/18 6/18/18 CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min 10/20/17 1/2/20 Sarcoidosis of lung 6/27/16 6/26/20 Uncontrolled type 2 diabetes mellitus with stage 3 chronic kidney disease, without long-term current use of insulin 6/27/16 12/13/17 Overview: Recent onset HbA1C 4/21/16 11.9. Last FBS-110 5/17/16 Diabetic eye exam 9/23/16 no diabetic retinopathy. fup one year. Hypothyroidism (acquired) 6/27/16 12/13/17 Exertional dyspnea 6/27/16 6/26/20 Tobacco abuse 11/19/08 9/23/11 documented as of this encounter (statuses as of 01/29/2021) Patient Active Problem List Diagnosis ? Obstructive sleep apnea syndrome ? Pulmonary emphysema (*) ? Aortic valve replaced ? Hypothyroid ? Hypertriglyceridemia ? Essential hypertension with goal blood pressure less than 130/85 ? Anxiety, generalized ? Bilateral leg edema ? Proteinuria ? Psoriasis ? Morbid obesity due to excess calories (*) ? Obesity (BMI 35.0-39.9 without comorbidity) ? Severe obesity (BMI 35.0-39.9) with comorbidity (*) ? Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin (*) ? Alkaline reflux gastritis ? Abnormal blood smear ? Recurrent major depressive disorder, in partial remission (*) ? Secondary hyperparathyroidism of renal origin (*) ? Stone of salivary gland or duct ? Hypokalemia ? COVID-19 virus infection ? Acute hypoxemic respiratory failure (*) Past Medical History: Diagnosis Date ? Anxiety ? Arthritis ? Asthma ? Back pain ? Chronic kidney disease, stage II (mild) 10/20/2017 ? Dependent edema ? DJD (degenerative joint disease) ? Gastritis ? Glucose intolerance (impaired glucose tolerance) ? History of pulmonary function tests 10/20/2010 showing decreased lung flow consistent with normal variant versus mild obstruction and emphysema ? History of stress test 12/2009 Normal ? Hyperlipidemia ? Hypothyroid Previously had hyperthyroidism ? Kidney stone 05/1999 Right ? Proteinuria 10/20/2017 ? Psoriasis ? Sarcoidosis ? Sleep apnea Past Surgical History: Procedure Laterality Date ? AORTIC VALVE REPLACEMENT 05/2001 #25 St. Jude''s aortic valve replacement ? APPENDECTOMY 1960''s ? CHOLECYSTECTOMY 1994 ? COLONOSCOPY 2010 ? COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD N/A 11/21/2018 COLONOSCOPY with hot polypectomy snare ? OTHER SURGICAL HISTORY 09/2018 spot removed from left arm ? TOTAL KNEE ARTHROPLASTY Right 11/19/2012 ? UPPER GI ENDOSCOPY,DIAGNOSIS N/A 11/21/2018 EGD with cold biopsies performed ? WISDOM TOOTH EXTRACTION
Allergies: Review of patient''s allergies indicates: Allergies Allergen Reactions ? Other [Uncoded Nonscreenable Allergen] Rash Neoprene
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client was administered the vaccine while symptomatic (01/25/21) although client did not know he was symptomatic for COVID-19. He had been exposed to a family member who had tested positive and should have been in quarantine but wasn''t either because it was not felt he was considered a close contact by his family opinion or his family member never notified public health of this close contact...?. Clinet had presented to the ED following day after vaccination for shortness of breath and fatigue and an antigen test showed he was positive for COVID-19. He was sent home that same day 01/26/21. He was back in ED on 01/28/21 for worsening symptoms and admitted to hospital and later placed on ventilator. He passed away on 02/09/2021 (date of death was per his wife).

VAERS ID:	1020651 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-10
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Cardiac failure, Condition aggravated
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Write-up: Patient admitted to hospital with diagnosis of heart failure exacerbation.

VAERS ID:	1022496 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-02-05
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / IM

Administered by: Private Purchased by: ?
Symptoms: Acute myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Write-up: STEMI, transferred via helicopter to Hospital.

VAERS ID:	1022513 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-02-05
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Angiogram cerebral abnormal, Arteriogram carotid abnormal, Cerebrovascular accident, Dysarthria, Vertebral artery occlusion
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Write-up: Arrived to ED with slurred speech, potential stroke, was transferred to Hospital for higher level of care.

VAERS ID:	1022529 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-02-09
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-02-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL8982 / 1	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-09
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Venlafaxine Hcl ER 150 daily, Multi vitamin, Aspirin 81mg, Nitro 0.4 prn, Vitamin E 200 daily, Ipratropium-Albuterol 0.5-2.5 inhalation q 6 hrs, omeprazole 20mg daily, isorbide monintrate ER 60mg daily, spironolactone 50mg , mens multi vita
Current Illness: pt was seen 1/8/21 for a Scatica flare Pt had a follow up colonscopy performed 1/21/21 where a couple polyps were found and diverticulosis
Preexisting Conditions: pt has COPD and used Oxygen at night, Coronary atherosclerosis, Diabetes Type 2, hypertriglyceridemia, OSA, hyperlipidemia, hypertension, IBS, pulmonary emphysema, acute or chronic heart failure, morbid obesity, atrial fibrillation, depression, hypercholesteremia, stage 3 kidney disease
Allergies: Amoxicillin(rash), Lisinopril (cough)
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt suffered Cardiac Arrest and respiratory arrest on 2/9/21 and passed away at a local hospital. He had multiple health conditions likely contributing to this. he arrested at home and CPR was attempted and unsuccessful. Pt received his Covid vaccine #1 on 1/27/21. No issues were noted after vaccine and was due for his 2nd dose next week. However, we were notified he passed away on 2/9/21. Very likely death not at all related to vaccine but wanted to document as patient was in the middle of the covid vaccine series.

VAERS ID:	1024000 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-02-11
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-02-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL8982 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: COVID-19, Dyspnoea, Respiratory distress, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received his first dose of the Pfizer COVID-19 vaccine on 2/2/20201. Pt presented to a local ED on 2/10/2021 with symptoms of dyspnea and respiratory distress and was transferred/admitted to our hospital. He tested positive per PCR testing for SARS-CoV-2 on 2/10/2021. He is still currently admitted to our hospital receiving care. It was noted in his H&P that he had a COVID exposure approximately 2 weeks prior to presenting to the ED (unknown if he was alerted to this before getting his vaccine). He is currently recieveing remdesivir and dexamethazone to treat his COVID.

VAERS ID:	1024131 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-26
Onset:	2021-01-26
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	029L20A / 2	LA / IM

Administered by: Work Purchased by: ?
Symptoms: Appendicectomy, Appendicitis, Headache, Pain
SMQs:

Write-up: Very severe headache very severe body aches and appendecitis I am not sure if the appendicitis is related to the shot but I thought I should report that

VAERS ID:	1024946 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-02-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN5318 / UNK	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Angioedema, Chest discomfort, Dry eye, Electrocardiogram normal, Irritable bowel syndrome, Paraesthesia oral, Swollen tongue
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Anticholinergic syndrome (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Corneal disorders (broad), Conjunctival disorders (narrow), Lacrimal disorders (narrow), Hypersensitivity (narrow), Noninfectious diarrhoea (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol, ASA, biotin, Wellbutrin, klonopin, Vit B -12 injections, Lasix, amaryl, insulin, lisinopril, Prilosec, potassium, fish oil, multivitamin, metoprolol, metformin, Claritin, relafen
Current Illness: none
Preexisting Conditions: HTN, DM, hyperlipidemia, gerd, IBS
Allergies: latex, seasonal allergies
Diagnostic Lab Data: EKG was wnl
CDC Split Type:

Write-up: angioedema, lip paresthesia, tongue swelling, dry eyes, chest tightness

VAERS ID:	1025300 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-01
Onset:	2021-02-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN5318 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Blood creatinine, Blood electrolytes normal, Chest X-ray normal, Condition aggravated, Gait disturbance, Gait inability, Troponin
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: allopurinoL (ZYLOPRIM) 300 MG tablet Take 300 mg by mouth Daily. amiodarone (PACERONE) 200 MG tablet 1 tablet by mouth Daily. aspirin 81 mg chewable tablet Take 81 mg by mouth Daily. bisacodyl (DULCOLAX) 5 mg EC tablet 10 mg by mouth Dai
Current Illness: See chronic problem list below
Preexisting Conditions: Hypertension (*) Hypothyroid (*) Type 2 diabetes mellitus with diabetic polyneuropathy (*) Posterior tibial tendon dysfunction Atherosclerosis Malignant neoplasm of urinary bladder (*) Malignant neoplasm of urinary organ (*) Paroxysmal A-fib (*) CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min Hypercholesteremia (*) Diabetes (*) H/O carpal tunnel repair Total knee replacement status Gout OSA (obstructive sleep apnea) Psoriasis (*) Vitamin D deficiency Depression (*) History of asthma Colon polyps Tremor Acquired pes planus of both feet Acquired keratoderma Hammertoe Abnormal chest x-ray Mycotic toenails Unsteady gait Macrocytosis Microalbuminuria Post-nasal drip Type 2 diabetes mellitus with microalbuminuria (*) Spondylosis of lumbar region without myelopathy or radiculopathy Atypical atrial flutter (*) Coronary artery disease due to calcified coronary lesion (*) Localized edema Longstanding persistent atrial fibrillation (*) S/P CABG x 3 11/19/2016 Status post Maze operation for atrial fibrillation/Cox Maze IV On amiodarone therapy Bilateral carotid artery stenosis (*) Ischemic cardiomyopathy (*) Chronic atrial fibrillation (*) Stenosis of right carotid artery (*) Closed sternal manubrial dissociation fracture with nonunion Atelectasis, right Bradycardia Iron deficiency anemia Medication intolerance Hematuria Generalized weakness Acquired palmar and plantar hyperkeratosis Cholelithiasis History of actinic keratoses RBBB Chronic diastolic heart failure (*)
Allergies: Remicade [Infliximab]Itching RosuvastatinOther (See Comments) SimvastatinOther (See Comments) NaproxenItching, Rash
Diagnostic Lab Data: Multiple labs and chest X-ray
CDC Split Type:

Write-up: 75 year old M, worsening weakness for the past several weeks. Seems to have gotten worse since Monday when he had his first Covid vaccine here at the hospital. Denies any headaches or neck pain. No fevers or chills. No cough or shortness of breath. No abdominal pain. No vomiting or diarrhea. No black or bloody stools. No dizziness. Today he almost fell and the son had to catch him. He did not suffer any trauma. He offers no symptoms of pain. Here he is fully awake and alert. Nothing to clinically suspect a stroke. His vitals are stable. Chest x-ray shows nothing acute. Creatinine is better than baseline. Electrolytes are stable. Troponin reassuring. He had no chest pain or shortness of breath to suspect angina. Spoke to the wife via telephone, he is getting so weak that he was unable to walk. Paramedics report they had lift him as he could not take a step. He was unable to ambulate here in the emergency room. At this time it does not seem like I can safely discharge him home.

VAERS ID:	1026270 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-02-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6201 / 2	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Death, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-11
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albeterol Inh Soln 0.083 % Calcium 600mg + D 400 IU One Daily Woman 50 + tablet Cetirizine HCL 10 mg Tablet Digozin 0.125 mg Tablet Levothyroxine 100 mcg tablet Metoprolol Tartrate 50 mg Tablet Esomeprazole Mag. Dr 40 mg Capsule Nitroglyc
Current Illness:
Preexisting Conditions: primary hypertension Mitral Valve regurgitation COPD Osteoporosis Kyphoscoliosis deformity of spine Rheumatoid factor positive GERD history of cellulitis of leg history of C-diff post ATB therapy Monoclonal gammopathy Iron deficiency anemia, unspecified Hypothyroidism, unspecified Hyperlipidemia, unspecified Coronary atherosclerosis due to lipid rich plaque Nonrheumatic tricuspid valve disorder, unspecified Chronic atrial fibrillation Allergic rhinitis, unspecified Barrett''s esophagus without dysplasia Other specified urinary incontinence
Allergies: Ceftin, Cefuroxine, Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: At 10:33 am Patient pushed her pendant for staff, staff arrived to her apartment and Patient was found unresponsive in her bathroom. Patient received her second COVID-19 Pfizer vaccine about 75 minuets prior to this, she had no adverse reaction''s within the first hour of receiving the second dose. CPR was started until paramedics arrived, they took over and tried to resuscitate. Patient was pronounced dead at 11:33 am at scene.

VAERS ID:	1026499 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-02-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016M20A / 2	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Body temperature increased, Cardio-respiratory arrest, Chills, Death, Pulse absent, Tremor, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-05
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lactulose, Lasix, Megestrol Acetate, Metoprolol Tartrate, Spironolactone, Lasix, Vitamin B12, Rifaximin, Milk Thistle, Tramadol
Current Illness: Enterococcus UTI, acute on chronic systolic and diastolic heart failure
Preexisting Conditions: ,chronic kidney disease stage 3, cirrhosis, HTN, hypomagnesemia, hypothyroidism, neurocognitive disorder, hx of hepatic encephalopathy
Allergies: Carvedilol, Tizanidine, Augmentin, ACE inhibitors, Bees
Diagnostic Lab Data: None done at facility
CDC Split Type:

Write-up: Resident reviewed for incident. Resident received the second dose of the Moderna Covid-19 vaccine lot# 016M20A Exp 5/2/2021 on 2/5/2021 from clinic through pharmacy. Resident had her temp/O2 taken on AM shift and was 98.6/93%, beginning PM shift 98.4/95%. A few hours later noted that resident to have chills and was shaking RN assessment completed and vitals taken resident noted to have temp of 102.2, oxygen 95%, pulse 110. Resident alert and oriented at that time and talking to staff. Reported findings to APNP with order to send to ER. 911 called, residents brother updated. Upon EMT arrival RN went down to residents room with EMT and resident had an emesis as resident was getting cleaned up resident went unresponsive. Pulse noted to still be present at that time, resident did briefly respond to sternal rub and then went unresponsive again. Resident full code and EMT transferred to gurney and said that if they lost a pulse in route that they would transfer to hospital B instead of hospital A being the closest facility. RN called brother and gave update. Facility notified from Hospital that resident had passed away.

VAERS ID:	1029068 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-07
Onset:	2021-02-08
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-09
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Mental health, dementia
Preexisting Conditions:
Allergies: No known
Diagnostic Lab Data: Covid-19 positive
CDC Split Type:

Write-up: Patient was given vaccine the following day he died ,

VAERS ID:	1030323 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-05
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-02-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / UNK	- / IM

Administered by: Other Purchased by: ?
Symptoms: Blood potassium normal, Blood sodium normal, Carbon dioxide normal, Cardio-respiratory arrest, Death, Fall, Haemoglobin decreased, Laboratory test, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-05
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol Alirocumab Asprin Atrorvastatin Calcium Budesonide-Formoterol Fumarate Calcitriol Calcium Acetate Carvedilol Clopidogrel Bisulfate Erogcalciferol Ezetimibe Fluticasone-Salmetrol Lasix Glucagon Hydralazine Insulin Ipratropium inhal
Current Illness: Asymptomatic COVID Hospital for Polymosis January
Preexisting Conditions: ESRD Diabetes Type 2 Heart disease CHF CAD CABG
Allergies: Niacin
Diagnostic Lab Data: 2/3 labs potassium 4.5, sodium 137, CO2 29, hgb 9.7
CDC Split Type:

Write-up: Patient had COVID vaccination on 2/3 with no adverse s/s before leaving unit. Upon coming to treatment Friday 2/5 he reported to the RN that he had fallen on thursday 2/4 due to "getting up fast" did not hit head or hurt anything per RN discussion. Began treatment without difficulty. About 3/4 way through treatment was talking with staff and became unresponsive - code was called and pt expired after 30 minute resuscitation efforts.

VAERS ID:	1030521 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-28
Onset:	2021-01-29
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Intensive care, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Write-up: I am 77 yrs old, male , , 150# and 5ft 6inches...Within 24 hours of receiving the shot, my body thru-up clots in my left leg. and I spent 4 days in the hospital ( 3 days in surgical ICU), breaking up the clots to save the leg. This is too much of a coincidence to ignore and I will not receive the 2nd shot.

VAERS ID:	1030893 (history)
Form:	Version 2.0
Age:	92.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-10
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-02-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	UN / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Fall, Food refusal, General physical health deterioration, Mobility decreased, Pyrexia, Restlessness, Urinary tract infection, Walking aid user
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-12
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, amlodipine, atorvastatin, clonazepam, furosemide, guaifenesin DM
Current Illness: Resident had a low grade fever day of vaccine and was not feeling well. Pharmacy stated it would be ok to have vaccine and administered in resident''s room.
Preexisting Conditions: Osteoporosis, type 2 diabetes, vitamin B deficiency, anxiety, achalasia of cardia, GERD, iron deficiency, atrial fibrillation, chronic kidney disease
Allergies: Fluoxetine and Metformin
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident had slight/slow decline in health prior to vaccine but continued to be able to walk around with walker at community. The day of the vaccine she had a fever. 2 days after vaccine resident did not get out of bed all day and refused to eat. She had small amounts of orange juice as her blood sugar level was low due to not eating. Resident was diagnosed with a UTI and began an oral antibiotic. 3 days after and on day 5 after vaccine resident began feeling weak and had a fall on each day. The following day again resident spent the day in bed. The next day she was quite restless, was on the edge of her bed attempting to self transfer often throughout the day. Resident continued to be restless on the 10th of Feb, had further decline on the 11th of Feb. Resident passed away early the AM of Feb. 12th.

VAERS ID:	1031560 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-02-12
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-02-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Blood electrolytes, Computerised tomogram, Eyelid disorder, Facial paralysis, Facial paresis, Full blood count, Hypoaesthesia oral, Lacrimation increased, Oropharyngeal discomfort
SMQs:, Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Hearing impairment (broad), Lacrimal disorders (narrow), Periorbital and eyelid disorders (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: vitamin c, vitamin d, tumeric, thyroid supplement
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: 02.13.21-CT Scan & routine CBC and electolytes
CDC Split Type:

Write-up: Morning-back of R side throat discomfort, R eye tearing, 24 hrs later- numbness of R side tongue, R side of lips and cheek lose of muscular control, R eyelid remains open. Evaluated in ER 48 hrs after start of symptoms. DX-Bells Palsy treated with Prednisone & anti-viral. Symptoms continue.

VAERS ID:	1031582 (history)
Form:	Version 2.0
Age:	35.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-13
Onset:	2021-01-25
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-02-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Pericarditis
SMQs:, Systemic lupus erythematosus (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: 35 yo woman with new onset pericarditis. Possibly related to the covid vaccine - had second dose 1/13/21. There are case reports of pericarditis with the covid virus, but none so far with covid vaccine. No known covid exposure recently. Covid test on 1/24/21 (date of admission) = not detected. Or more likely presentation could be related to Humira (started December 2020 for psoriatic arthritis and had 3 doses total). There have been case reports of pericarditis with Humira. Also, pt was on a medrol dose pack for radicular symptoms after injuring her neck, she finished the dose pack on 1/17/21. Since stopping solumedrol she has had increasing hip pain and also has costochondral pain. Per H&P, It is possible that weaning off of solumedrol dose pack caused a flare up in her psoriatic arthritis leading to increase hip pain, costochondritis and pleuritis and/or pericarditis. Pt was admitted for further treatment and monitoring.

VAERS ID:	1031790 (history)
Form:	Version 2.0
Age:	94.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-06
Onset:	2021-02-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	042L20A / 1	- / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Cerebrovascular accident, Magnetic resonance imaging brain abnormal, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Write-up: Received influenza vaccine 1/29 at PCP clinic. Received Moderna vaccine on 2/6 by pharmacist at her place of residence. She was taken to the ER on 2/9, unresponsive. Staff reported she wasn''t acting normally since 2/7. During her hospital course (2/9-2/13) she was only able to open her eyes. Unable to follow any commands. MRI showed large right MCA stroke. She was discharged from the hospital on hospice.

VAERS ID:	1033014 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-06
Onset:	2021-02-15
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-02-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9269 / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Asthenia, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Cough, Dyspnoea, Pneumonia, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first dose of Pfizer COVID-19 vaccine on 2/6/2021. Pt subsequently developed symptoms of COVID-19 and presented to the ER on 2/15/2021. Chief complaint was cough, fever, and shortness of breath. Reports that he had a negative nasal swab as recently as 2 weeks ago. Reported that symptoms of cough, sob, and weakness started 3 days prior to presenting at ER (2/12/2021). Chest Xray had features of bilateral pneumonia. Pt is still currently inpatient at our hospital, receiving treatment for COVID-19, including dexamethason and remdesivir. He is currently receiving 3L of supplemental O2 via NC.

VAERS ID:	1033091 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-04
Onset:	2021-01-22
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-02-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	037K20A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Back pain, Blood alkaline phosphatase increased, C-reactive protein increased, Chest pain, Computerised tomogram, Dyspnoea, Echocardiogram abnormal, Electrocardiogram, Fibrin D dimer increased, Full blood count abnormal, Hepatitis, Laboratory test, Liver function test abnormal, Liver function test increased, Pericardial effusion, Pericarditis, Platelet count increased, Pleural effusion, Pneumonitis, White blood cell count increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatitis, non-infectious (narrow), Anaphylactic reaction (broad), Haematopoietic leukopenia (broad), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Chronic kidney disease (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Zinc, vit D3, vit C
Current Illness: None, was exposed to Covid 19 just prior to getting the vaccination
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Ct with PE protocol, EKG, labs, echo documented moderate to severe pericardial effusion no tamponade, documented pleural effusions with pneumonitis documented d dimer in the thousands and elevated CRP above 100, abnormal liver function tests and cbc.
CDC Split Type:

Write-up: approximately 2.5 wks after vaccination, development of severe increasing back pain and chest pain and shortness of breath Dx acute moderately severe pericarditis with pericardial effusion, pneumonitis with bilateral small pleural effusions, hepatitis with elevated alk phos and LFT, bone marrow reaction with elevated WBC, new anemia and elevated platelets, markedly elevated d dimer and CRP with normal troponin and negative imaging for PE.

VAERS ID:	1033682 (history)
Form:	Version 2.0
Age:	95.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-02-05
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9269 / 2	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Arterial disorder, Contusion, Death, Dysphagia, Haematoma, Haemorrhage, Limb mass, Oedema peripheral, Peripheral swelling, Skin discolouration, Suture insertion, Thrombosis, Vein disorder
SMQs:, Cardiac failure (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Thrombophlebitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-12
Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: metoprolol tartrate 25 mg, 81 mg aspirin, 10 mg lisinopril, 2 mg glimepride, 20 mg furosemide (lasix)
Current Illness: polycythemia vera, dementia, type 2 diabetes mellitus, HTN
Preexisting Conditions: Type II DM
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: L hand edema, hematoma which burst and caused bleeding sending pt to the ER for pressure dressing and 2 stitches. L hand and arm progressively got more edematous and bruised looking (severely black/blue/purple) and the hand continued to bleed and swell on 2/6/21. Severe arterial and venous issues and apparent blood clots. On 2/7/21 there were also lumps noted on left inner thigh. Pt. stopped eating or drinking on 2/8/21 and expired on 2/12/21.

VAERS ID:	1033966 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-10
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043C20A / 2	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Hypoxia, Pulmonary embolism, Pyrexia
SMQs:, Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Write-up: post vaccine fever, hypoxia, pulmonary embolisms

VAERS ID:	1035845 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-11
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-02-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012M20A / 1	RA / IM

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

Write-up: We were informed by EMS that the patient was found deceased on 2/11/2021 at her home. EMS states she was dead for some time, no medical care given.

VAERS ID:	1036099 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-10
Onset:	2021-02-11
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Body temperature increased, Infection, Neuralgia, Pruritus
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Had the vaccine on Wed and then Thursday and Friday had 101.0 temp. By Saturday feeling better. Saturday evening began feeling itchy and painful nerve pain throughout my body. Finally went to ER on Sunday evening and kept as inpatient until Tuesday 2/16. I was also on an antibiotic for an infection and Dr. feels that this was the primary source of my reaction, but not sure if it was compounded by the vaccination. It?s been a rough couple of days, but feeling better now.

VAERS ID:	1036403 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-18
Onset:	2021-01-19
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL0142 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram, Asthenia, Cerebral haemorrhage, Computerised tomogram, Dyspnoea, Haemorrhagic stroke, Laboratory test, Lumbar puncture, Magnetic resonance imaging, Petechiae, Platelet count abnormal, Scan with contrast
SMQs:, Anaphylactic reaction (broad), Haematopoietic thrombocytopenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad)

Write-up: Hemorrhagic stroke, abnormal platelet count, petechai. Patient had my!triple CTs, MRI and angiogram after finding brain bleed. Once released home from brain bleed patient developed petechai, weakness, shortness of breath

VAERS ID:	1038403 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-13
Onset:	2021-02-15
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-02-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN5318 / 2	LA / IM

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

Write-up: admitted to hospital for a stroke

VAERS ID:	1038670 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-02-03
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-02-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Aphasia, Asthenia, Computerised tomogram head, Infarction
SMQs:, Myocardial infarction (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: atorvastatin 20mg daily, losartan 25mg daily, metoprolol 200mg daily, isosorbide mononitrate 60mg daily, pramipexole 1mg nightly, warfarin 5mg daily
Current Illness:
Preexisting Conditions: atrial fibrillation, bradycardia with pacemaker
Allergies: codine
Diagnostic Lab Data: CT brain
CDC Split Type:

Write-up: The patient received the vaccine on 1/27/21. He had a therapeutic INR on 1/25/21 and also on 2/15/21. On 2/3/21 he developed expressive aphasia with naming difficulties and generalized weakness. CT brain on 2/15/21 showed a left hemisphere subcortical infarction. He has been on warfarin for atrial fibrillation for 9 years without any strokes prior to this.

VAERS ID:	1039271 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-02-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012M20A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Death, Fall, Head injury, Injection site ulcer, Malaise, Neck pain
SMQs:, Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Arthritis (broad)

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

Write-up: Gentleman received his 1st Moderna dose on Thu. 2/11 at 0849. Vaccination protocol was completed. Pt reported feeling fine, no fever, and that he had no allergies which would prevent him from getting the vaccine. Pt played cards with friends later that day 2/11, but left at 1930 (normally plays late into evening) telling his companions he didn''t feel well and his neck hurt. A welfare call was completed on Sat. 2/13, and the patient was found deceased in the bathroom by his son. It appears patient fell off toilet and hit his head on the tub. Pressure ulcer present under injection site. The presumed time of death was Thur. evening.

VAERS ID:	1041081 (history)
Form:	Version 2.0
Age:	92.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-26
Onset:	2021-01-01
Submitted:	0000-00-00
Entered:	2021-02-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, COVID-19, Fatigue, SARS-CoV-2 test positive
SMQs:, Guillain-Barre syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient came to our ED on 2/6/2021 with worsening weakness and fatigue, which he claimed that had been experiencing since the date of vaccination on 1/26/2021. His rapid COVID test came back positive. He was admitted and treated in our COVID unit. His condition improved and he was discharged to home on room air on 2/10/2021.

VAERS ID:	1041784 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-23
Onset:	2021-01-25
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-02-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EK4176 / 1	AR / SYR

Administered by: Military Purchased by: ?
Symptoms: Cerebrovascular accident, Confusional state, Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Multivitamin, Thiamine, Amlodipine, Cholecalciferol, Donepezil, Folic Acid, Atorvastatin
Current Illness:
Preexisting Conditions: A stroke a year and half before, AVM, Arthritis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On the 25th he was home alone, he called 911 and let them know he thought he was having a stroke. EMS arrived and transported him to Hospital. It was massive stroke, he was not able to comprehend anything, he was put into Hospice the following day and passed away on the 27th. There was no autopsy preformed.

VAERS ID:	1042636 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-02-16
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-02-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Public Purchased by: ?
Symptoms: Blindness, Cerebrovascular accident, Hypoaesthesia
SMQs:, Peripheral neuropathy (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad)

Write-up: Left CVA Right sided numbness vision loss 2/16/2021

VAERS ID:	1043123 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-28
Onset:	2021-02-06
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-02-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-06
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Positive COVID-19 PCR collected postmortem
Preexisting Conditions: Hypertension, COPD, T2DM, Obesity
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death

VAERS ID:	1044569 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-02-20
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-02-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6198 / 4	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Cerebral artery thrombosis, Cerebrovascular accident, International normalised ratio increased, Magnetic resonance imaging brain abnormal, Thrombotic stroke
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Haemorrhage laboratory terms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Write-up: THROMBOTIC STROKE IN THE DISTRIBUTION OF THE LEFT MCA DISTRIBUTION

VAERS ID:	1044780 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-02-19
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6198 / 3	RA / IM

Administered by: Private Purchased by: ?
Symptoms: AST/ALT ratio abnormal, Blood lactic acid increased, Diarrhoea haemorrhagic, Encephalopathy, Endotracheal intubation, Hypotension, Liver injury, Septic shock
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Angioedema (broad), Lactic acidosis (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Toxic-septic shock conditions (narrow), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Accidents and injuries (narrow), Ischaemic colitis (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: SEPTIC SHOCK ACUTE LIVER INJURY ENCEPHALOPATHIC PRESENTED WITH BLOODY DIARRHEA. TRANSAMINASES IN THE 1000S. IN SEPTIC SHOCK. INTUBATED AT PRESENT

VAERS ID:	1046578 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-21
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-02-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood pressure increased, COVID-19, Dizziness, Headache, Hypertension, Hypertensive urgency, SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Hypertension (narrow), Vestibular disorders (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first dose of Pfizer COVID-19 at Vaccine Clinic 2/3/2021. Patient had previously tested positive for COVID at a community testing center on 10/2/2020, but is outside of the 90 day window where retesting is not recommendation. Pt began having headache and dizziness 2/21/2021, BP checked at home and was very elevated. Presented to ED and was diagnosed with hypertensive urgency, then admitted. Pt tested for COVID via PCR, positive.

VAERS ID:	1046670 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-12
Onset:	2021-02-18
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-02-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031M20A / 1	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Confusional state, Dyspnoea, Exposure to SARS-CoV-2, Pneumonia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first dose of COVID-19 vaccine on 2/12/2021. Pt presented to ED 2/18/2021 with shortness of breath and confusion. He reported having an exposure to someone positive for COVID-19 prior to date of vaccination but was unaware of exposure until after. Pt had findings indicating pneumonia on chest X-ray and required supplemental O2 with admission to hospital (2/18/2021). Pt was discharged the evening of 2/21/2021.

VAERS ID:	1047381 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-18
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-02-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	AR / IM

Administered by: Private Purchased by: ?
Symptoms: Contusion, Immune thrombocytopenia, Immunoglobulin therapy, Petechiae, Platelet count decreased
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Accidents and injuries (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Patient was diagnosed with Immune Thrombocytopenic Purpura on 2/21/2021. -petechial rash, bruising -Platelets 4 thousand at hospital admission -Patient is receiving prednisone and IVIG with improvements in platelet count currently

VAERS ID:	1048210 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-30
Onset:	2021-02-01
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-02-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1283 / 1	LA / OT

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Body temperature, Computerised tomogram, Computerised tomogram abdomen, Computerised tomogram pelvis, Decreased appetite, Fatigue, Malaise, Pain, Sleep disorder, Stoma site haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Guillain-Barre syndrome (broad)

Write-up: Bleeding out of ileostomy; Did not sleep; no appetite; Feeling unwell; achy; tired; weaker; This is a spontaneous report from a contactable consumer (patient''s daughter). An 88-years-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) (lot number: EL1283), intramuscular on 30Jan2021 09:45 at SINGLE DOSE in left arm for Prevention. Medical history included Type 2 diabetes diagnosed 10 years ago, Quadruple Bypass surgery in 2003, High blood pressure. He was Diabetic, was a heart patient. Before he had his ostomy, he had colitis that causes the patient to bleed when pooping and his guts were ravaged. His stomach might be weakened from having it for years and years in his 30''s, 40''s to early 50''s. Family medical history included Grandfather died at 42 of bleeding ulcer in his stomach. There were no concomitant medications. Prior Vaccinations within 4 weeks was none. He has allergies to pills but was not taking any. He does not have a fever. She has the names of the pills he is allergic to as follows: Simvastatin, Lisinopril, Losartan, Aggrenox cap. They are listed on his report from (institution name withheld) that he has allergies to. He received his first dose of the Pfizer COVID-19 vaccine on 30Jan2021. There was no prescriber on 30Jan2021 through 01Feb2021, everything was good. On 02Feb2021, that is when his ostomy shot out blood like a faucet when he was taking a shower. He was changing the bandage that day, he was changing his right sided ileostomy bag and he told her that blood shot out of it "like a faucet." On 3Feb2021 was nerve wracking, but there was no blood. He was changing his ostomy pad again on 04Feb2021 and it started bleeding so much that he went to the hospital. He was discharged within a few hours because "they couldn''t find anything wrong." He has had colitis for years and has an ileostomy, where they take out a bunch of his colon. This week he has had some funny bleeding in his ileostomy. It was spurting out blood. He had to go to the ER on 4Feb2021 night because it was bleeding and then it stops. People in ER did not know what the bleeding was from. He was bleeding in the ileostomy on 04Feb2021 and 05Feb2021. On 05Feb2021 his ostomy bled a little bit more but it has not bled again since 06Feb2021. She also reports that he feels, " icky, tired, no appetite and achy." The feeling unwell began on 7Feb2021. That worsened since loss of blood made him weaker and worried. When he got back from the hospital/ER, he said they were rude. There was a blizzard. He checked in around 8pm and they discharged him around 11pm that same night. ER visit at the institution on 04Feb2021, 8pm to 11pm and released. They performed CT scan abdomen and Pelvis and IV. Results are unknown. Now he was good. The achiness and tiredness was between persistent and worsened. He was worrying now. She took his forehead temperature and it was good on 7Feb2021. She took everybody''s and they were all good. He just feels icky and the blood thing is nerve wracking. He is convinced it is coming back. He was not on a blood thinner or anything listed on the vaccine fact sheet. The patient experienced Feeling unwell on 6Feb2021 with outcome of Not Recovered (Feeling unwell was reported as worsened), achy and tired on 5Feb2021 with outcome of unknown, No appetite on 7Feb202108:30 with outcome of Not Recovered, Bleeding out of ileostomy on 2Feb2021 09:45 with outcome of Recovering, Did not sleep on 7Feb2021 21:30 with outcome of Not Recovered. He has a lot of the risk factors; He is Diabetic, is a heart patient, and has high blood pressure, but he really wanted to get the shot. The patient''s primary care provider''s nurse do not believe the bleeding had anything to do with the Pfizer COVID-19 vaccine.

VAERS ID:	1049445 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-08
Onset:	2021-01-09
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	LA / -

Administered by: Private Purchased by: ?
Symptoms: Blood test, Dysgeusia, Dyspnoea, Fatigue, X-ray
SMQs:, Anaphylactic reaction (broad), Taste and smell disorders (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Write-up: Hospitalized w/Covid symptoms 5 days. Shortness of breath, fatigue , bad taste in back of throat still exist today 02/23/2021

VAERS ID:	1049814 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-10
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Cerebrovascular accident, Computerised tomogram head abnormal, Echocardiogram normal, Magnetic resonance imaging brain abnormal
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Write-up: Stroke confirmed on MRI.

VAERS ID:	1051268 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-02-10
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-02-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / -

Administered by: Unknown Purchased by: ?
Symptoms: Cerebrovascular accident, Headache, Hypoaesthesia
SMQs:, Peripheral neuropathy (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad)

Write-up: Possible Stroke; Increase pressure and numbness in fingers; Headache; A spontaneous report was received from a pharmacist concerning an 81-year old male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273) and experienced possible stroke, face numbness, startled speech, increase pressure and numbness in fingers and headache. The patient''s medical history was not provided. Products known to have been used by the patient, within two weeks prior to the event, included alprazolam and hydroxyzine. On 02 Feb 2021, prior to the onset of the events, the patient received his first of two planned doses of mRNA-1273 (Lot number: unknown) in the left arm for prophylaxis of Covid-19 infection. On unknown date, days after the vaccine was administered, the patient reported that he started having a headache, increased pressure and numbness in fingers. Patient had been having intermittent symptoms for 9 days. Patient was admitted to hospital on 10 Feb 2021 due to possible stroke. On 11 Feb 2021, the patient began to have startled speech and face numbness. Patient was evaluated by Neurology and an MRI was done. No further information was provided. Treatment for headache included Excedrin Migraine, ibuprofen and acetaminophen. Action taken with mRNA-1273 in response to the events were not reported. The outcome for the events possible stroke, face numbness, startled speech, headache, increase pressure and numbness in fingers, were considered as unknown at the time of this report.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.

VAERS ID:	1051522 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-22
Onset:	2021-02-23
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Atrial fibrillation, Blood creatinine increased, Blood potassium increased, Blood urea increased, Cerebrovascular accident, Computerised tomogram head normal, Full blood count normal, Hemiparesis, International normalised ratio normal, Muscle twitching, Seizure like phenomena
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Supraventricular tachyarrhythmias (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dyskinesia (broad), Dystonia (broad), Noninfectious encephalitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient brought to emergency department at 2210 with concern for stroke d/t left sided weakness. Upon arrival patient appeared to have seizure like activity and was given 2mg of ativan and keppra 1000mg. Patient remained able to converse with providers during episode. Seizure activity/muscle twitching resolved after ativan/keppra administration. At the time of filing this report the patient is being admitted to the hospital.

VAERS ID:	1051675 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-28
Onset:	2021-02-01
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-02-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL8982 / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated, Death
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: congestive heart failure
Preexisting Conditions: congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 2/1/21 at the Health System. She was there for congestive heart failure (CHF) which had been a problem for her since contracting COVID-19 (symptoms began 10/29/20 and tested positive 10/30/20). She had been to see her medical provider several times after her isolation period as well as a few trips to the hospital for, what they called "CHF flare-ups". Her last hospitalization began on January 30, 2021. Her social worker reported on t1/31/21 that "she would likely be returning in another day or two".

VAERS ID:	1051713 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-21
Onset:	2021-02-21
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9269 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Alanine aminotransferase normal, Albumin globulin ratio normal, Amnesia, Angiogram cerebral normal, Anion gap, Arteriogram carotid normal, Aspartate aminotransferase normal, Basophil count normal, Basophil percentage, Bilirubin urine, Blood albumin normal, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium normal, Blood chloride normal, Blood cholesterol normal, Blood creatinine normal, Blood glucose increased, Blood potassium normal, Blood sodium normal, Blood triglycerides normal, Blood urea nitrogen/creatinine ratio increased, Blood urea normal, Blood uric acid normal, COVID-19, Carbon dioxide normal, Cerebral atrophy, Chest X-ray normal, Claustrophobia, Computerised tomogram head normal, Confusional state, Differential white blood cell count normal, Electrocardiogram, Eosinophil count normal, Eosinophil percentage, Full blood count, Glomerular filtration rate decreased, Glucose urine absent, Haematocrit decreased, Haemoglobin decreased, High density lipoprotein decreased, Low density lipoprotein normal, Lymphocyte count normal, Lymphocyte percentage decreased, Magnetic resonance imaging brain, Magnetic resonance imaging brain abnormal, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Mean cell volume abnormal, Mean cell volume decreased, Mean platelet volume normal, Metabolic function test, Monocyte count normal, Monocyte percentage, Neutrophil count normal, Neutrophil percentage increased, Nitrite urine absent, Perfusion brain scan normal, Platelet count normal, Protein total decreased, Protein urine absent, Red blood cell count normal, Red cell distribution width increased, SARS-CoV-2 test positive, Scan with contrast, Specific gravity urine normal, Total cholesterol/HDL ratio normal, Urine analysis normal, Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine, White blood cell count normal, White matter lesion, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (broad), Dyslipidaemia (narrow), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Biliary system related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Lipodystrophy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: OTC and Vitamins: C, D, zinc, ocuvite, aspirin 81 mg, tylenol, Dulcolax RX: furosemide, hydrocodone, pantoprazole, potassium chloride, pravastin, silodosin, stool, eliquis, symbicort, voltaren, zonisamide
Current Illness: none
Preexisting Conditions: high blood pressure, heart, atrial fibrillation, COPD
Allergies: shellfish, seasonal rhinitis
Diagnostic Lab Data: HEMOGRAM - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range WBC 7.5 Thou/uL 4.0 to 10.0 Thou/uL 4.0 - 10.0 Thou/uL RBC 4.98 Mill/uL 4.50 to 5.70 Mill/uL 4.50 - 5.70 Mill/uL Hgb 11.3 g/dL 13.0 to 16.8 g/dL 13.0 - 16.8 g/dL Hct 39.0 % 42.0 to 52.0 % 42.0 - 52.0 % MCV 78.3 fL 80.0 to 101.0 fL 80.0 - 101.0 fL MCH 22.7 pg 27.0 to 32.0 pg 27.0 - 32.0 pg MCHC 29.0 g/dL 30.0 to 35.0 g/dL 30.0 - 35.0 g/dL RDW 19.2 % 11.5 to 15.0 % 11.5 - 15.0 % Platelets 250 Thou/uL 150 to 400 Thou/uL 150 - 400 Thou/uL MPV 9.3 fL 9.0 to 12.5 fL 9.0 - 12.5 fL The above 10 analytes were performed by Lab General Information Ordered by MD Collected on 02/22/2021 5:03 AM from Blood Resulted on 02/22/2021 5:31 AM Result Status: Final result METABOLIC PANEL, BASIC (BMP) - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range Sodium 140 mmol/L 136 to 145 mmol/L 136 - 145 mmol/L Potassium 3.5 mmol/L 3.5 to 5.1 mmol/L 3.5 - 5.1 mmol/L Chloride 105 mmol/L 100 to 110 mmol/L 100 - 110 mmol/L Total CO2 25.0 mmol/L 22.0 to 29.0 mmol/L 22.0 - 29.0 mmol/L Calcium 9.3 mg/dL 8.4 to 10.4 mg/dL 8.4 - 10.4 mg/dL BUN 13 mg/dL 7 to 26 mg/dL 7 - 26 mg/dL Creatinine 0.62 mg/dL 0.60 to 1.30 mg/dL 0.60 - 1.30 mg/dL Glucose 107 mg/dL 74 to 99 mg/dL 74 - 99 mg/dL Anion Gap 14 mmol/L 5 to 20 mmol/L 5 - 20 mmol/L BUN/Creatinine Ratio 21 Ratio 10 to 20 Ratio 10 - 20 Ratio $g60 mL/min/1.73sqm mL/min/1.73sqm mL/min/1.73sqm $g60 mL/min/1.73sqm mL/min/1.73sqm mL/min/1.73sqm An Estimated result less than or equal to 60 mL/min/1.73 sqm is indicative of renal disease. The Estimated result is derived from serum creatinine, age, gender, average body surface area and race using the IDMS-traceable MDRD study equation (for creatinine methods calibrated to an IDMS reference method) as recommended by NKDEP (National Kidney Disease Education Program). The above 12 analytes were performed by lab General Information Ordered by MD Collected on 02/22/2021 5:03 AM from Blood Resulted on 02/22/2021 5:52 AM Result Status: Final result K+ PROTOCOL POTASSIUM, MG RFLX - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range Potassium 3.5 mmol/L 3.5 to 5.1 mmol/L 3.5 - 5.1 mmol/L The above 1 analytes were performed by lab General Information Ordered by MD Collected on 02/22/2021 5:03 AM from Blood Resulted on 02/22/2021 5:52 AM Result Status: Final result MRI BRAIN WO CONTRAST - Details? ?About This Test Details Study Result Narrative Exam: MRI BRAIN WO CONTRAST Clinical History: History of stroke with acute onset altered mental status. Technique: Multisequence, multiplanar imaging of the brain without IV contrast was performed. The exam was discontinued prematurely due to claustrophobia. Contrast Dose: None. Comparison: None available. FINDINGS: A mild volume of scan. Nonspecific T2/FLAIR white matter hyperintensities are present in the periventricular, deep, and subcortical white matter. There is an old infarct involving the left inferior frontal gyrus and insular, as well as in the left centrum semiovale. No diffusion abnormality. Moderate diffuse cerebral volume loss with corresponding sulcal and ventricular prominence is present. Remaining midline structures normal. No evidence of hemorrhage. No extra-axial fluid collection. No midline shift. Basal cisterns maintained. Ventricles unremarkable. Central arterial flow voids preserved. Calvarium unremarkable. Extracranial soft tissues normal. Normal appearance of skull base structures. Orbits unremarkable. Paranasal sinuses normally aerated. Temporal bone structures unremarkable. There is a small Tornwaldt cyst. IMPRESSION: No acute infarct. Background of moderate generalized cerebral volume loss and scattered nonspecific T2/FLAIR white matter signal abnormality likely representing chronic microvascular alterations with old infarcts in the left centrum semiovale and left inferior frontal gyrus. Location Code 67 Authenticated by MD, Radiologist on 2/21/2021 5:55 PM If you are a healthcare provider with questions about this report and would like to talk to the radiologist, please call. For a Nuclear Cardiology report read by a Cardiologist, please call. Component Results There is no component information for this result. General Information Ordered by MD Collected on 02/21/2021 5:46 PM Resulted on 02/21/2021 5:55 PM Result Status: Final result 2019 CORONAVIRUS SARS-COV-2 RAPID - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range 2019 Coronavirus SARS-CoV-2 Rapid Positive Negative Negative Is this the first test for COVID-19? No Employed in Healthcare No Patient symptomatic No Is patient hospitalized for Covid No Patient admitted to ICU No Lives in a Congregate site No General Information Ordered by MD Collected on 02/21/2021 5:10 PM from Nasopharynx/Oropharynx Resulted on 02/21/2021 6:18 PM Result Status: Final result XRAY CHEST PORTABLE - Details? ?About This Test Details Study Result Narrative LOCATION CODE 15 CHEST 1 VIEW HISTORY: 72 years, Male, Covid vaccine administration , confusion COMPARISON: November 2020 FINDINGS: Pulmonary vascularity appears normal Cardiac and mediastinal contours are stable. Is small calcified granuloma in the left upper lobe. There is no focal consolidation. There is no significant pleural effusion.No pneumothorax observed. IMPRESSION: 1. No acute cardiopulmonary process. Authenticated by MD, Radiologist on 2/21/2021 5:23 PM If you are a healthcare provider with questions about this report and would like to talk to the radiologist, please call. For a Nuclear Cardiology report read by a Cardiologist, please call. Component Results There is no component information for this result. General Information Ordered by MD Collected on 02/21/2021 5:22 PM Resulted on 02/21/2021 5:23 PM Result Status: Final result T UA MACRO WMICRO IF INDICATED - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range Type, Ur Midstream Color, Ur Yellow Yellow,Straw,Amber Yellow,Straw,Amber Appearance, Ur Clear Clear Clear Glucose, Ur Negative mg/dL Negative mg/dL Negative mg/dL Bilirubin, Ur Negative Negative Negative Ketones, Ur Negative mg/dL Negative mg/dL Negative mg/dL Specific Gravity, Ur 1.010 1.005 to 1.030 1.005 - 1.030 Occult Blood, Ur Negative Negative Negative pH, Ur 7.5 5.0,5.5,6.0,6.5,7.0,7.5,8.0 5.0,5.5,6.0,6.5,7.0,7.5,8.0 Protein, Ur Negative mg/dL Negative,Trace mg/dL Negative,Trace mg/dL Urobilinogen, Ur 0.2 EU/dL 0.2,1.0 EU/dL 0.2,1.0 EU/dL Nitrite, Ur Negative Negative Negative Leukocyte Esterase, Ur Negative Negative Negative The above 13 analytes were performed by Lab General Information Ordered by MD Collected on 02/21/2021 4:40 PM from Urine Resulted on 02/21/2021 4:47 PM GLUCOSE, FINGERSTICK - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range Glucose POC 119 mg/dL 74 to 99 mg/dL 74 - 99 mg/dL The above 1 analytes were performed by Laboratories General Information Ordered by MD Collected on 02/21/2021 4:08 PM from Capillary or Arterial Resulted on 02/21/2021 4:11 PM Result Status: Final result ECG 12-LEAD - Details? ?About This Test Details Component Results There is no component information for this result. General Information Ordered by MD Collected on 02/21/2021 3:59 PM Resulted on 02/22/2021 1:59 PM Result Status: Final result CT BRAIN PERFUSION - Details? ?About This Test Details Study Result Narrative EXAM: CT BRAIN PERFUSION WITH CONTRAST CLINICAL HISTORY: 72 years old Male presents with stroke symptoms COMPARISON: CT head performed earlier today TECHNIQUE: Standard CT perfusion protocol was utilized following administration of intravenous contrast (50 mL Omnipaque 350). Dynamic color maps of cerebral blood flow, cerebral blood volume and mean transit time were generated on an independent workstation and uploaded to PACS. Postprocessing parametric maps were created using RAPID software and reviewed. Automated exposure control and iterative reconstructive were utilized for dose reduction. FINDINGS: Cerebral blood flow, mean transit time, and cerebral blood volume are calculated as follows Calculated parameters: CBF <30% volume: 0 mL Tmax $g6.0s volume: 46 mL Mismatch volume: 46 mL Mismatch ratio: Infinite The numbers are however felt to be nondiagnostic IMPRESSION: nondiagnostic exam due to limited bolus. No confirmable abnormality is seen. If clinically indicated, MR brain could be considered CRITICAL RESULTS were discussed with DR 2/21/2021 4:28 PM with readback. CT ANGIO HEAD NECK W WO CONTRAST - Details? ?About This Test Details Study Result Narrative LOCATION CODE 15 CT ANGIOGRAM OF THE HEAD AND NECK WITHOUT AND WITH CONTRAST CLINICAL HISTORY: 72 years old Male presents with stroke symptoms. Confusion COMPARISON: CT head performed earlier today TECHNIQUE: CT angiogram of the head and neck is obtained without and with IV contrast. 3D Multiplanar reformats were generated by the technologist. Dedicated 3D reformats were generated by the radiologist at a separate workstation. CT dose reduction techniques utilized. NASCET criteria utilized for stenosis evaluation. FINDINGS: The study is markedly limited by limitations in the phase of contrast administration and patient motion and body habitus NECK: Aortic arch and its branches: No definite significant focal stenosis. Right: Right common carotid artery: No definite significant focal stenosis. Right internal carotid artery: No definite significant focal stenosis. Right external carotid artery: No definite significant focal stenosis. Right vertebral artery: Cannot be confidently identified. Left: Left common carotid artery: No definite significant focal stenosis. Left internal carotid artery: No definite significant focal stenosis. Left external carotid artery: No definite significant focal stenosis. Left vertebral artery: Cannot be confidently identified. No definite evidence of vascular cutoff or significant aneurysm is noted. INTRACRANIAL: Evaluation is limited but no definite thrombosis or vessel cutoff is seen Other structures: Limited evaluation of the brain demonstrates no gross hemorrhage. No midline shift or mass effect. No osseous destructive lesions are noted. Soft tissues of the neck are grossly unremarkable. IMPRESSION: 1. Markedly limited diagnostic quality due to limitations in the contrast bolus, patient body habitus and motion. No definite vascular occlusion identified. CRITICAL RESULTS were discussed with DR 2/21/2021 4:11 PM with readback. Authenticated by MD, Radiologist on 2/21/2021 4:27 PM If you are a healthcare provider with questions about this report and would like to talk to the radiologist, please call. For a Nuclear Cardiology report read by a Cardiologist please call. Component Results There is no component information for this result. General Information Ordered by MD Collected on 02/21/2021 4:02 PM Resulted on 02/21/2021 4:27 PM Result Status: Final result METABOLIC PANEL,COMPREHENSIVE(CMP) - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range Sodium 140 mmol/L 136 to 145 mmol/L 136 - 145 mmol/L Potassium 4.0 mmol/L 3.5 to 5.1 mmol/L 3.5 - 5.1 mmol/L Chloride 103 mmol/L 100 to 110 mmol/L 100 - 110 mmol/L Total CO2 28.0 mmol/L 22.0 to 29.0 mmol/L 22.0 - 29.0 mmol/L Calcium 9.0 mg/dL 8.4 to 10.4 mg/dL 8.4 - 10.4 mg/dL BUN 14 mg/dL 7 to 26 mg/dL 7 - 26 mg/dL Creatinine 0.71 mg/dL 0.60 to 1.30 mg/dL 0.60 - 1.30 mg/dL Glucose 107 mg/dL 74 to 99 mg/dL 74 - 99 mg/dL Total Protein 6.1 g/dL 6.2 to 8.3 g/dL 6.2 - 8.3 g/dL Albumin 3.7 g/dL 3.5 to 5.2 g/dL 3.5 - 5.2 g/dL Bilirubin, Total 0.3 mg/dL 0.2 to 1.2 mg/dL 0.2 - 1.2 mg/dL AST (SGOT) 14 U/L 5 to 40 U/L 5 - 40 U/L Alkaline Phosphatase 124 U/L 40 to 121 U/L 40 - 121 U/L ALT (SGPT) 9 U/L 0 to 55 U/L 0 - 55 U/L Anion Gap 13 mmol/L 5 to 20 mmol/L 5 - 20 mmol/L Albumin/Globulin Ratio 1.5 Ratio 1.0 to 2.2 Ratio 1.0 - 2.2 Ratio BUN/Creatinine Ratio 20 Ratio 10 to 20 Ratio 10 - 20 Ratio $g60 mL/min/1.73sqm mL/min/1.73sqm mL/min/1.73sqm $g60 mL/min/1.73sqm mL/min/1.73sqm mL/min/1.73sqm An Estimated result less than or equal to 60 mL/min/1.73 sqm is indicative of renal disease. The Estimated is derived from serum creatinine, age, gender, average body surface area and race using the IDMS-traceable MDRD study equation (for creatinine methods calibrated to an IDMS reference method) as recommended by NKDEP (National Kidney Disease Education Program). The above 19 analytes were performed by Lab General Information Ordered by MD Collected on 02/21/2021 3:34 PM from Blood Resulted on 02/21/2021 3:58 PM Result Status: Final result HEMOGRAM W/DIFFERENTIAL - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range WBC 7.9 Thou/uL 4.0 to 10.0 Thou/uL 4.0 - 10.0 Thou/uL RBC 5.14 Mill/uL 4.50 to 5.70 Mill/uL 4.50 - 5.70 Mill/uL Hgb 11.6 g/dL 13.0 to 16.8 g/dL 13.0 - 16.8 g/dL Hct 40.3 % 42.0 to 52.0 % 42.0 - 52.0 % MCV 78.4 fL 80.0 to 101.0 fL 80.0 - 101.0 fL MCH 22.6 pg 27.0 to 32.0 pg 27.0 - 32.0 pg MCHC 28.8 g/dL 30.0 to 35.0 g/dL 30.0 - 35.0 g/dL RDW 19.0 % 11.5 to 15.0 % 11.5 - 15.0 % Platelets 266 Thou/uL 150 to 400 Thou/uL 150 - 400 Thou/uL MPV 8.8 fL 9.0 to 12.5 fL 9.0 - 12.5 fL Segs 75.1 % 42.0 to 75.0 % 42.0 - 75.0 % Lymphocytes 14.1 % 15.0 to 45.0 % 15.0 - 45.0 % Monocytes 7.8 % 4.0 to 11.0 % 4.0 - 11.0 % Eosinophils 2.4 % 0.0 to 6.0 % 0.0 - 6.0 % Basophils 0.3 % 0.0 to 2.0 % 0.0 - 2.0 % Immature Granulocytes 0.3 % 0.0 to 1.0 % 0.0 - 1.0 % Neutrophils Absolute 5.9 Thou/uL 1.6 to 7.5 Thou/uL 1.6 - 7.5 Thou/uL Lymphocytes Absolute 1.1 Thou/uL 1.1 to 4.0 Thou/uL 1.1 - 4.0 Thou/uL Monocytes Absolute 0.6 Thou/uL 0.3 to 1.0 Thou/uL 0.3 - 1.0 Thou/uL Eosinophils, Absolute 0.2 Thou/uL 0.0 to 0.6 Thou/uL 0.0 - 0.6 Thou/uL Basophils Absolute 0.0 Thou/uL 0.0 to 0.2 Thou/uL 0.0 - 0.2 Thou/uL Absolute Immature Granulocytes 0.02 Thou/uL 0.00 to 0.09 Thou/uL 0.00 - 0.09 Thou/uL Immature granulocyte (promyelocytes, myelocytes, metamyelocytes) $g 1.0% indicates the presence of immature white blood cells. Band forms are not included in the immature granulocyte count but are included in the automated neutrophil count. Morphology See Note Automated differential - smear not reviewed The above 23 analytes were performed by Laboratory General Information Ordered by MD Collected on 02/21/2021 3:34 PM from Blood Resulted on 02/21/2021 3:44 PM Result Status: Final result URIC ACID - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range Uric Acid 6.6 mg/dL 3.5 to 7.2 mg/dL 3.5 - 7.2 mg/dL N-Acetyl-4-benzoquinone Imine (NAPQI), a metabolite of Acetaminophen at very high levels may lead to falsely low results. N-Acetyl-L-Cysteine at therapeutically achieved concentrations may lead to falsely low results. The above 1 analytes were performed by Laboratories General Information Ordered by MD Collected on 02/21/2021 3:34 PM from Blood Resulted on 02/21/2021 7:39 PM Result Status: Final result LIPID PANEL - Details? ?About This Test Details Past Results Graph of Past Results Component Results Component Your Value Standard Range Triglycerides 115 mg/dL 0 to 149 mg/dL 0 - 149 mg/dL Cholesterol 136 mg/dL 0 to 199 mg/dL 0 - 199 mg/dL HDL 39 mg/dL 41 to 999 mg/dL 41 - 999 mg/dL LDL Cholesterol 74 mg/dL 0 to 129 mg/dL 0 - 129 mg/dL Chol/HDL Ratio 3.5 0.0 to 6.0 0.0 - 6.0 Non-HDL-Chol (LDL+VLDL) 97 mg/dL 0 to 129 mg/dL 0 - 129 mg/dL NCEP GUIDELINES - (2001) Test Desirable Borderline Higher Risk Triglyceride <150 150-199 200-499 Cholesterol <200 200-239 $g239 HDL-Cholesterol $g60 <40 LDL-Cholesterol (Calculated) <100* 130-160 $g160 *100-129 is considered low risk Chol/HDL Ratio A ratio of $g6.0 has been associated with a greater risk of Coronary Heart Disease. Non-HDL Cholesterol When the Triglyceride level is greater than 199 mg/dL, Non-HDL Cholesterol is a better indicator of coronary heart disease risk than a calculated LDL Cholesterol. The above 6 analytes were performed by Laboratories General Information Ordered by MD Collected on 02/21/2021 3:34 PM from Blood Resulted on 02/21/2021 7:39 PM Result Status: Final result CT HEAD WO CONTRAST - Details? ?About This Test Details Study Result Narrative EXAM: CT HEAD WO CONTRAST CLINICAL HISTORY: 72 years old Male presents with confusion Stroke Symptoms COMPARISON: None TECHNIQUE: Contiguous axial noncontrast images of the brain were obtained. One or more of the following dose reduction techniques were used: automated exposure control, adjustment of the mA and/or kV according to patient size, use of iterative reconstruction. FINDINGS: This study is mildly limited by patient motion There is no evidence for acute intracranial hemorrhage, mass effect, midline shift or acute large vessel territory infarct. There is no evidence of obstructive hydrocephalus. No evidence for acute sinusitis or significant sinus disease. The mastoid air cells are clear. No evidence for calvarial fracture. IMPRESSION: 1. No evidence for intracranial hemorrhage, mass effect, acute large vessel territory infarct or acute intracranial process. CRITICAL RESULTS were discussed with DR 2/21/2021 3:36 PM with readback. Location Code 15 Authenticated by MD, Radiologist on 2/21/2021 3:39 PM If you are a healthcare provider with questions about this report and would like to talk to the radiologist, please call. For a Nuclear Cardiology report read by a Cardiologist. Component Results There is no component information for this result. General Information Ordered by MD Collected on 02/21/2021 3:35 PM Resulted on 02/21/2021 3:39 PM Result Status: Final result This test result has been released by an automatic process.
CDC Split Type:

Write-up: Covid 19 vaccine was administered at 2:45 pm on 2-21-21. By 2:55 pm patient began to experience Confusion and loss of short term memory. He suddenly did not know where is was, how he got there, or why he was there. He continuously asked those questions throughout the balance of the day. The nurses on duty in the clinic got a wheel chair and escorted us to the hospital ER in the same building. He was immediately taken to a room where a doctor met us and began asking him questions. The Dr quickly ordered a multitude of tests. Results shown in item 19

VAERS ID:	1052711 (history)
Form:	Version 2.0
Age:	92.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-02-24
Days after vaccination:	28
Submitted:	0000-00-00
Entered:	2021-02-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / SYR

Administered by: Private Purchased by: ?
Symptoms: Deep vein thrombosis, Fibrin D dimer increased, Pulmonary embolism, Respiratory failure, Ultrasound scan abnormal
SMQs:, Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, celexa, benadryl, ceterizine, metoprolol succinate, mirtazipine, potassium, prednisone, probiotic, torsemide, diclofenac topical, aspirin EC 81mg, ferrous gluconate, levothyroxine,
Current Illness: Atrial fibrillation, chronic, rate controlled, on aspirin Congestive heart failure, with preserved EF, valvular disease GERD Insomnia Hypertension Hypothyroidism Gout, on chronic prednisone
Preexisting Conditions: Atrial fibrillation, chronic, rate controlled, on aspirin Congestive heart failure, with preserved EF, valvular disease GERD Insomnia Hypertension Hypothyroidism Gout, on chronic prednisone
Allergies: No known allergies
Diagnostic Lab Data: 2/24/21: d-dimer of 14,738; oxygen saturation of 82% on 2 liters of oxygen, with oxygen needs increasing now up to 55L/Min via high flow nasal cannula to maintain her saturations in the 90s. ULTRASOUND OF THE LOWER EXTREMITY VENOUS SYSTEM- UNILATERAL, RIGHT LEG 1. Acute deep venous thrombosis in the right popliteal and trifurcation vessels of the calf
CDC Split Type:

Write-up: The patient has developed an acute deep venous thrombosis in the right popliteal and trifurcation vessels of the calf. She has an elevated d-dimer of 14,738 and acute hypoxic respiratory failure due to pulmonary embolism.

VAERS ID:	1052774 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-22
Onset:	2021-02-22
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Cerebral infarction, Facial paralysis, Hemiparesis, Ischaemic stroke, Magnetic resonance imaging brain abnormal, Speech disorder
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine, calcium carbonate, cetirizine, vitamin D3, fish oil, latanoprost ophthalmic solution, losartan, metoprolol succinate, multivitamin, saline nasal spray, timolol 0.5% ophthalmic gel
Current Illness: Osteoporosis Hypertension DJD Glaucoma vasomotor rhinitis Paroxysmal supraventricular tachycardia History of mycobacterium avium lung infection/ colonization Prediabetes
Preexisting Conditions: Osteoporosis Hypertension DJD Glaucoma vasomotor rhinitis Paroxysmal supraventricular tachycardia History of mycobacterium avium lung infection/ colonization Prediabetes
Allergies: No known allergies
Diagnostic Lab Data: MRI of the brain wo contrast 2/24/21: 1. Moderate-sized acute to subacute right-sided MCA infarct as detailed above. 2. Tiny focus of acute subacute infarct within the cortex or subcortical white matter of the right occipital lobe in a posterior cerebral distribution which suggests a central embolic source versus extension through a posterior to communicating artery.
CDC Split Type:

Write-up: The patient has developed an acute ischemic stroke on the evening of receiving the COVID vaccine #1 dose. She is in the hospital with left sided weakness, facial droop and speech changes. She is receiving blood thinner and therapies.

VAERS ID:	1053378 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-02-22
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-02-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	UN / SYR

Administered by: Private Purchased by: ?
Symptoms: Abdominal distension, Computerised tomogram thorax abnormal, Condition aggravated, Dizziness, Dyspnoea, Headache, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad)

Write-up: Patient presented on 2/24/21 with B pulmonary emboli, with symptoms of dyspnea started around 2/22/2021, she was have headache, dizziness and abdominal bloating on presentation.

VAERS ID:	1054045 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-23
Onset:	2021-02-23
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6201 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Chest pain, Troponin increased
SMQs:, Myocardial infarction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: Chest pain

VAERS ID:	1054424 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-02-19
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Amnesia, Chest X-ray, Computerised tomogram head, Conversion disorder, Disorientation, Electroencephalogram normal, Facial paralysis, Fall, Fatigue, Full blood count, Magnetic resonance imaging normal, Nervous system disorder, Pyrexia, Ultrasound scan normal, Unresponsive to stimuli, X-ray limb
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hearing impairment (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Patient resides in an assisted living facility and received the second COVID-19 vaccination. She experienced fatigue in the morning following vaccination. She fell on 2/22/21. Ambulance was called and she was transported to the hospital. Initial symptoms included fever of 101 F, disorientation, left face droop, unresponsive to commands and loss of memory.

VAERS ID:	1054586 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-22
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-02-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	UN / SYR

Administered by: Unknown Purchased by: ?
Symptoms: Fibrin D dimer increased, Hyperhidrosis, Hypotension, Nausea, Tremor
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Write-up: The patient developed sudden onset nausea, diaphoresis and hypotension and shaking. Symptoms improved with IV fluids and rest. She was hospitalized 2 days.

VAERS ID:	1054699 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-20
Onset:	2021-01-21
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	042L20A / 1	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-21
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, tamsulosin, M vit. clopidogrel; aspirin; sertraline, melatonin, losartan, myrbetriq, senna, vit. D
Current Illness:
Preexisting Conditions: PRimaRy hypertension, HypeRlipidemia, BRadycaRdia
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found at 6 AM on 01/21/2021 - he passed away during his sleep

VAERS ID:	1055243 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-01-25
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EK9231 / UNK	LA / -

Administered by: Other Purchased by: ?
Symptoms: Aphasia, Chest X-ray, Computerised tomogram, Electrocardiogram, Hemiplegia, Magnetic resonance imaging head
SMQs:, Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Write-up: 75-year-old male presenting with speech changes. Patient accompanied by need he reports that he was last seen normal between 11 and 12:00 a.m.. Patient went to get his COVID vaccine and then to the grocery store. He drove home and pulled into the garage but when he did not get out of the car his neighbor went to check on him. His neighbor states patient was awake but aphasic and paralyzed on the right side. He moved into the passenger seat and drove directly to the hospital. Patient started to talk and had difficulty expressing words. Patient denies headache, chest pain shortness of breath, nausea orvomiting, abdominal pain or diarrhea. Neighbor states patient has a history of a bleeding stroke 2 years It was a bleed into the outside of the brain on the left side of head as a result of a hall that caused problems for me.

VAERS ID:	1279601 (history)
Form:	Version 2.0
Age:	95.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-02-23
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-02-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	042L20A / 1	- / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011M20A / 2	- / -

Administered by: Senior Living Purchased by: ?
Symptoms: Computerised tomogram, Groin pain, Hypoaesthesia, Magnetic resonance imaging, Movement disorder
SMQs:, Peripheral neuropathy (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Osteonecrosis (broad)

Write-up: 2/23/2021 - patient found in room w/ left groin pain & right sided numbness - upon admission to hospital he has no movement in right leg & minimal movement in right arm.

VAERS ID:	1056471 (history)
Form:	Version 2.0
Age:
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-13
Onset:	2021-01-13
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Anaphylactic shock
SMQs:, Anaphylactic reaction (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: she did go to anaphylactic shock; A spontaneous report was received from a consumer concerning a 38-year-old female patient who experienced immediate anaphylactic shock (she did go to anaphylactic shock). The patient''s medical history was not provided. No relevant concomitant medications were reported. On 13-JAN-2021, the patient received their first of two planned doses of mRNA-1273 (Lot number: unknown) through an unknown route in an unknown arm for prophylaxis of COVID-19 infection. The reporter stated that her daughter had an immediate anaphylactic shock after receiving the vaccine on 13-JAN-2021 in another state. The reporter''s daughter was treated with EpiPen (epinephrine) x 2 and then was transferred to an emergency room (ER) by ambulance where she was observed all day. She reports that her daughter is not allowed to get the second shot. The second dose of mRNA-1273 was discontinued in response to the event. The outcome of the event was not reported.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.

VAERS ID:	1057377 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-02-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-02-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood test, Chills, Dysstasia, Fall, Mobility decreased, Paralysis, Pyrexia, Red blood cells urine positive, Respiratory viral panel, SARS-CoV-2 test, Urine analysis abnormal, Vaccination complication, White blood cell count normal
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Chronic kidney disease (broad), Tubulointerstitial diseases (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Several anti-depressants and anti-psychotic medications
Current Illness: Covid infection 70 days before vaccination
Preexisting Conditions: Cerebral palsy with enlarged ventricles of the brain; Vaccination resulted in partial paralysis for a little more than a day, suggesting a severe neuroinflammatory response. Will not follow up with the second shot.
Allergies: None
Diagnostic Lab Data: In the ER she was tested for Covid, a UTI, respiratory disfunction. Blood was drawn and tested to detect an infection. No high white cell count. A higher level of red blood cells was found in her urine.
CDC Split Type:

Write-up: On the evening of the first vaccination, my sister experienced chills and fever. The next morning she experienced a kind of paralysis, could not sit up or stand up, was falling out of bed and out of her chair, had to be carried to the bathroom, although she usually can walk by herself. This lasted about a day. I took her to the ER where they excluded other possible causes of her condition and simiply attributed it to the vaccine. No treatment was prescribed.

VAERS ID:	1058358 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-23
Onset:	2021-02-24
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-02-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	006M20A / 2	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Abdominal distension, Aortic valve incompetence, Atrial enlargement, Back pain, Blood folate, Brain natriuretic peptide increased, Cardiac failure acute, Cardiac failure congestive, Cellulitis, Chest X-ray abnormal, Chest X-ray normal, Compression fracture, Computerised tomogram abdomen, Computerised tomogram abdomen abnormal, Computerised tomogram head normal, Computerised tomogram pelvis abnormal, Dyspnoea, Echocardiogram abnormal, Ejection fraction, Headache, Hypersensitivity, Hypoxia, Lethargy, Lung infiltration, Mental status changes, Metabolic encephalopathy, Mitral valve incompetence, Oedema peripheral, Pleural effusion, Pyrexia, Rash, Respiratory tract congestion, Right ventricular systolic pressure, SARS-CoV-2 test negative, Spinal compression fracture, Staphylococcus test positive, Thrombocytopenia, Tricuspid valve incompetence, Vaccination complication, Vitamin B12 normal, Vitamin D deficiency, Wheezing
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic thrombocytopenia (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations: COVID19 (Moderna) on 1/26/2021
Other Medications: Coumadin 3 mg PO HS, Vitamin C 1000mg PO daily, Cholecalciferol 125mcg PO daily, Lasix 10 mg PO daily, Protonix 40mg PO HS, Zincate 220(50Zn) one tablet PO daily, Pramoxine (Sarna Sensitive) 1% lotion apply topically 2 times daily after usi
Current Illness: COVID positive 12/30/2020
Preexisting Conditions: CVA (cerebral vascular accident) (CMS/HCC) o Hyperbilirubinemia o Benign prostatic hyperplasia without lower urinary t CVA (cerebral vascular accident) (CMS/HCC) o Hyperbilirubinemia o Benign prostatic hyperplasia without lower urinary tract symptoms o Hemiplegia affecting dominant side, post-stroke (CMS/HCC) o Personal history of PE (pulmonary embolism) o Calculus of proximal right ureter
Allergies: No known allergies
Diagnostic Lab Data: Allergic reaction to COVID vaccine - POA with Skin rash, wheezing, sob, improving, continue on steroid taper, continue on antihistaminics and Pepcid, continue to monitor Allergic reaction to COVID vaccine - POA with Skin rash, wheezing, sob, improving, continue on steroid taper, continue on antihistaminics and Pepcid, continue to monitor o Metabolic encephalopathy POA - multifactorial secondary to the allergic reaction, infection, acute respiratory failure in patient with history of CVA, Improving, CT head negative for acute findings, avoid sedatives and opiates, add Thiamine, normal B12 and folic acid levels o Acute on chronic diastolic CHF -POA SOB with bilateral lower limbs edema, Chest x ray and CT abdomen revealed bilateral small pleural effusion and mild congestion, BNP elevated o Likely ppt by recent steroid use o Echo done revealed EF 63%, severe Bi atrial enlargement, mild MR, AR and TR, RVSP is 23.6 o Continue on Metoprolol but switched to Toprol, switch lasix to IV o Monitor I&O, Monitor vitals, renal functions and electrolytes o Recent covid pneumonia with possible secondary bacterial infection - COVID pneumonia treated in January 2021, currently with persistent bilateral basal infiltrates, repeat COVID pcr is negative, MRSA nasal swab is positive, started on Cefazolin will continue and add Doxycycline PO o Acute Hypoxemic respiratory failure POA secondary to the above, resolving, weaning off O2, continue to monitor O2 sat o Right lower limb cellulitis POA improving, continue on Cefazolin o Thrombocytopenia likely secondary to recent COVID infection, stable and improving, will continue to monitor CBC o Vitamin D deficiency with subacute T11 and T12 superior endplate compression fracture incidental finding in the CT abdomen and pelvis, mild back pain, pain management, avoid opiates o Continue on Vitamin D supplements o H/O CVA with residual dense right hemiplegia and expressive aphasia - continue on PT/OT, continue on aspirin, Warfarin and statin o Metabo
CDC Split Type:

Write-up: 2/24/2021 admitted to hospital with hypoxia, lethargy, rash, altered mental status with HA. Altered mental status with HA, could be due to metabolic encephalopathy and reaction to COVID-19 vaccine. Will check ABG, CT head. Hold gabapentin. Check depakote level. Rash, likely due to allergic reaction to COVID-19 vaccine, hx of reaction to first COVID-19 vaccine with fever needing hospitalization. Start patient on Solu-Medrol and Pepcid. Benadryl p.r.n. Suspected right lower extremity cellulitis, start patient on Ancef. Check MRSA, will rule out right DVT Abn CXR, Bilateral LE edema, CXR seems stable to me, clinically no pneumonia. He does not have "hypoxia" when I was in room, however assisted living reporte 2/24/2021 admitted to hospital with hypoxia, lethargy, rash, altered mental status with HA. Altered mental status with HA, could be due to metabolic encephalopathy and reaction to COVID-19 vaccine. Will check ABG, CT head. Hold gabapentin. Check depakote level. Rash, likely due to allergic reaction to COVID-19 vaccine, hx of reaction to first COVID-19 vaccine with fever needing hospitalization. Start patient on Solu-Medrol and Pepcid. Benadryl p.r.n. Suspected right lower extremity cellulitis, start patient on Ancef. Check MRSA, will rule out right DVT Abn CXR, Bilateral LE edema, CXR seems stable to me, clinically no pneumonia. He does not have "hypoxia" when I was in room, however assisted living reported he was hypoxic this AM, wife said he was wheezy on Sunday could be due to acute on chronic diastolic congestive heart failure, IV Lasix x1. reeval in AM. Echo TTE is pending Abdominal pain and distension, CT abdomen without contrast to rule out other etiology that can cause altered mental status Hx of COVID-19 pneumonia, history of CVA with dense right hemiplegia and expressive aphasia, chronic atrial fibrillation, depression, Will reorder home meds after pharmacist reconciles medication list Generalized weakness, PT/OT DVT prophylaxis warfarin and SCD

VAERS ID:	1058464 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-02-08
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-02-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3248 / 1	- / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-13
Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: o Atrial fibrillation (*) o BPH (benign prostatic hyperplasia) o Cataract bilateral o COPD (chronic obstructiv
Allergies: NKA
Diagnostic Lab Data: Covid test
CDC Split Type:

Write-up: Pt tested Covid positive 2/8/2021.

VAERS ID:	1058579 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-25
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-02-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN5318 / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Body temperature increased, COVID-19, Confusional state, Fatigue, Hallucination, Malaise, SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first dose of Pfizer COVID-19 vaccine on 2/9/2021. Pt developed COVID symptoms and presented to hospital, tested positive 2/25/2021 via SARS-CoV-2 PCR NP. Symptoms: generalized fatigue and malaise, max temp 103, confusion with hallucinations, needed supplemental O2. Admitted on 2/25/2021.

VAERS ID:	1058800 (history)
Form:	Version 2.0
Age:	41.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-19
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-02-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	010M20A / 2	LA / IM

Administered by: Work Purchased by: ?
Symptoms: Brain oedema, Electrocardiogram, Electroencephalogram, Generalised tonic-clonic seizure, Magnetic resonance imaging, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Write-up: ON FEBRUARY 19,2021, PATIENT HAD A GRAND MAL SEIZURE IN THE EVENING. SHE REPORTED TO THE EMERGENCY DEPARTMENT AND THE CASE WAS DISMISSED AND SHE WAS SENT HOME. ON FEBRUARY 21, 2021, PATIENT HAD ANOTHER GRAND MAL SEIZURE AND WAS HOSPITALIZED. SHE WAS DISCHARGED ON KEPPRA 1000 MG TWICE DAILY. SHE REPORTS SHE HAS SWELLING ON THE LEFT SIDE OF HER BRAIN AND CONTINUES TO HAVE SMALLER SEIZURES WHERE SHE IS AWAKE BUT NOT RESPONSIVE.

VAERS ID:	1058963 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-02-18
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-02-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9264 / 1	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-18
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: aortic sclerosis with stenosis as well as mitral and tricuspid
Preexisting Conditions: See above
Allergies: Protonix and Piroxicam
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/182021: Witnessed cardiorespiratory arrest with PEA arrest upon EMS arrival

VAERS ID:	1062457 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-02-09
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-03-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Public Purchased by: ?
Symptoms: Angiogram abnormal, Asthenia, Blood pressure increased, Cerebral ischaemia, Chills, Cold sweat, Confusional state, Dry throat, Dysarthria, Dyspnoea, Dyspnoea exertional, Echocardiogram, Embolic cerebral infarction, Fatigue, Head discomfort, Headache, Hypoaesthesia, Magnetic resonance imaging abnormal, Magnetic resonance imaging brain abnormal, Transient ischaemic attack, Tremor
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Patient admitted for fatigue, dry throat, generalized weakness, dyspnea on exertion. Durion hospitalization was identified to have an acute ischemic CVA -- unclear time of symptom onset, possibly evening of 2/9 or morning of 2/10. Time course suspicious for possible COVID vaccine adverse event. He received his first Moderna COVID vaccine on 2/2/21 per WIR. Per PCP note on 2/9/21: Patient is here today accompanied by his wife with concerns for fatigue, headaches, head pressure and tremors. Received vaccine last Tuesday. Around 10 PM that evening he developed pressured in the head. On Wednesday morning, he states he got out of bed and was in a cold sweat - he states he pajamas were soaked in sweat and he felt chilled. He experienced brief numbness of the left arm down to his fingers. On Thursday, he felt fine - he went out to snow blow. Friday he developed headaches and head pressure. At night, he felt his breathing was labored as he was "gasping for air." On Saturday and Sunday, he sat and laid around all day. On Monday, he wakes up at 125 AM and his blood pressure was 165/104 and it remained elevated for 3 separate readings. Patient was then admitted on 2/10/21 with weakness and confusion, then on 2/11 MD noted ?word finding difficulty, slurred speech, possible subtle right upper lip droop, and possibly some mild right hemineglect? with MRI showing likely embolic source of infarcts and cerebral MRA with possible acute thrombus. His symptoms the day after the vaccine seem a bit suspicious for TIA. Per Drug Policy Manager call to Moderna, no current reports of TIA/stroke secondary to COVID vaccine, so time course may be incidental. Patient had echocardiogram without right to left shunt or clot identified, no known history of atrial fibrillation. Was monitored on telemetry for the duration of his hospitalization without any noted arrhythmias, discharged on e patch for 14-day outpatient monitoring.

VAERS ID:	1063000 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-02-27
Days after vaccination:	33
Submitted:	0000-00-00
Entered:	2021-03-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012L20A / 1	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-27
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away within 60 days of receiving a COVID vaccine

VAERS ID:	1063305 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-22
Onset:	2021-02-23
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Arthralgia, Asthenia, Fall, Mobility decreased, Troponin increased
SMQs:, Myocardial infarction (narrow), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: levothyroxine 75 MCG tablet traZODone (DESYREL) 50 MG tablet melatonin 5 MG ASPIRIN 81 PO Ferrous Sulfate (IRON PO) allopurinol (ZYLOPRIM) 300 MG tablet amLODIPine (NORVASC) 5 MG tablet dutasteride (AVODART) 0.5 MG capsule omeprazol
Current Illness: None known.
Preexisting Conditions: Benign prostatic hyperplasia with urinary obstruction Hyperactive airway disease Essential hypertension GERD Gout Insomnia secondary to depression with anxiety Depression Hypothyroidism DJD (degenerative joint disease), multiple sites Right knee DJD H/O hiatal hernia DJD (degenerative joint disease) of cervical spine Coronary Artery Disease Diverticulosis of colon Internal hemorrhoids Hyperlipidemia LDL goal < 100 Stage III chronic kidney disease (CMS/HCC) Left hip pain /Advanced DJD hip[719.45] Left shoulder pain Degenerative arthritis of left shoulder region CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min (CMS/HCC) SCC (squamous cell carcinoma), face Severe aortic stenosis LVH (left ventricular hypertrophy) History of 2019 novel coronavirus disease (COVID-19)
Allergies: Levaquin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to Medical Center on 02/23/2021 for weakness and fall. Patient had received his 1st Moderna COVID-19 vaccine on 02/22/2021. Was weak unable to rise out of the chair the next day. Patient has a history of COVID-19 in November of 2020. Patient was admitted to the hospital on 02/23/2021. Patient was ultimately diagnosed with generalized weak, right knee pain status post fall and elevated troponin level. Patient was managed conservatively and recovered over 24 hours. Patient was discharged on 02/24/2021 to follow-up.

VAERS ID:	1063882 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-21
Onset:	2021-02-23
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Acute myeloid leukaemia, Acute undifferentiated leukaemia, Alanine aminotransferase increased, Aspartate aminotransferase increased, Asthenia, Atelectasis, Biopsy bone marrow abnormal, Blood albumin normal, Blood bilirubin normal, Blood creatine phosphokinase increased, Blood creatinine normal, Blood culture positive, Blood smear test, Body temperature increased, C-reactive protein increased, Cellulitis, Chest X-ray abnormal, Computerised tomogram abdomen normal, Computerised tomogram head normal, Computerised tomogram pelvis, Cytogenetic analysis, Escherichia test positive, Groin pain, HLA marker study positive, Haemoglobin decreased, Mental status changes, Muscular weakness, Myalgia, Neutropenia, Normocytic anaemia, Oedema, Parasite blood test, Platelet count decreased, Pleural effusion, Protein total decreased, Red blood cell sedimentation rate increased, SARS-CoV-2 test negative, Scan with contrast abnormal, Staphylococcus test negative, Swelling, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Agranulocytosis (broad), Angioedema (broad), Haematopoietic cytopenias affecting more than one type of blood cell (broad), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Peripheral neuropathy (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (broad), Dementia (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteonecrosis (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Malignant lymphomas (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Haematological malignant tumours (narrow), Infective pneumonia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (broad)

Write-up: Patient is an 80 year old male who has a history of multiple medical problems, including body mass index of 30, hypertension, dyslipidemia, giant-cell arteritis on a slow prednisone taper (currently 2 mg daily), past pulmonary embolism on warfarin, sleep apnea, history of diverticulitis (treated in August 2020), past abdominal surgeries (including umbilical hernia repair ?2 and open recurrent incarcerated epigastric hernia repair with mesh in October 2020), chronic anemia, and type-2 diabetes. The patient had received the first dose of the COVID-19 (SARS-CoV-2) vaccine on January 31, 2021 and the second dose on February 21. He presented to his primary care provider?s office on February 22, 2021 with complaints of 10 days of progressive weakness and muscle soreness. The weakness had reportedly involved the bilateral thighs and arms and was associated with muscle aches. Blood pressure measured 90/40 mmHg and examination was notable for symmetrical proximal weakness in the upper and lower extremities. The peripheral blood leukocyte count measured 3.5 x10e3/?L, hemoglobin 8.3 grams per deciliter and platelets 147 x10e3/?L. A peripheral blood smear was consistent with neutropenia and normocytic anemia with 9% circulating blasts. Total CK measured 1424 U/L. The patient was referred to hematology/oncology and rheumatology and had appointment scheduled for both on February 26. With the above background, he presented to emergency room on February 24 with altered mental status and continued weakness. He was taken to the hospital by emergency medical services. A temperature of 103 degrees Fahrenheit was recorded when emergency medical personnel had arrived. The peripheral blood leukocyte count was 1.4 x10e3/?L for an ANC of 0.8 x10e3/?L. Hemoglobin was 8.1 g/dL and platelets 111 x10e3/?L. A few schistocytes and teardrop cells were noted. The serum creatinine was 1.47 mg/dL. AST was 174, ALT 91 and alkaline phosphatase 93 U/L. The lactic acid level of the venous blood was 2.1 mmol per liter. A repeat total CK was 4631 U/L. Sedimentation rate measured 34 mm/h and CRP 52.3 mg/L. Urinalysis showed 0-2 wbc?s/hpf, 0-2 rbc?s/hpf, 3+ blood, negative nitrites, negative leukocyte esterase. A haptoglobin level of the blood was within normal limits. The lactic acid level of the venous blood was 2.0 mmol/L. LDH measured 838 U/L. A ferritin level was 3464 nanograms/mL. A test for COVID-19 (SARS-CoV-2) was negative. A chest radiograph showed minimal streaky right basilar atelectasis, trace left effusion and a mildly enlarged cardiac silhouette. A head CT showed no acute abnormality. An abdominopelvic CT without contrast was limited by motion artifact. No acute intra-abdominal or pelvic finding was noted. Nonspecific soft tissue stranding was seen in the right inguinal region. There was no soft tissue gas or drainable fluid collection. Cultures of specimens of the blood were obtained. The patient was started on empiric cefepime, vancomycin and doxycycline and admitted for further care. A peripheral blood smear for intracellular parasites was negative. The admission blood cultures came back positive for E. coli. With the blood culture results, the vancomycin and doxycycline were discontinued. The E. coli isolate has since been determined to be pansusceptible. A MRSA PCR of the nares was negative. He was found on exam to have swelling, cellulitis and exquisite pain of the right groin area on February 25. Surgical consultation was pursued. They did not feel that he had necrotizing fasciitis. The CT scan of the abdomen and pelvis was repeated with contrast, revealing increased extensive subcutaneous edema of the right groin region with extension into the thigh musculature and mild extension into the right inferior pelvis. There was no associated soft tissue gas or drainable abscess. A bone marrow biopsy was performed February 25. Results showed acute undifferentiated leukemia with 60-70% infiltration of the bone marrow with blasts. The blasts were negative for lineage markers. He was faintly CD33 positive. He is felt to likely have acute myeloid leukemia. Cytogenetics are pending.

VAERS ID:	1063984 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-20
Onset:	2021-02-21
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal distension, Alanine aminotransferase normal, Arrhythmia, Arteriosclerosis coronary artery, Ascites, Aspartate aminotransferase increased, Atrial fibrillation, Bacteraemia, Blister, Blood creatine phosphokinase increased, Blood creatinine normal, Blood culture, Blood lactate dehydrogenase increased, Blood lactic acid decreased, Blood pH increased, Breath sounds normal, C-reactive protein increased, Cellulitis, Chest X-ray abnormal, Cholelithiasis, Computerised tomogram, Computerised tomogram abdomen abnormal, Computerised tomogram abdomen normal, Computerised tomogram pelvis, Computerised tomogram thorax normal, Condition aggravated, Crystal urine, Culture, Culture urine positive, Diarrhoea, Dyslipidaemia, Dyspnoea, Ecchymosis, Echocardiogram, Electrocardiogram abnormal, Erythema, Fat tissue increased, Hypertension, Hypotension, Hypothyroidism, Immunoglobulin therapy, Immunoglobulins decreased, Inappropriate schedule of product administration, Intensive care, Lymphoma, Myalgia, Myositis, Nephrolithiasis, Neutrophil count, Nitrite urine absent, Oedema peripheral, Pain, Pain in extremity, Peripheral swelling, Plantar erythema, Platelet count, Platelet count decreased, Procalcitonin increased, Pyrexia, Rash, Rash erythematous, Rash macular, Respiratory distress, Respiratory rate increased, Scan with contrast, Skin warm, Staphylococcal sepsis, Tachycardia, Tachypnoea, Tenderness, Thrombocytopenia, Troponin increased, Urinary casts, Urinary nitrogen increased, Urine analysis abnormal, Vomiting, White blood cell count, X-ray limb abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Severe cutaneous adverse reactions (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Dyslipidaemia (narrow), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Gallbladder related disorders (narrow), Gallstone related disorders (narrow), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypothyroidism (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Other ischaemic heart disease (narrow), Lipodystrophy (broad), Osteonecrosis (broad), Hypersensitivity (narrow), Malignant lymphomas (narrow), Noninfectious diarrhoea (narrow), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Haematological malignant tumours (narrow), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: ? acetaminophen (TYLENOL) 500 MG tablet Take 500 mg by mouth every 4 hours as needed for Fever or Pain Maximum allowable Acetaminophen amount = 4 Grams (4000 mg) / 24 hours. ? ? ? acyclovir (ZOVIRAX) 400 MG tablet TAKE 1 TAB TWICE DAILY 60
Current Illness: none
Preexisting Conditions: PAST MEDICAL HISTORY: Hypertension, dyslipidemia, hypothyroidism, follicular lymphoma, past DVT, past PE, history of colonic polyps, nephrolithiasis, osteopenia. ? PAST SURGICAL HISTORY: Tonsillectomy, left carpal tunnel release, hysteroscopy ?2, thyroidectomy, D&C, colonic polyp removal, bone marrow biopsy ?2, cervical lymph node excision, tailbone excision, laser therapy of left retinal tear.
Allergies: hydrocodone - severe restless legs
Diagnostic Lab Data: Imaging Xr Tibia Fibula Right 2vw Result Date: 2/25/2021 Reading Radiologist - Releasing Radiologist - Dictation Date Time - 02/25/2021 13:02 CST Signed Date Time - 02/25/2021 13:04 CST Transcriptionist - NA ? Ct Lower Ext Right W Contrast Result Date: 2/25/2021 IMPRESSION: 1. Extensive edema about the subcutaneous tissues of the right lower leg and infiltration of the fat about the muscles of the right lower leg, which in this clinical setting likely represents cellulitis and fasciitis, and possible myositis. However, there is no air within the subcutaneous tissues or muscles to suggest necrotizing fasciitis. No evidence of abscess. 2. Mild right knee joint effusion and moderate degenerative changes of the right knee. See the Radiology Information System for this patient for the contrast type and quantity. Report called to Dr. Reading Radiologist - Releasing Radiologist - Dictation Date Time - 02/25/2021 17:12 CST Signed Date Time - 02/25/2021 19:43 CST Transcriptionist - ? Ct Abdomen Pelvis W Contrast Result Date: 2/26/2021 IMPRESSION: 1. Small amount of free fluid in the abdomen around the liver. 2. Cholelithiasis with no evidence of acute cholecystitis or biliary dilatation. 3. Nonobstructing 5 mm stone of the mid pole of the left kidney. 4. Coronary artery calcifications. 5. Mild infiltration of the fat in the inferior retroperitoneum and along the right common iliac region with small nodes in this region, similar compared with 9/24/2020, but improved compared with 4/30/2020, consistent with response of lymphoma to chemotherapy. 6. Foley catheter balloon within decompressed urinary bladder. 7. Myomatous uterus, including small calcified fibroids. Report called to Dr. See the Radiology Information System for this patient for the contrast type and quantity. Reading Radiologist - Releasing Radiologist - Dictation Date Time - 02/25/2021 17:14 CST Signed Date Time - 02/26/2021 08:22 CST Transcriptionist - ? Xr Chest 1vw Portable Result Date: 2/25/2021 IMPRESSION: Status post placement of a right internal jugular line. The tip is at the junction of the superior vena cava and right atrium. No pneumothorax is seen. There has been no other change. Reading Radiologist - Releasing Radiologist - Dictation Date Time - 02/25/2021 18:54 CST Signed Date Time - 02/25/2021 18:56 CST Transcriptionist - NA ? Xr Chest 1vw Portable Result Date: 2/25/2021 IMPRESSION: Possible, but not definite, mild atelectasis or infiltrate at the left lung base. Reading Radiologist - Releasing Radiologist - Dictation Date Time - 02/25/2021 10:49 CST Signed Date Time - 02/25/2021 10:54 CST Transcriptionist - NA ? Xr Abd Obstr Series W Chest 1vw Result Date: 2/25/2021 IMPRESSION: 1. Air-filled distended loops of large and small bowel, most likely representing ileus, although distal colonic obstruction is also possible. CT of the abdomen and pelvis could be performed if further assessment is felt clinically warranted. 2. Probable minor left basilar atelectasis. Otherwise no evidence of acute chest disease. Reading Radiologist - Releasing Radiologist - Dictation Date Time - 02/25/2021 16:32 CST Signed Date Time - 02/25/2021 18:38 CST Transcriptionist - LABS: 3/1/21 CK 504, WBC 2.3, hemoglobin 9.4, platelets 37, absolute neutrophils 1.59, absolute lymphocytes 0.14, metamyelocytes 12%, myelocytes 6%, BUN 39, creat 0.74, AST 46, ALT <5, alk pho 54, albumin 1.7, calcium 7.6 CK was 1067 on 2/28/21 and peaked at 6,085 on 2/26/21.
CDC Split Type:

Write-up: Patient had her second COVID vaccine on 2/20/21. The next day she developed diffuse body aches. She went on to develop worsening dyspnea and fever to 103?F on February 23. She had a fever again on February 24. The patient also experienced a few episodes of vomiting and diarrhea but no abdominal pain and had pain of the legs, right greater than left. Blotchy red patches of the hands and arms developed. She therefore presented to the ER on 2/25/21. See full history below from infectious disease note on 3/1/21: Patient is an 80 year old female who has a past medical history notable for hypertension, dyslipidemia, and hypothyroidism. The patient was diagnosed with a high-grade lymphoma of the retroperitoneum in 2004 and completed 4 cycles of multi-chemotherapy (Cytoxan, Adriamycin, vincristine, methotrexate, and IT chemotherapy (Magrath-like regimen)). She completed 4 cycles with complete remission on PET scan. The biopsy of a left cervical lymph node in 2007 revealed follicular lymphoma and she completed radiation therapy to the neck with complete remission. A left axillary lymph node biopsy in 2016 revealed grade-3 follicular lymphoma with mixed follicular and diffuse histology. Chemotherapy was pursued. The biopsy of a pelvic lymph node in 2019 was consistent with G1-2 follicular lymphoma. ?She completed radiation to the pelvis in May of 2019. ?She developed progressive pelvic adenopathy in April of 2020 and received 5 cycles of chemotherapy. Subsequent CT showed improvement in the adenopathy. ?Her course was complicated by pulmonary emboli (September 2020). ?In November of 2020 she was started on maintenance Rituxan every 2 months. ?She received the 2-dose Pfizer COVID vaccine series on 1/29/21 and 2/20/21. With the above background, the patient presented to the emergency room on February 25, 2021 with complaints of diffuse body aches, which had developed that day after receiving her second dose of COVID-19 (SARS-CoV-2) vaccine. ?She went on to develop worsening dyspnea and fever to 103?F on February 23. ?She had a fever again on February 24. The patient also experienced a few episodes of vomiting and diarrhea but no abdominal pain and had pain of the legs, right greater than left. Blotchy red patches of the hands and arms developed. ?She called Oncology on February 20 and it was recommended that she go to the emergency room for evaluation. ? She was afebrile on presentation to the emergency room. ?She was tachycardic, however, with a pulse rate of 117 bpm. ?She was breathing at 48 breaths per minute. ?Blood pressure was 105/80 mmHg. ?Oxygen saturation by pulse oximetry was 96%. Examination was notable for paraspinous muscle tenderness, tachypnea, mild respiratory distress, and a mildly distended abdomen. ?Mild erythematous patches of the feet and forearm were noted, as well as evidence of edema of the right leg from the knee to the lower leg. The peripheral blood leukocyte count measured 0.8x10e3/?L. ?ANC was 0.48x10e3/?L. ?Platelets measured 96x10e3/?L. ?Creatinine was 0.97 mg/dL. ?AST was 86 and ALT 20 U/L. The lactic acid level of the venous blood was 3.6 mmol/L. The procalcitonin level of the blood measured 28.37 ng/mL. The C-reactive protein level was 313.7 mg/deciliter. The creatine kinase (CK) level was 4023 U/L. ?LDH measured 314 U/L. Troponin was 3.22 ng/mL. ?Urinalysis showed 6-10 wbc?s, 0-2 rbc?s/hpf, 3+ blood, negative nitrites, hyaline and granular casts as well as amorphus crystals. A chest radiograph showed possible, but not definite, mild atelectasis or infiltrate at the left lung base. ?A radiograph of the right tibia/fibula showed circumferential soft tissue edema seen within the knee and upper to mid aspect of the lower leg. ?EKG showed sinus tachycardia but no evidence of arrhythmia or ischemia. Cultures of specimens of the blood were obtained. ?The patient was started empirically on vancomycin and cefepime and was admitted. ? Faint erythema and ecchymosis of the right leg extending to the dorsal right foot and right wrist erythema were noted following the patient?s admission. ?Her condition subsequently destabilized with increased respiratory rate, worsening pain, and hypotension, so she was transferred to the ICU. An abdominopelvic CT on February 25 revealed a small amount of free fluid in the abdomen around the liver, cholelithiasis with no evidence of acute cholecystitis or biliary dilatation, a nonobstructing 5-mm stone of the mid pole of the left kidney, coronary artery calcifications, mild infiltration of the fat in the inferior retroperitoneum and along the right common iliac region with small nodes in this region, similar compared with September 24, 2020, but improved compared with April 30, 2020, and consistent with response of lymphoma to chemotherapy; a myomatous uterus. A CT scan of the right lower extremity showed extensive edema about the subcutaneous tissues of the right lower leg and infiltration of the fat about the muscles of the right lower leg, likely representing cellulitis and fasciitis, and possible myositis. However, there was no air within the subcutaneous tissues or muscles to suggest necrotizing fasciitis and no evidence of abscess. ? ? The patient?s antibiotic treatment was later changed to vancomycin, piperacillin-tazobactam and clindamycin. Cultures of specimens of the blood were later reported as being positive for methicillin-susceptible Staphylococcus aureus on 2/2 sets. Repeat blood cultures (February 26) were positive as well. Her antibiotics were modified to cefazolin monotherapy. Repeat blood cultures on Feb 27 and 28 were negative. ? TTE completed 2/27/21 without obvious vegetation. ? TODAY (3/1/21): Cultures negative 2/27 and 2/28. Remains on IVIG. Afebrile. She complaints of continued pain in the Right leg and swelling at that left arm. Exam GENERAL: NAD EYES: Sclera and conjunctiva clear NECK: no adenopathy LUNGS: Breath sounds normal and symmetric. No rales or wheezes. HEART: regular rhythm, no murmur appreciated ABDOMEN: Soft without mass, tenderness, organomegaly or hernia. EXTREMITIES: RLE with ecchymosis, slight overlying erythema and anterior blister: blistering more pronounced today. left foot with plantar erythema, some tenderness today. LUE fullness with some heat/tenderness SKIN: No other rashes or other abnormalities are noted. NEUROLOGICAL: alert, appropriate Assessment 1. MSSA septicemia with shock. Positive blood cultures 2/25 and 2/26 thus far. Negative since 2/27. 2. Multifocal cellulitis and interstitial infective myositis of LE- suspect related to above. CT scan was negative for apparent necrotizing infection. 3. Elevated CK due to above- improving 4. Recurrent lymphoma- has been on maintenance rituximab (11/2020). Immunocompromised state. 5. Low immunoglobulins- remains on IVIG 6. Positive urine cultures with Staph aureus- this is typically secondary seeding from bacteremia rather than primary staph uti. CT abd/pelvis negative for nidus of infection along GU track (no renal abscess for example) 7. LUE swelling/tenderness. ? Plan 1. Cont Cefazolin without change: goal dosing 8gm/24hr 2. Following repeat blood cultures, negative thus far (tentative D0= 2/27/21) 3. Pending course, anticipate likely TEE--- $g presently precluded due to thrombocytopenia 4. Will obtained LUE doppler for completeness given pain/swelling here. Down the line, may need to consider additional imaging (CT?) if concern for abscess, etc). 5. ID will follow along with you. Please call if any questions/concerns. Patient is still admitted, and is in the ICU.

VAERS ID:	1067404 (history)
Form:	Version 2.0
Age:	41.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-08
Onset:	2021-01-27
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-03-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Dyskinesia, Dysphemia, Erythema, Fatigue, Hypoaesthesia, Laboratory test normal, Magnetic resonance imaging normal, Muscle spasms, Muscular weakness, Peripheral swelling, Pruritus, Skin warm, Tenderness, Tremor
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Dyskinesia (narrow), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: Red, warm, swollen, tender on arm for 2 weeks. Went in on 1/14/21 for muscle weakness, numbness, and muscle spasms. Stuttering verbally started 1/27/21 and has not stopped. Muscle spasms, muscle weakness and fatigue have increased drastically from date of injection til now, tremors all over in the body, when laying down to rest extremities at different times will involuntary jump. Had itching all over with no rash since 2nd week in February.

VAERS ID:	1068751 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-02-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012M20A / 1	LA / OT

Administered by: Unknown Purchased by: ?
Symptoms: Cardiac stress test, Chest discomfort, Electrocardiogram, Myocardial necrosis marker, Vaccination site pain, Vaccination site warmth
SMQs:, Anaphylactic reaction (broad)

Write-up: Pressure between shoulder blades. It went away then started again on carotid then down arm; Sore arm; hot feeling initially; A spontaneous report was received from a consumer, who was a 66-year-old, female patient who received Moderna''s COVID-19 vaccine and who experienced a serious adverse event of chest discomfort requiring hospitalization (reported as: "heart attack like symptoms, pressure between shoulder blades that went away and then started again on her carotid then down her arm" and in addition non-serious events of sore arm, and hot feeling. The patient''s medical history included borderline type 2 diabetes and allergies to adhesive tape, bleach and chlorine. Concomitant product use was not provided. The patient received her first of two planned doses of mRNA-1273 (LOT 012M20A) on 05-Feb-2021 intramuscularly in the left arm for prophylaxis of COVID-19 infection. Initially on 05-Feb-2021, patient experienced a sore arm that was warm to the touch. However, on 15-Feb-2021, she reported having had heart attack-like symptoms. She stated that it started as pressure between shoulder blades that initially went away and then started again on her carotid and travelled down her arm. She thought it was from loading wood. The patient then went to Emergency Room (ER) where she received a nitro pill which alleviated the pain. The EKG, cardiac enzyme tests, nuclear imaging and stress test were all negative according to the patient''s report. She reported having been hospitalized for 2 days. Treatment for the event included a nitroglycerin tablet. Action taken with mRNA-1273 in response to the events was not provided. The outcome of the events, sore arm, hot feeling initially, heart attack like symptoms, pressure between shoulder blades that went away and then started again on her carotid then down her arm, was not reported.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship for events cannot be excluded.

VAERS ID:	1069619 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-02-27
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Anaphylactic shock, Nasal congestion
SMQs:, Anaphylactic reaction (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (narrow)

Write-up: Around 9:55 pm on 2/27/2021 client took Afrin nasal spray for nasal congestion. About 5 minutes later (10:00 pm) client states he went into anaphylactic shock. The ambulance was called by his wife. Per client, her received infusions of epi and Benadryl from ambulance staff. Client was taken to Hospital for further treatment. He was subsequently transferred to Heart Hospital for overnight observation due to possible heart issues. Note: Client has take Afrin nasal spray for over 30 years and has never had a reaction.

VAERS ID:	1071498 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-03
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	02&A21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Chest X-ray abnormal, Dysstasia, Fall, Pneumonia
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Write-up: patient became progressively weak after vaccination, fell at home and was unable to get up

VAERS ID:	1071969 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-11
Onset:	2021-01-15
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-03-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025320-2A / 1	RA / IM

Administered by: Military Purchased by: ?
Symptoms: Angiogram cerebral normal, Angiogram normal, Computerised tomogram head abnormal, Exertional headache, Full blood count normal, Hyperlipidaemia, Intensive care, Lipids abnormal, Lumbar puncture normal, Nausea, Primary headache associated with sexual activity, Prothrombin level normal, Prothrombin time normal, Reversible cerebral vasoconstriction syndrome, Subarachnoid haemorrhage
SMQs:, Acute pancreatitis (broad), Dyslipidaemia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Lipodystrophy (broad), Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (broad)

Write-up: Headache and nausea starting 5:30am 15 Jan with exertion. Same symptoms on 16 Jan, 17, and 21 Jan with sexual activity. BP started to be in 150-160/110 range (used home BP cuff) on 19 Jan. No neurological deficits. Presented to ER on 21 Jan with c/o headache an d nausea. BP was 160+/110+. CT scan showed SAH. Transferred to hospital for eval. Was in neurosciences ICU x 1 night and neuro ward x 2 nights. Discharged on 24 Jan. DSA and MRA showed no AVM or aneurysm. LP showed no inflammatory or infectious process. CBC WNL. PT/PTT WNL. Lipids showed hyperlipidemia. Working diagnosis is Reversible Cerebral Vasoconstriction Syndrome.

VAERS ID:	1072982 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-14
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-03-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Chest pain, Computerised tomogram thorax abnormal, Condition aggravated, Dyspnoea, Electrocardiogram, Electrocardiogram abnormal, Fat necrosis, Inappropriate schedule of product administration, Myocardial necrosis, Pain, Scan with contrast abnormal
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Medication errors (narrow)

Write-up: between the first dose on 1/20/21 a week later I experience pain under my left rib cage and trouble catching my breath which I thought was due to shoveling heavy snow, then received my 2nd dose on 2/9/21 and on 2/14/21 I couldn''t breathe and pain was so intense and went to Hospital at 9:30 PM and stayed overnight

VAERS ID:	1073047 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-03
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	13A21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram, Angiogram pulmonary normal, Bradycardia, Computerised tomogram head normal, Continuous positive airway pressure, Electrocardiogram abnormal, Electrocardiogram normal, Peripheral swelling, Pulmonary hypertension, Sinus node dysfunction, Troponin increased, Unresponsive to stimuli
SMQs:, Cardiac failure (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Disorders of sinus node function (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Write-up: Patient recieved 2nd dose COVID vaccine and had unresponsive episode in car after monitoring period, staff assessed in car and patient had recovered, staff encouraged family to take to ED for evaluation. From ER MDs note: EKG was normal sinus rhythm, narrow QRS, delayed transition, minimal lateral st depression V4. Patient IV access on arrival, would Brady down to the 40s 1 time as low as 27 but remained alert, blood pressure is not dip. Troponin was mildly elevated and decision was made to transfer the patient. Prior to transfer is necessary to rule out pulmonary embolism, intracranial injury Patient wished to proceed with CT angio chest and noncontrast CT of head which were without acute findings. Patient given aspirin 81 mg to supplement the 81 mg he had earlier today. Discussed with hospitalist, patient was accepted in transfer. Suspect this is combination of patient''s beta blockade with underlying sinus node dysfunction. Patient does have prominent lower extremity swelling and suspect pulmonary hypertension despite treatment with CPAP but cannot exclude valvular heart disease. Patient was went to Hospital. Symptoms thought to be unlikely from seizure. Doubt CVA, ongoing cardiac ischemia.

VAERS ID:	1073060 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-25
Onset:	2021-02-27
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Chills, Confusional state, Fatigue, Laboratory test abnormal, Vomiting, Weight bearing difficulty
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: She had weakness to the point she wasn''t able to bear weight on her extremities, confusion, chills, emesis,and fatigue. She was sent to ER @ Hospital. Continues with confusion and weakness as of 3/4/2021.

VAERS ID:	1075247 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-12
Onset:	2021-02-12
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / OT

Administered by: Unknown Purchased by: ?
Symptoms: Deep vein thrombosis, Dyspnoea, Pulmonary embolism, Sluggishness, Ultrasound Doppler, Vaccination site pain
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad)

Write-up: Deep vein thrombosis left calf; Difficulty breathing; Pulmonary Embolism; Felt doggy, sluggish, punky; Arm hurt; A spontaneous report was received from a nurse concerning a 54-year-old, male patient who experienced pulmonary embolism, deep vein thrombosis, vaccination site pain, sluggishness and dyspnoea. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. On 12-Feb-2021, approximately 2 days prior to the onset of the symptoms, the patient received their first of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly in the left arm for prophylaxis of COVID-19 infection. The patient received his vaccine on 12-Feb-2021 and reported that his arm hurt a little for a few days. On 14-Feb2021, he reported that he started feeling sluggish and on 20-Feb-2021 he began to have difficulty breathing and pain in the right lower base of rib cage. He went to urgent care where he was diagnosed with a pulmonary embolism for which he received treatment. On the evening of the same day, he again started having difficulty breathing with pain upon inhalation. He returned to urgent care and was subsequently admitted at 12:30 AM on 21-Feb-2021. That Monday, 22-Feb-2021, a doppler ultrasound revealed a deep vein thrombosis in the left calf. Patient was treated with heparin intravenously (IV). He was discharged 22-Feb-2021. Treatment for the event included Xarelto 20mg twice per day for two weeks and Heparin IV. Action taken with mRNA-1273 in response to the events was not provided/unknown. The outcome of the events, pulmonary embolism, deep vein thrombosis and dyspnea, was considered recovering/resolving as of discharge on 22-Feb-2021. The outcome of the events, vaccination site pain and sluggishness, were considered recovered/resolved.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.

VAERS ID:	1075318 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-02-27
Submitted:	0000-00-00
Entered:	2021-03-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Brain stem infarction
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Write-up: Patient admitted to hospital pontine stroke following day.

VAERS ID:	1075597 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-04
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, C-reactive protein increased, Condition aggravated
SMQs:, Guillain-Barre syndrome (broad)

Write-up: Patient had generalized weakness event, similar to MS exacerbation. It lasted approximately 24 hours, rapid recovery after overnight admission to the hospital.

VAERS ID:	1075657 (history)
Form:	Version 2.0
Age:	94.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-01
Onset:	2021-03-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043L20A / 2	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Back pain, Condition aggravated, Death
SMQs:, Retroperitoneal fibrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-04
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650MG BID, Eliquis 2.5MG BID, Furosemide 20MG BID, Morphine 5MG every 2 hours as needed, Potassium Chloride 10 mEq daily, Spironolactone 12.5MG daily, Zolpidem 5MG daily
Current Illness: Currently on Hospice
Preexisting Conditions: Personal history of COVID-19, Acute combined systolic (congestive) and diastolic (congestive) heart failure, Other specified diseases of liver, Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity, Other pulmonary embolism without acute cor pulmonale, Cardiomyopathy, unspecified, Coronary angioplasty status, Essential (primary) hypertension, Hyperlipidemia, unspecified, Age-related osteoporosis without current pathological fracture, Edema, unspecified, Chronic kidney disease, stage 3 (moderate), Anemia, unspecified Note: Acute chronic, Constipation, unspecified, Unspecified fracture of shaft of right fibula, initial encounter for closed fracture, Unspecified sensorineural hearing loss, Syncope and collapse, Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture, Zoster without complications (History of), Acute respiratory failure with hypoxia, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, Peripheral vascular disease, unspecified, Cerebrovascular disease, unspecified Nonrheumatic aortic (valve) stenosis Atherosclerotic heart disease of native coronary artery without angina pectoris Nonrheumatic aortic (valve) insufficiency Alzheimer''s disease, unspecified
Allergies: Penicillin
Diagnostic Lab Data: Death on 03/04/2020 but was on Hospice
CDC Split Type:

Write-up: Resident was having back pain but did have previous back pain prior too.

VAERS ID:	1075725 (history)
Form:	Version 2.0
Age:	99.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-01
Onset:	2021-03-02
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043L20A / UNK	- / -

Administered by: Senior Living Purchased by: ?
Symptoms: Chest pain, Decreased appetite, Fluid intake reduced, Lethargy
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-04
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bumetanide 2 MG daily, Metoprolol 25 MG daily, Morphine 4 MG daily plus every hour as needed, Nitroglycerin 0.4 MG PRN, Ondansetron 4 MG BID,
Current Illness:
Preexisting Conditions: Anemia, unspecified, Transient cerebral ischemic attack, unspecified, Malignant neoplasm of esophagus, unspecified, Acute pyelonephritis Muscle weakness (generalized) Lack of physical exercise Unspecified systolic (congestive) heart failure Chronic kidney disease, stage 3 (moderate) Atherosclerotic heart disease of native coronary artery without angina pectoris Unspecified osteoarthritis, unspecified site Essential (primary) hypertension Hyperlipidemia, unspecified Vitamin B12 deficiency anemia, unspecified Gastro-esophageal reflux disease without esophagitis Presence of cardiac pacemaker Barrett''s esophagus with high grade dysplasia Abdominal aortic aneurysm, without rupture Congenital malformations of other endocrine glands Cerebral infarction, unspecified Idiopathic gout, unspecified site
Allergies: Amoxicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident started have chest pain on 3/02 and on 03/03 he was lethargic and wasn''t eating or drinking Resident was on Hospice

VAERS ID:	1077758 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-01
Onset:	2021-03-02
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	AR / IM

Administered by: Private Purchased by: ?
Symptoms: Amnesia, Anaemia, Atrial fibrillation, Confusional state, Disorientation, Dyspnoea, Fear, Renal impairment, Somnolence
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Per neurology consult: "Patient was at his baseline until when he received his 2nd dose of SARS-CoV-2 vaccination. He complained of dyspnea and fear of impending doom after waking up the following morning with some disorientation. He was found to be in AFib with RVR after it was brought to ER the following morning and the rhythm was converted to normal sinus rhythm. Patient continues to have confusion after admission yesterday that seem to get worse today to the point where he did not know his own name or birthdate, and seemed to have global amnesia. Patient has been more drowsy this afternoon after receiving lorazepam 1 mg IV for potential seizure activity so no reliable neurologic exam was obtained. Patient remains afebrile with pulse ox in the low 90s on 4 L of supplemental nasal oxygen in the hospital. He had moderate decrease in kidney function upon admission that has improved. He has baseline anemia with hemoglobin at around 10. Incidentally patient had shingles in the right thoracic dermatome week ago for which he received valacyclovir.

VAERS ID:	1082968 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-01-25
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EK9231 / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Aphasia, Hemiparesis
SMQs:, Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Write-up: could not speak; weak in right side; This is a spontaneous report from a contactable consumer (reporting for himself). A 75-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection; lot number EK9231) via an unspecified route of administration, on 25Jan2021 13:00, single dose for COVID-19 immunization. Relevant medical history included subdural hematoma in 2019 (2 years prior), epilepsy, Hyperlipidemia in 2002, Hypertension in 2007, Thyroid disease, appendectomy in 1955, brain surgery (outside of the brain) in 1985, bypass graft femoral to femoral to support R leg blood flow, & Peripheral vascular disease. Concomitant medications were not reported. The patient did not receive other vaccines in the last 4 weeks. The patient was not diagnosed with COVID prior vaccination. On 25Jan2021, at 16:15, the patient was found by a tenant in the car with engine running, could not speak and weak in right side. The patient was taken right away to ER for which the patient as subsequently admitted in the hospital on 25Jan2021 and was discharged on 26Jan2021 (1 day). It was unknown if the patient received treatment in response to the event. The patient was not tested for COVID post vaccination. Outcome was recovered on an unspecified date.

VAERS ID:	1083103 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-03-03
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-03-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9264 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Blood calcium decreased, Blood sodium decreased, COVID-19, Dehydration, Diarrhoea, Full blood count, Hyponatraemia, Metabolic function test, Nausea, SARS-CoV-2 test positive, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Infective pneumonia (broad), Dehydration (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient was admitted to hospital on 3/3/21 for weakness and dehydration. Had presented to ED with nausea, vomiting, and diarrhea for 3 days. Tested COVID 19 positive. Found to be hyponatremic. Was treated with IV fluids. Discharged on 3/6/21. Follow labs on 3/8/21.

VAERS ID:	1085302 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-03-01
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-03-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Acute respiratory failure, Blood glucose increased, Cardiac failure acute, Death, Mechanical ventilation, Metabolic encephalopathy
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg oral tablet Atorvastatin Calcium 80 MG Oral Tablet Empagliflozin (Jardiance) 10 MG Oral Tablet Fiber FluoGlimepiride 4 MG Oral Tablet Propranolol HCl (Propranolol HCl ER) 60 MG Oral Capsule Extended Release 24 Hour Sitagliptin
Current Illness:
Preexisting Conditions: Diabetes, Hyperlipidemia, Hypertension, Hyperpotassemia, Chronic Kidney Disease, Tremors
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to Hospital on 3/1/21. Blood Sugar of 758. Patient diagnosis with Acute respiratory failure with hypoxia and acute heart failure and Metabolic encephalopathy. Patient put on ventilator and passed away on 3/2/21 at 17:04.

VAERS ID:	1085452 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-23
Onset:	2021-02-26
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-03-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / SYR

Administered by: Private Purchased by: ?
Symptoms: Cardiac failure, Dyspnoea, Respiratory failure
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Write-up: SOB a few days after vaccination; one week later, new onset of acute exacerbation of HFrEF with subsequent respiratory failure and hospitalization

VAERS ID:	1085854 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-03-06
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	13A21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Atrial fibrillation, Bilevel positive airway pressure, Chest X-ray abnormal, Dyspnoea, Emotional distress, Fatigue, Feeling hot, Hypoxia, Laboratory test, Nausea, Pneumonia, Tachycardia
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Depression (excl suicide and self injury) (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad)

Write-up: Received 2nd COVID 19 vaccine 3/4/21. On 3/5/21, was tired, but otherwise did okay. On morning of 3/6/21, she awoke short of breath, felt hot, was a little nauseated, and did not take her medication. She has gradually grown more short of breath and distressed since then. She appears weak, distressed with tachycardia and hypoxemia. Bilateral pneumonia seen on xray. She arrived to the ED in A-fib with RVR HR 150''s. O2 90% on 12L NRB. After IV access was obtained and labs drawn patient was transitioned to BiPAP setting 10/5 and 30% per MD at 1300. Her saturations were not maintaining above 90% and O2 was titrated up to achieve a O2 % $g 90. She was given a loading dose of Diltiazem per protocol and started on a DilIazemt gtt, the drip was titrated up to max 15 to achieve target HR <100. Her BP remained stable during this course. She received a bolus of NS. 1 gram of Tylenol via IV. 1 gram of Rocephin infusing upon transfer. D5LR infusing at 200 upon transfer.During her course in the ED she was able to communicate with staff when asked questions.

VAERS ID:	1087965 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-06
Onset:	2021-01-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	037K20A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Eye irritation, Headache, Herpes zoster, Rash
SMQs:, Anaphylactic reaction (broad), Corneal disorders (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Opportunistic infections (broad)

Write-up: On Thurs I start exp headache. Then on Saturday I developed a rash on my right side of forehead. I exp irritation to my eye was referred to Ophthalmologist. I went to the Urgent Care was diagnosed with Shingles.

VAERS ID:	1088516 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-08
Onset:	2021-03-09
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 2	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Cough, Mental status changes, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: hospitalization for cough, fever and acute change in mental status

VAERS ID:	1089536 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-12
Onset:	2021-02-15
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-03-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	006M20A / 1	AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-15
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, CoQ10, fish oil, hydrochlorothiazide, lovastatin, multivitamin, saw palmetto, vitamin d3
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA Heart attack Death

VAERS ID:	1091448 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-06
Onset:	2021-03-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Decreased appetite, Diarrhoea, Fatigue, Nausea
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Write-up: patient started feeling adverse effects on 3/7/2021, day after vaccination. She reports being nauseous, appetite loss, fatigue, no fever and having diarrhea. She had the corona virus 19 in November and was hospitalized. We recommended to take loperamide for the diarrhea or Pepto-bismol and emetrol or nauzene for nausea. She wanted to go to urgent care which we said is a good idea.

VAERS ID:	1091538 (history)
Form:	Version 2.0
Age:	94.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-11
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	UN / UN

Administered by: Private Purchased by: ?
Symptoms: Arrhythmia, Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-11
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clopidogrel, Novolog, Lantus, Isosorbide, Losartan-HCTZ, Atorvastatin, Omeprazole, Furosemide
Current Illness:
Preexisting Conditions: Diabetes, hypertension, high cholesterol, gastroesophageal reflux disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: According to his daughter, patient did not appear to have any ill effects from his second COVID-19 vaccine on 03/09/2021. However, on 03/11/2021, he suffered what is suspected to be a fatal arrhythmia/myocardial infarction. It is unknown if there is any correlation to the vaccine.

VAERS ID:	1092578 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-02-26
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / UNK	- / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood creatinine normal, Blood potassium decreased, Blood urea normal, Dehydration, Face injury, Fall, Hypophagia, Nausea, Syncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (narrow), Hypokalaemia (narrow)

Write-up: LTC Pharmacy was notified of a potential vaccine related hospital admission on 3/8/2021. The following information was gathered from discussion with RPH at Hospital. The patient received second dose of Pfizer COVID vaccine on 2/26/2021. The patient then had nausea, vomiting, and poor oral intake. On 2/27/2021, the patient went to the bathroom and while on the toilet, had a vasovagal event which led to her hitting the side of the face while falling. Patient was then taken to the hospital for evaluation. The patient does have a pacemaker but the cause of the event was determined to likely be due to dehydration. Lab work was performed and pertinent lab values include: potassium of 3.1, SCr of 0.8, and BUN of 13. The patient received potassium supplementation and IV hydration in the hospital. Patient was discharged on 2/28/2021. Of note, the patient does have a pacemaker and a follow-up appointment with cardiology to evaluate the pacemaker was scheduled upon discharge.

VAERS ID:	1092649 (history)
Form:	Version 2.0
Age:	94.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-23
Onset:	2021-02-25
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Fall, Head injury, Injection site erythema, Injection site pruritus, Injection site rash, Rhabdomyolysis, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)

Write-up: Red pruritic rash at the injection site Two days following vaccination, she had an episode of syncope with fall, head trauma, rhabdomyolysis that resulted in hospitalization

VAERS ID:	1094287 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-28
Onset:	2021-03-01
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Blood creatine, Chest pain, Chills, Dyspnoea, Metabolic function test, Palpitations
SMQs:, Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: chills, racing heart, pain in chest, difficulty breathing, weakness

VAERS ID:	1094935 (history)
Form:	Version 2.0
Age:	96.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-22
Onset:	2021-03-10
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-03-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	041L20A / 1	RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	041L20A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Hypoxia, SARS-CoV-2 test positive
SMQs:, Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: COVID Testing Positive. Hypoxia.

VAERS ID:	1094954 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-12
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6199 / 2	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Asthenia, Blood magnesium normal, Blood potassium decreased, Dehydration, Haemoglobin normal, Nausea, Pyrexia, Vomiting, White blood cell count decreased
SMQs:, Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow), Hypokalaemia (narrow)

Write-up: Nausea, vomiting, fever, generalize weakness, dehydration

VAERS ID:	1095908 (history)
Form:	Version 2.0
Age:	92.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-10
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Dizziness, Walking aid user
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

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

Write-up: A customer came with questions regarding dizziness they have been having since receiving the second dose of the Moderna vaccine. She states that any time she takes a step down (not up), she feels very dizzy. She has started using a cane because of this which she is dissatisfied with. This started after she got the second dose on the 10th of March, and has been continual for her since then. She is not our patient and we do not have any real information about her except that she received both of her doses from the Health Department.

VAERS ID:	1100271 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-08
Onset:	2021-02-10
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Aphasia, Mobility decreased, Paralysis, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Write-up: Lost control of muscles; ended up blacking out; could not move; could not talk; A spontaneous report was received from a Consumer concerning about a 82 years old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced Paralysis, Syncope, Mobility decreased and Aphasia. The patient''s medical history was provided as diabetes, dementia as current illness. Relevant concomitant medication was reported as blood thinner for blood clots. On 08 FEB 2021, prior to the onset of event, the patient received their first dose of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 10 FEB 2021, the patient experienced Paralysis, Syncope, Mobility decreased and Aphasia. Due to these events patient''s required hospitalization and on oxygen. Laboratory details was not provided. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was unknown. The outcome of the event''s Paralysis, Syncope, Mobility decreased, and Aphasia was as unknown.; Reporter''s Comments: The events were consistent with increased risk of cerebrovascular complications associated with elderly age of patient. Company assessed the events to be unlikely related to company product.

VAERS ID:	1101947 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-03-04
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027-A21A / 1	LA / SYR

Administered by: Public Purchased by: ?
Symptoms: Lip pruritus, Lip swelling, Swollen tongue, Tongue pruritus
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Itchy tongue, swelling of tongue, Lips itchy and swollen.

VAERS ID:	1102229 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-12
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Aphasia, Blood glucose normal, Chest X-ray normal, Computerised tomogram thorax normal, Confusional state, Dehydration, Disorientation, Encephalopathy, Fibrin D dimer increased, Gait disturbance, Hypertension, Memory impairment, Mental status changes, Mobility decreased, Refusal of treatment by patient, Specific gravity urine normal, Ultrasound Doppler, Urine analysis abnormal, Urine ketone body present
SMQs:, Peripheral neuropathy (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Depression (excl suicide and self injury) (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (narrow), Immune-mediated/autoimmune disorders (broad)

Write-up: Admitted to hospital 3/13 with encephalopathy for monitoring. Discharged 3/14. At the beginning of ED visit, Patient did not know her daughter''s name. She was unable to lift her legs at home when daughter tried to help patient to dress. At ED patient was given Tylenol and fluid. Patient now recognizes her daughter and was able to get up to the bathroom with only minor assistance. During encounter, patient is awake and able to follow directions. Patient is not oriented to time, though she know she is in the hospital. Patient states that she had COVID this morning and that is the reason why she was in the hospital. Daughter at bedside helped history. Patient received 2nd Moderna COVID 19 vaccination yesterday. Daughter called but patient did not respond at noon. daughter went over to see the patient. Patient could not finish the sentence to questions. Patient could not get her dressed up by herself. Patient went to bathroom for urination but she wiped the toilet, and folded the towel. But she did not do what she was there for. Also she could not life her legs to get helped to get dressed to come to the hospital. Now patient is able to shuffle to the toilet. Now she is able to answer her name and birthday. But still patient looks confused and not her baseline. Patient has difficulty remembering her medications. Patient does remember her children''s name and home address. Patient lives alone at home and daughter wishes patient to be monitored as she has not recovered completely. Hospital Course/Treatment Rendered 78/F, CC : altered mental status PMHx Endometrioid adenocarcinoma stage IA, grade 2, status post hysterectomy and BSO on 04/06/2015. Diabetes type 2. HTN. HLD. Altered mental status, Encephalopathy, metabolic, likely related to COVID 19 vaccination. Neuro status as well as hemodynamics been monitored. Fall precaution. PT/OT was consulted for home safety evaluation as patient lives alone. Neurology, Dr. was consulted. Patient refused lumber puncture in ED. CT chest - no pneumonia or Pulmonary embolism. UA - ketone positive and dehydrated but no UTI. In the morning of 3/14/2021, patient has improved and mental status back to baseline. PT deemed patient able to go home safe. Uncontrolled hypertension at ED. Gentle hydration as patient has dehydration(urine specific gravity 1.026) and continue antihypertensives such as losartan. SBP 145-165mmHg, Asymptomatic. Will continue home medication. High D-dimer. CTA chest - excluded DVT. Venous duplex US of Both Lower extremity in AM done and no evidence of DVT. Type 2 Diabetes Mellitus. continue to monitor blood glucose and continue glipizide. controlled with blood glucose 188-135.

VAERS ID:	1102231 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-12
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Blood test, Computerised tomogram, Dizziness, Headache, Loss of consciousness, Malaise, Nausea, Pyrexia, SARS-CoV-2 test negative, Urine analysis
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Write-up: pt got to feeling really sick w/ headache, nausea, light headed and fever of 100.9. Pts son called ambulance. Pt passed out when EMTs were treating her. Pt was taken to hospital ER on 3/12/2021. They did blood work, covid test (negative) and CT. She was given fentanyl then admitted to the 2nd floor room for observation and given an IV. DX was reaction for Covid Vax. She was discharged on 3/14/2021 to FU w/ PCP within 1 week.

VAERS ID:	1102633 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-30
Onset:	2021-02-04
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-03-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Cerebrovascular accident, Fall, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Write-up: Client claims she had a stroke d/t covid vaccination. She developed symptoms of weakness, nausea/vomiting 5 days after receiving first dose of Moderna (February 4, 2021). On Feb. 5th client fell 3 times while at home and on Feb. 6th her daughter took her to the ED where she was diagnosed with having a CVA. Client was hospitalized 2/6/2021 thru 2/16/21. On 2/16 she was transfered to another hospital where she had another stroke and was discharged 2/23/2021. Please note client received her second covid vaccine on 02/27/2021. Writer called client''s PCP office and spoke with RN. RN verified client was prescribed medications listed in box 9 prior to stroke. RN also stated client had diagnosis of hypertension prior to stroke but did not have any record of medications to treat hypertension on file prior to stroke.

VAERS ID:	1102817 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-12
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram cerebral abnormal, Arteriogram carotid abnormal, Brain stem infarction, Cerebral artery stenosis, Computerised tomogram head abnormal, Dysphagia, Gait disturbance, Hypoaesthesia, Magnetic resonance imaging head abnormal, Nausea, Speech disorder, Vomiting
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Write-up: Patient is an 79 year old male who had his 2nd Moderna vaccination in his dominant right arm Thursday afternoon. Upon awakening Friday morning, he had difficulty walking. His legs were strong enough to hold him, but he was unstable. He also had some numbness on the palmar surfaces of some index and middle fingers of his left hand. His speech was somewhat garbled, but when his wife would encourage him to repeat himself, he could enunciate more clearly. He had some nonspecific difficulty swallowing. He attributed this all to adverse reaction to the vaccination, which would pass... Friday mid day his wife took him to the barber, and on return home he was briefly nauseated and vomited. Later in the day on Friday they went for car ride, and on return home he was briefly nauseated and vomited. He had no other episodes of nausea. He had no fevers or chills. He had no visual disturbances. He had no other numbness or paresthesias. He was aware of no clear weakness. Finally today, the gait instability persisted and the numbness in the left hand, so he came to the ER for evaluation. Patient is currently recovering in the hospital

VAERS ID:	1103978 (history)
Form:	Version 2.0
Age:	96.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-03-07
Days after vaccination:	24
Submitted:	0000-00-00
Entered:	2021-03-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Senior Living Purchased by: ?
Symptoms: Bell's palsy, Computerised tomogram normal, Ear pain, Electrocardiogram normal, Facial paralysis, Laboratory test normal, Magnetic resonance imaging head normal, Neck pain, Urine analysis normal
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Hearing impairment (broad), Arthritis (broad)

Write-up: Bell''s Palsy Left side-3/08/2021 Seen at Emergency Room and was given treatment of Prednisone, ValAcyclovir, and ointment to left eye at night. She experienced severe left sided neck and left ear pain on Saturday 3/06/2021 and then got drooping of left mouth and left eye around 3 pm on Sunday, 3/07/2021, and was seen at healthcare Clinic and Emergency Room 3/08/2021 2 Doses Pfizer given: #1 on 1/21/2021 and #2 on 2/11/2021

VAERS ID:	1104199 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-23
Onset:	2021-03-12
Days after vaccination:	17
Submitted:	0000-00-00
Entered:	2021-03-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 2	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Chest X-ray, Computerised tomogram, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient received Pfizer Covid 19 vaccine dose #1 on 02/02/2021 Lot # EL9264 in left deltoid IM. Dose #2 as listed above in item 17 administered on 02/23/2021. Patient presented to ER with family on 03/15/2021 with breathing difficulty. COVID PCR Positive. Specimen sent to State Lab for genetic sequencing and reported to VAERS as required.

VAERS ID:	1105077 (history)
Form:	Version 2.0
Age:	45.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-12
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Nephrolithiasis, Ureterolithotomy
SMQs:

Write-up: I had kidney stones that had to be removed not sure if connected to vaccine & happened right after shot. Happened suddenly right after I has symptoms

VAERS ID:	1105484 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-03-05
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6206 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal X-ray, Blood test, Chest X-ray, Computerised tomogram abdomen, Computerised tomogram thorax, Echocardiogram, Electrocardiogram, Electroencephalogram, Intensive care, Magnetic resonance imaging head, Seizure like phenomena, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Write-up: Pt was given first dose Covid vaccine 3/4/2021. then had seizure like activity 3/5/2021. Became unresponsive. Does have a Hx of seizure X1. strong family Hx of seizures. was transported to Hospital Via EMS, Admitted to ICU.

VAERS ID:	1105627 (history)
Form:	Version 2.0
Age:
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-03-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood culture, Hypophagia, Hypotension, Transfusion, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Write-up: Had 2nd COVID vaccine at a retail pharmacy on 3/3/21. On 3/12/21, present to our hospital ER after an unresponsive episode at home. Patient has a recent diagnosis metastatic adenocarcinoma. She had a pancreatic stent placed 3/10/21, minimal intake since that time. Hypotensive on admission, hemoccult positive, received IV fluids and blood. Decision to be comfort care, hospice consult.

VAERS ID:	1105820 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-12
Onset:	2021-02-14
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory distress syndrome, Acute respiratory failure, Agonal respiration, Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Base excess negative, Basophil count decreased, Basophil percentage, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood culture, Blood electrolytes normal, Blood glucose increased, Blood lactic acid increased, Blood pH increased, Blood potassium normal, Blood pressure decreased, Blood sodium decreased, Blood urea increased, Bradycardia, C-reactive protein increased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Continuous positive airway pressure, Cyanosis, Death, Differential white blood cell count abnormal, Dyspnoea, Echocardiogram, Electrocardiogram QT prolonged, Electrocardiogram T wave peaked, Electrocardiogram abnormal, Eosinophil count normal, Eosinophil percentage, Fibrin D dimer increased, Full blood count abnormal, General physical health deterioration, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Haemoptysis, Leukocytosis, Lung infiltration, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume, Mean platelet volume normal, Mechanical ventilation, Metabolic acidosis, Monocyte count, Monocyte percentage, Multiple organ dysfunction syndrome, Myocardial ischaemia, Neutrophil count increased, Neutrophil percentage increased, Oxygen saturation decreased, PCO2 decreased, PO2 decreased, Platelet count decreased, Pneumonia, Procalcitonin increased, Protein total normal, Pulse absent, Red cell distribution width normal, Respiratory alkalosis, Respiratory symptom, SARS-CoV-2 test, SARS-CoV-2 test negative, Sepsis, Septic shock, Suspected COVID-19, Tachypnoea, Troponin T increased, Troponin increased, Venipuncture, White blood cell count
SMQs:, Torsade de pointes/QT prolongation (narrow), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-14
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Rivaroxaban 15 and 20 MG, Tylenol, Meclizine 25 MG; Aspirin 18 MG daily, Pravastatin 20 MG daily, Multivitamins, BP formulation, Norvasc 5mg tablet daily . atenolol 25MG tablet daily
Current Illness: none
Preexisting Conditions: Abdominal Aortic Anuerysm, Atypical chest pain, Benign essential Hypertension, Pure hypercholesterolemia
Allergies: none
Diagnostic Lab Data: Diagnostics: Results for orders placed or performed during the hospital encounter of 02/14/21 CBC WITH DIFFERENTIAL Result Value Ref Range White Blood Cells 10.8 3.8 - 10.8 K/uL Red Blood Cells 3.94 (L) 4.33 - 5.75 M/uL Hemoglobin 13.0 (L) 13.4 - 17.6 g/dL Hematocrit 38.0 (L) 38.2 - 50.2 % MCV 96.4 (H) 82 - 96 fL MCH 33.0 (H) 28.0 - 32.8 pg MCHC 34.2 32.4 - 35.7 g/dL RDW 13.2 11.2 - 15.6 % Platelet Count 131 (L) 140 - 390 K/uL MPV 9.4 6.7 - 10.6 fL Neutrophil % 91.2 % Lymphocyte % 1.7 % Monocyte % 6.8 % Eosinophil % 0.0 % Basophil % 0.3 % Absolute Neutrophils 9.8 (H) 1.8 - 7.1 K/uL Absolute Lymphocytes 0.2 (L) 0.9 - 3.5 K/uL Absolute Monocytes 0.7 0.2 - 0.9 K/uL Absolute Eosinophils 0.0 0.0 - 0.5 K/uL Absolute Basophils 0.0 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range Sodium 135 133 - 144 mEq/L Potassium 4.8 3.5 - 5.0 mEq/L Chloride 103 95 - 107 mEq/L Carbon Dioxide 22 22 - 32 mEq/L Anion Gap 10 6 - 15 mEq/L BUN 38 (H) 8 - 24 mg/dL Creatinine 1.41 (H) 0.50 - 1.30 mg/dL Glomerular Filt Rate 44 (L) $g60 mL/min Glucose 164 (H) 70 - 100 mg/dL Albumin 3.4 (L) 3.5 - 5.2 g/dL Calcium 8.5 (L) 8.6 - 10.4 mg/dL AST 39 11 - 41 IU/L ALT 14 11 - 66 IU/L Alkaline Phosphatase 51 35 - 121 IU/L Bilirubin, Total 0.9 <1.5 mg/dL Total Protein 6.6 6.2 - 8.5 g/dL Globulin 3.2 1.8 - 3.7 g/dL A:G Ratio 1.1 (L) 1.2 - 2.7 TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 176 (HH) <12 ng/L PROCALCITONIN Result Value Ref Range Procalcitonin 0.36 (H) <0.25 ng/mL COVID (SARS-COV-2) BY RAPID ANTIGEN Result Value Ref Range COVID-19 Antigen Not detected NOTD TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 233 (HH) <12 ng/L LACTIC ACID Result Value Ref Range Lactate 2.5 (H) 0.4 - 2.0 mmol/L CRP C REACTIVE PROTEIN QUANT Result Value Ref Range C Reactive Protein, Quantitative 7.34 (H) <0.80 mg/dL COVID AG DIRECT OPTICAL BILL Result Value Ref Range CPT 87811 Covid Antigen Direct Bill Billed for services performed D-DIMER Result Value Ref Range D-dimer 0.53 (H) <0.50 ug/mL FEU ARTERIAL BLOOD GAS Result Value Ref Range Patient Oxygen 100% pH, Arterial 7.46 (H) 7.35 - 7.45 pCO2, Arterial 29 (L) 30 - 45 mmHg pO2, Arterial 54 (L) 75 - 95 mmHg Base Deficit 2 0 - 2 Oxygen Saturation, Arterial 87 (L) 95 - 98 % Bicarbonate, Arterial 20 (L) 22 - 26 mmol/L Specimen type Arterial TCO2, Arterial 21 20 - 30 mEq/L Allens Test ALLENS TEST OK EKG (HOSPITAL) Result Value Ref Range Systolic BP 107 mmHg Diastolic BP 56 mmHg Ventricular Rate 82 BPM Atrial Rate 82 BPM QRS Duration 100 ms Q-T Interval 394 ms QTC Calculation(Bezet) 460 ms Calculated R Axis 17 degrees Calculated T Axis 45 degrees Diagnosis Accelerated Junctional rhythm Nonspecific ST and T wave abnormality Prolonged QT interval or tu fusion, consider myocardial disease, electrolyte imbalance, or drug effects Abnormal ECG When compared with ECG of 10-NOV-2020 10:24, Junctional rhythm has replaced Sinus rhythm Vent. rate has increased BY 30 BPM ST now depressed in Anterior leads CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Drawn from Left Antecubital area. Venipuncture Culture Pending Report Status Pending CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Venipuncture Drawn from Left Antecubital area. Culture Pending Report Status Pending Medical Decision Making: Patient is an 89-year-old male who presents emergency department for evaluation of shortness of breath and cough. Differential diagnosis includes, but is not limited to, acute coronary syndrome, pneumonia, pulmonary embolism, reaction from recent COVID-19 vaccine, COVID-19 infection, other viral upper respiratory infection, pleural effusion, or CHF. The patient denies any discrete chest pain at this time, though he has had some chest pain with exertion for the past 6 months. He has had shortness of breath along with his cough, increasing my suspicion for possible infectious process. Upon his arrival, the patient is known to be tachypneic, with normal oxygen saturation rates. He is not tachycardic or febrile, therefore does not meet SIRS criteria at this time. Plan at this time to obtain laboratory evaluations, chest x-ray, and EKG. Low threshold to broaden evaluations to include infectious workup. Please reference the remaining ED Course for further assessment, plan, and disposition documentation. ED Course as of Feb 14 1916 Sun Feb 14, 2021 1230 EKG reveals sinus rhythm at a rate of 82 beats per minute. QRS duration 100 milliseconds. QTC slightly prolonged at 460 milliseconds. There is somewhat concerning peaked T-waves in leads V2 and V3 along with with possible ST elevation in lead V1 this does represent a change from the patient''s previous study in November, 2020. EKG (Hospital) 1315 No leukocytosis. Hemoglobin and hematocrit within normal limits for the patient. No thrombocytopenia. Slight elevation in absolute neutrophil count. CBC (Complete Blood Count) With Differential(!) 1330 Elevated at 176. As the patient has been having pain for the past 2 days, I am uncertain if this is catching the increase in his troponin, or the downtrend. He continues to deny chest pain and has reported that his shortness of breath has resolved. TROPONIN T, HIGH SENSITIVITY(!!) 1419 Electrolytes within normal limits. Creatinine elevated at 1.41, though this is not significantly elevated in comparison to study obtained approximately 3 weeks ago at 1.2. Liver function tests within normal limits. No anion gap. Comprehensive Metabolic Panel(!) 1420 By my interpretation, multifocal bilateral infiltrates, most consistent with COVID-19. Also possible right middle lobe infiltrate, concerning for possible superimposed bacterial pneumonia. This is interesting as the patient did just receive his 2nd COVID-19 vaccine. Plan at this time to broaden infectious work up and order for the patient to receive empiric antibiotics. XR Chest 1V Portable 1437 Elevated at 2.5. I will provide the patient with another fluid bolus as his IVC does appear flat upon ultrasound. Lactic Acid(!) 1503 Continues elevated 233. Will consult cardiology. TROPONIN T, HIGH SENSITIVITY(!!) 1506 IMPRESSION: 1. Significant and concerning patchy airspace opacities of the right upper, right lower and left mid lung, concerning for a pneumonic process. Less likely, viral upper is for infection, including Covid 19, could be present. 2. No other etiology seen for symptoms S: 2/14/2021 14:45 CST Electronically Authenticated D: 2/14/2021 14:42 CST XR Chest 1V Portable 1506 I did have a discussion with the patient''s daughter regarding which she believes her father''s code status is. She agrees that he is likely DNR DNI, but does think that he would like to have the cardiac catheterization completed. I will confirm this with the patient. 1617 Patient noted to become hypoxic to 76%. Borderline hypotensive at 91/55. No associated tachycardia. Slightly tachypneic at 26 br/min. Oxygen increased to 15 L/min and RT paged for BiPAP. After a discussion with the patient, he endorses that he understands what DNR/DNI status means, as his wife recently passed away approximately five months ago. He does share that he wishes to be DNR/DNI, which he believes he has paperwork reflecting. I believe at this time that he is of sound mind to make this decision as well, should we not have paperwork available to us reinforce this. He does request that I contact his daughter. 1621 Bedside cardiac ultrasound does not reveal pericardial effusion. IVC appears flat. Will order for the patient receive a 2nd 500 cubic centimeters bolus. RT is present at the bedside Redding to place NIPPV. 1704 D-dimer does age adjust within normal limit. D-DIMER(!) 1705 Patient with acute primary respiratory alkalosis with secondary metabolic acidosis. Continues to be hypoxic on 100% FiO2 with saturation rates at 89%. At this point in time, I favor the patient''s NSTEMI is secondary to demand ischemia given his ongoing hypoxia. However, given his previous reported history of exertional chest discomfort and dyspnea on exertion, I will at least discuss the patient with another Hospital. ARTERIAL BLOOD GAS(!) 1805 Patient did have a significant desaturation event that resulted after he disconnected himself from NIPPV. Upon my arrival into the room, he was noted to be setting 8% with good waveform. He was cyanotic with agonal respirations. He was noted to have a pulse that corresponded with the monitor at a tachycardic rate. He was rapidly placed in a supine position and of bagged with a non-rebreather to increase his oxygen saturation rates. His oxygen saturation rate did increase, but has not completely recovered. We did bag him for several minutes and his oxygen level is now in the low 80s. He is currently on non-rebreather at 15 liters/minute. He is not following commands. His daughter is present and I did advise her of this recent update. I did speak to another Hospital and inform them that the patient would not be transferred at this time. Patient''s blood pressure is noted to be 124/73 mmHg, therefore I will order him some morphine for air hunger. I did brief the patient''s daughter on his current status and we will have her be present in the room with him. 1851 Patient continued to deteriorate, ultimately coughing up bloody secretions. He was suctioned, but continued to be tachypneic and have increased work of breathing. He became bradycardic with heart rates in the 30s. After a discussion with the patient''s daughter, the decision was made to silence alarms. Patient was accompanied by his daughter, ultimately noted to lose pulses and time of death was called at 1830, confirmed by loss of palpable pulses and lose of auscultated pulses. Time was spent discussing the patient with his daughter. We did expedite his PCR COVID swab so as to ultimately know his COVID-19 status. We did offer to contact additionally family members on the behalf of the patient''s family.
CDC Split Type:

Write-up: Patient seen and evaluated by PA-C. with myself. We agreed on the clinical findings and implemented our plan together. Please see PA''s note for details. All relevant procedures supervised. Patient arrived to the emergency department due to respiratory symptoms, hypoxic, reported that Wednesday he received his 2nd dose of COVID vaccine. His initial workup was concern for NSTEMI with elevated troponin and peaked T-waves, his chest x-ray concerning for COVID/pneumonia. Patient initially tolerated oxygen by nasal cannula and sepsis protocol was started including IV fluid resuscitation that was done cautiously due to the concern of COVID with respiratory failure. The biotics were given. PA-C readdressed code status with patient who confirmed that his DNR DNI, she so contacted his daughter. Patient had multiorgan failure including acute kidney injury, and pneumonia with respiratory failure +/- respiratory failure. Due to the concern of NSTEMI patient was initially going to be transfer to was hospital and transfer was started. Patient respiratory status started deteriorating and his blood pressure dropped slightly but improved after 500 cubic centimeters of IV fluid and he was also placed on a NIPPV. Around 6:00 p.m. patient has significantly desaturation and he discontinued himself NIPPV. Due to inability to intubate patient, he was ventilated with BVM, patient is slowly improved saturation levels and was opening his eyes, he was placed on a non-rebreather. At this point there is high concern of ARDS and due to inability to intubate or give for the respiratory support His daughter was at bedside and updated of current medical status and poor prognosis. Patient continued deteriorating and at this point he had agonal breathing. His daughter was at bedside and she was made aware of the futile prognosis of patient due to his respiratory failure. Patient rapidly became bradycardic and went into cardiac arrest. No CPR was done due to the DNI DNR status of the patient. Critical Care Procedure Note Authorized and Performed by: MD Total critical care time: Approximately 30 minutes Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient''s response to treatment; frequent reassessment; and, discussions with other providers. This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see MDM section and the rest of the note for further information on patient assessment and treatment. PE: VITAL SIGNS: BP: 126/75 Pulse: (!) 122 Resp: (!) 40 SpO2: (!) 82 % Temp: 98.1 ?F (36.7 ?C) Height: 5'' 8" (172.7 cm) Weight: 152 lb (68.9 kg) General: Alert, nontoxic, in no acute distress. Lungs: Clear to auscultation bilaterally. CLINICAL IMPRESSION: 1. Sepsis with acute hypoxic respiratory failure and septic shock, due to unspecified organism (HCC) 2. Suspected COVID-19 virus infection 3. NSTEMI (non-ST elevated myocardial infarction) (HCC) 4. Multifocal pneumonia 5. ARDS (adult respiratory distress syndrome) (HCC) 6. Acute kidney injury (HCC) Further care and disposition otherwise as outlined by PA. ED on 2/14/2021 Revision & Routing History Detailed Report Note filed date Mon Feb 15, 2021 8:46 AM

VAERS ID:	1106910 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-02-06
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9269 / 1	- / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Arthralgia, Neck pain, Pain in extremity
SMQs:, Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsilosin Fentanyl patch Simvastatin
Current Illness: None
Preexisting Conditions: Sciatica Cholesterol high Low platelets
Allergies: None
Diagnostic Lab Data: Medical appointment to rule out onfection
CDC Split Type:

Write-up: Arm, shoulder and neck pain. Has lasted since 2/6/21

VAERS ID:	1108006 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-15
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood glucose increased, Blood pressure decreased, Dizziness, Gait inability
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Vestibular disorders (broad), Dehydration (broad)

Write-up: Symptoms started 8 minutes after injection. Reported by patient 15 minutes after injection Symptoms noted: light headedness Treatments: vitals taken, water given and patient reclined Outcome: extended monitoring, patient given orders for IVF bolus, taken to hospital floor for monitoring during bolus. Per hospital staff, pt improved. Respirations 16 and Blood Pressure 95/65, BP after another 10 minutes 95/65. Finger stick glucose taken about 30 minutes later at 209. Pt encouraged to get up and walk a few steps, but was unable. BP taken again 40 minutes post injection up to 162/62. Pt stood and turned in circle then sat back down and BP was 120/65.

VAERS ID:	1109385 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1805025 / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Abdominal discomfort, Abdominal pain, Appendicectomy, Appendicitis, Computerised tomogram abnormal, Delirium, Dizziness, Eructation, Headache, Infection, Lethargy, Pain, Pyrexia, Tremor, Vomiting, White blood cell count abnormal
SMQs:, Acute pancreatitis (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (narrow), Retroperitoneal fibrosis (broad), Dementia (broad), Parkinson-like events (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: On March 11th at around 10pm I experienced severe shaking, fever, headache and delirium. The next day I improved but had a fever on and off of 99.1. I felt like I was stable, but felt dizziness increasing, and was lethargic through the weekend. Then on Monday the 15th, I had a noticeable cramp in my right abdomen. At around 8pm CST I began feeling like I needed to burp and that I had GI problems. The problems increased that night at around 10pm I had pain where the cramp started. Two hours later I started throwing up because of the pain and feeling of too much air inside of me. I could not stop vomiting after 2 hours so went to the Hospital ED at around 2:30 AM Tuesday the 16th. I was admitted after a CT scan showed and white cell counts confirmed and infection and drastically enlarged appendix. I was diagnosed with an appendicitis and they immediately scheduled me for surgery.

VAERS ID:	1110703 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-03-04
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Bedridden, Diet refusal, Disorientation, Neuroleptic malignant syndrome, Pyrexia, Refusal of treatment by patient, Tremor, Unresponsive to stimuli, Urinary incontinence
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (narrow), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Pfizer-BioNTech COVID-19 Vaccine EUA Pt chronic schizophrenia with subsequent mild cognitive impairment over the past year who was brought to hospital after 4 days of food/medication refusal, withdrawal from care and more recently disorientation and tremor. Pt was recently transitioned from haldol decanoate to clozapine. Last dose haldol decanoate was on 2/16/21. First dose clozapine 12.5 mg was on 2/24/21. Increased to 12.5 BID the following day. Increased to 25 mg BID on March 2, without reported side effects or other issues. Pt got his first dose of Pfizer COVID vaccine on March 4, and that night was less engaged with staff, felt feverish. Did not spike a temp per bedside accompaniment who was with him that day. The following day, he barely ate any food and did not get out of bed all day. This continued for the entirety of the weekend - bed bound, turning to look at staff when called but did not engage/respond verbally. He was incontinent of urine over the weekend. Treated for Neuroleptic malignant syndrome 2/2 clozapine Uncertain if vaccine contributed to event, but recent case report published relating clozapine toxicity and Pfizer COVID vaccine, so submitting to VAERS for evaluation

VAERS ID:	1115965 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-17
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-03-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Acute kidney injury, Coagulation test normal, Deep vein thrombosis, Leukocytosis, Metabolic function test abnormal, Pain, Weight bearing difficulty, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Telmisartan Levothyroxine Duloxtine Tizanidine Omega 3 Turmuric Boswellia Magnesium Cetirizine MVI B complex vitamins Ginger Guaifenisin
Current Illness: No new illnesses
Preexisting Conditions: Fibromyalgia Allergic rhinitis Essential hypertension Hypercholesterolemia Hypothyroidism
Allergies: No known allergies
Diagnostic Lab Data: Lab tests (on 3/17) did demonstrate leukocytosis with WBC of 23.5. Normal coagulation studies. Complete metabolic panel demonstrated slight acute renal injury.
CDC Split Type:

Write-up: Pt developed a new onset, acute deep vein thrombosis approximately 6-7 days after vaccination in the R lower extremity with extreme pain and inability to bear weight.

VAERS ID:	1116362 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-03-18
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Asthenia, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Write-up: Syncope and generalized weakness. Blood pressure taken 90/50 with a heart rate of 38. First response notified. Blood pressure repeated 113/56 with a heart rate of 40. Patent was transported to the Emergency Department via first response.

VAERS ID:	1120117 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-02-19
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031M20A / 1	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Cardiomyopathy (broad)

Write-up: Blood clot in his lung

VAERS ID:	1123118 (history)
Form:	Version 2.0
Age:	18.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-09
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Dysphagia, Dyspnoea, Rash
SMQs:, Anaphylactic reaction (narrow), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Difficulty swallowing; Shortness of breath; Big rash; A spontaneous report was received from a consumer concerning a 18-year old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced events shortness of breath, difficulty breathing, tightness on the throat, difficulty swallowing, big rash in forehead and under her eyes. The patient''s medical history was not provided. Concomitant medications reported were birth control pill for drug use for unknown indication. On 9 Mar 2021, prior to the onset of the events the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 9 Mar 2021, the patient experienced the event shortness of breath, difficulty breathing, tightness on the throat, difficulty swallowing, big rash in forehead and under her eyes. Treatment details included went to the emergency room (ER), epinephrine, diphenhydramine, and dexamethasone.. Action taken with mRNA-1273 in response to the events was not reported. The outcome of event, shortness of breath, difficulty breathing, tightness on the throat, difficulty swallowing, big rash in forehead and under her eyes was unknown.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.

VAERS ID:	1123522 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-19
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 2	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Hepatic enzyme increased, Pain, Pyrexia, Systemic inflammatory response syndrome
SMQs:, Liver related investigations, signs and symptoms (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Bisacodyl, citalopram, docusate, furosemide, ibuprofen, florajen, levothyroxine, melatonin, sumatriptan succinate, calcium carbonate, ascorbic acid, oxycodone,
Current Illness: none
Preexisting Conditions: liver cancer on chemo., macular degeneration, hyperlipidemia. peptic ulcer, muscular dystrophy, osteopenia, migraines , hypothyroidism HPV
Allergies: erythromycin, penicillin azithromycin morphine odansetron
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized with fever, body aches, inability to transfer and SIRS. Increased liver enzymes as well

VAERS ID:	1123683 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-16
Onset:	2021-03-17
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / -

Administered by: Private Purchased by: ?
Symptoms: Dyspnoea, Endotracheal intubation, Systemic inflammatory response syndrome
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol succinate Tranexamic acid Acyclovir Lasix Lisinopril Posaconazole Prednisone
Current Illness: Secondary acute myeloid leukemia with lack of hematologic response and ongoing pancytopenia
Preexisting Conditions: Secondary acute myeloid leukemia Heart failure with reduced ejection fraction Rheumatoid arthritis
Allergies: No
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient appeared to have had a systemic inflammatory syndrome vs anaphylactic type reaction to the vaccine. She presented with dyspnea 12 hours after receiving the vaccine and ultimately required brief intubation and vasopressor support. She was extubated and weaned off pressors within 2 days and discharged at her baseline functional status.

VAERS ID:	1123876 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-14
Onset:	2021-03-01
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-03-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031M20A / 1	- / OT

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

Write-up: Stroke; A spontaneous report was received from a consumer concerning her husband, a 75 years old, male patient who received Moderna (mRNA-1273) vaccine and experienced Stroke (Cerebrovascular accident). The patient''s medical history was not provided. Concomitant products known to have been used by the patient, within two weeks prior to the event, included: prefervifion. On 14-Feb-2021, prior to the onset of the symptoms, the patient received their first of two planned doses of mRNA-1273 (Batch number: 031M20A)intramuscularly for prophylaxis of COVID-19 infection. On 1-Mar-2021, the patient had a stroke and was hospitalized on the same day. The patient is still hospitalized. No laboratory details were provided. On 14 Mar 2021, the patient has their second shot scheduled. Treatment information provided by the reporter included: Aspirin, prolix, cleft, lovenox. Action taken with mRNA-1273 in response to the event was unknown The outcome of the event, Stroke was considered Not resolved.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.

VAERS ID:	1125212 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-02-08
Submitted:	0000-00-00
Entered:	2021-03-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	RA / -

Administered by: Private Purchased by: ?
Symptoms: Injection site coldness, Injection site induration, Injection site pain, Joint space narrowing, X-ray limb abnormal
SMQs:, Extravasation events (injections, infusions and implants) (broad), Osteonecrosis (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine Evening primrose oil Magnesium oxide Calcium supplement Vit D Daily women''s vitamin
Current Illness: None
Preexisting Conditions: Osteoarthritis
Allergies: Yeast Dairy Wheat
Diagnostic Lab Data: Shoulder X-ray March 17
CDC Split Type:

Write-up: Hardness in arm, extreme soreness in injection site 6 weeks out, after 2 days extreme pain in arm extending from shoulder, collar bone area to elbow,.restricted circulation ( hand, lower arm much colder than other arm) x-ray revealed narrowing of joint in shoulder. Still painful

VAERS ID:	1125300 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-19
Onset:	2021-03-21
Days after vaccination:	30
Submitted:	0000-00-00
Entered:	2021-03-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	623MZ0A / 1	UN / UN

Administered by: Private Purchased by: ?
Symptoms: Arrhythmia, Cardiac pacemaker insertion, Death
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-21
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol, Eliquis, Furosemide, Imdur, Lisinopril, Crestor, Shingrix, and Tamsulosin.
Current Illness: None.
Preexisting Conditions: Essential hypertension, tachy-brady syndrome, supraventricular tachycardia, atrial flutter, and sinus node dysfunction. He also had a pacemaker implanted on 03/19/2021.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had no known ill effects or complaints directly after receiving his first COVID-19 vaccine on 02/19/2021. However, on 03/21/2021, he was found deceased on his bedroom floor due to a suspected cardiac arrhythmia. It is unknown if there is any correlation.

VAERS ID:	1126678 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-20
Onset:	2021-03-21
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	046A21A / 1	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Chronic obstructive pulmonary disease, Hypoxia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient developed COVID-19 symptoms and tested positive on 3/21/2021 after getting vaccinated on 3/20/2021. Patient has a history of COVID - he tested positive on November 16 of 2020. Patient''s records also list "Acute respiratory failure with hypoxia (*) likely secondary to COPD exacerbation secondary to COVID-19 vaccine reaction" - this was listed as a Problem in his chart on 3/21/2021. - This is his listed prinicpal problem at admission to the hospital on 3/21/2021.

VAERS ID:	1127189 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-02-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031L20A / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Arthralgia, Asthenia, Communication disorder, Diarrhoea, Dysstasia, Fatigue, Headache, Pain, Pyrexia, Vomiting, Yellow skin
SMQs:, Cholestasis and jaundice of hepatic origin (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Arthritis (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: 1 bag Ozone blood IV w/IV, 1 bag Vitamin-C 50gm IV (Administered roughly once every 2 weeks.) Vitamin D3 15,000 IU every morning, Curapro 500mg Pure Cucuminoids + 250mg Curcumin Rhizome 1 every morning, OmegaMax 950mg Anchovy Fish Oil..One
Current Illness: NA
Preexisting Conditions: Hyperlipidemia Hypertension (HTN) Osteopenia Anticoagulant long-term use Elevated Troponin Chronic a-fib Ovarian cancer
Allergies: Lisinopril
Diagnostic Lab Data: Please call Dr at (personal cell) to discuss what tests were performed
CDC Split Type:

Write-up: 3 hours after Vaccine...Began to ache and feel very tired 12 hours after Vaccine...ached at all joints , headache , very tired, no energy 24 hours after Vaccine...Began to vomit and experience diarrhea 36 hours after Vaccine...No energy or strength to stand, high fever, begin to talk non sensical, skin turning yellow 39 hours after Vaccine...Called 911

VAERS ID:	1127468 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031M20A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	LA / IM

Administered by: School Purchased by: ?
Symptoms: Acute kidney injury, Blood test normal, Confusional state, Death, Decreased appetite, Dizziness, Echocardiogram normal, Lethargy, Malaise, Nausea, Retinal vascular thrombosis, Somnolence, Ultrasound kidney normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Retinal disorders (narrow), Vestibular disorders (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: LOSARTAN 100 MG HYDRALAZINE 50 MG LOVASTATIN 20 MG METFORMIN 1000 MG OMEPRAZOLE 20 MG FUROSEMIDE 20 MG INSULIN GLARGINE 100 UNIT/ML
Current Illness: NONE
Preexisting Conditions: DIABETES HIGH BLOOD PRESSURE POSTHERPETIC NEURALGIA SCIATICA
Allergies: NONE
Diagnostic Lab Data: She had just had a heart ultrasound and kidney ultrasound and blood work less than a month before her vaccine and they both showed normal function. She went into complete renal failure in a less than a week.
CDC Split Type:

Write-up: Severe lethargy after receiving the shot. Constant sleepiness and malaise, nausea, confusion, loss of appetite, dizziness, Blood vessels/clots formed in her eyes. Acute renal failure and eventually death on March 18, 2021.

VAERS ID:	1127818 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-16
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-03-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Cerebrovascular accident, Computerised tomogram head, Embolic stroke, SARS-CoV-2 test positive
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension, Type 2 diabetes, Hyperlipidemia, obesity, BPH. Dx with COVID-19 by PCR on 1/5/2021, PCR was still positive on 3/16/2021
Preexisting Conditions: Hypertension, Type 2 diabetes, Hyperlipidemia, obesity, BPH
Allergies:
Diagnostic Lab Data: CT brain 3/16/2021 SARS-COV-2 swab 3/16/2021
CDC Split Type:

Write-up: Pt suffered an embolic stroke to left MCA on 3/16/2021, 4 days after his vaccine. He was also within 90 days of PCR confirmed COVID-19 infection (tested positive 1/5/2021 and was still positive on 3/16/2021). This is likely unrelated as patient had multiple risk factors for stroke, but felt it worth reporting as no association cannot be found if people don''t report events like this.

VAERS ID:	1128208 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-03-21
Days after vaccination:	17
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Computerised tomogram thorax, Fibrin D dimer increased, Pulmonary embolism
SMQs:, Haemorrhage laboratory terms (broad), Embolic and thrombotic events, venous (narrow), Pulmonary hypertension (broad)

Write-up: bilateral pulmonary emboli

VAERS ID:	1128852 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-27
Onset:	2021-02-28
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	LA / -

Administered by: Work Purchased by: ?
Symptoms: Dehydration, Diarrhoea, Renal disorder, SARS-CoV-2 test, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow), COVID-19 (broad)

Write-up: Significant diarrehri; vomiting; severe dehydration; kidney damage; This is a spontaneous report from a contactable consumer (patient). A 65-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration in left arm at 14:15 on 27Feb2021 (Batch/Lot number was not reported) at single dose for COVID-19 immunization. Medical history included Crohn''s disease. On 28Feb2021, the patient experienced significant diarrehri (diarrhoea) and vomiting resulting in hospitalization for 3 days for severe dehydration and kidney damage. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. The patient received over the counter medications within 2 weeks of vaccination. The adverse event resulted Emergency room/department or urgent care and admitted for 3 days. Treatment (IV of fluids and pain medications and anti-nausea) received for the adverse event. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient been tested for COVID-19. The outcome of events was recovering. Information on the lot/batch number has been requested.

VAERS ID:	1129069 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-22
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EM9810 / 2	UN / UN

Administered by: Private Purchased by: ?
Symptoms: Arrhythmia, Coronary artery stenosis, Death, Hepatic steatosis, Hepatomegaly, Hypertension, Nephrosclerosis
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Neuroleptic malignant syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Other ischaemic heart disease (narrow), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-22
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Finasteride, vitamin C, vitamin D, aspirin, ibuprofen
Current Illness: None known
Preexisting Conditions: Gout, leukopenia, benign prostatic hypertrophy, glaucoma. He had a history of colon cancer in 1984 with a partial bowel resection.
Allergies:
Diagnostic Lab Data: An autopsy performed on 03/23/2021 revealed he had significant hypertensive and valvular cardiac disease with an occlusion of his LAD, as well as nephrosclerosis and hepatomegaly and hepatic stenosis.
CDC Split Type:

Write-up: Patient had no known immediate ill effects or complaints directly after receiving his second COVID-19 vaccination on 03/11/2021. However, on 03/22/2021, he suffered a fatal cardiac arrhythmia while exercising on his home elliptical machine.

VAERS ID:	1129801 (history)
Form:	Version 2.0
Age:	84.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-24
Onset:	2021-03-09
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 2	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-09
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: NONE
Preexisting Conditions: HEART DISEASE
Allergies: UNKNOWN
Diagnostic Lab Data: UNKNOWN
CDC Split Type:

Write-up: RECEIVED REPORT THAT TWO WEEKS AFTER HIS SECOND DOSE, HE DIED OF A MYOCARDIAL INFARCTION.

VAERS ID:	1130017 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-13
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026A21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Acute kidney injury, Brain natriuretic peptide, Cardiac failure acute, Echocardiogram, Ejection fraction, Left ventricular dysfunction, Wall motion score index abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Cardiomyopathy (broad), Other ischaemic heart disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Write-up: acute decompensated heart failure new left ventricular dysfunction (EF 35-40%) acute kidney injury

VAERS ID:	1130292 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-02-28
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6198 / 1	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Chills, Headache, Nausea, Palpitations, White blood cell count increased
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Pt reports that 48 hours after the inital vaccine she developed headache, chills, nausea, heart palpitations. Had blood work completed by her primary provider and was dicovered to have a significantly high WBC. Was admitted to hospital with diagnosis of UTI and started on IV antibiotics. Provider directed client not to get booster.

VAERS ID:	1130351 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-21
Onset:	2021-03-22
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram cerebral normal, Arteriogram carotid normal, Aspartate aminotransferase increased, Autoimmune hepatitis, Blood albumin decreased, Blood bilirubin, Blood calcium, Blood chloride normal, Blood creatine normal, Blood glucose normal, Blood potassium decreased, Blood sodium normal, Blood urea normal, Carbon dioxide decreased, Cerebral atrophy, Chest X-ray normal, Chills, Cholangitis, Cholelithiasis, Computerised tomogram abdomen, Computerised tomogram head abnormal, Diverticulum intestinal, Encephalopathy, Gallbladder enlargement, Haematocrit normal, Haemoglobin normal, Headache, Hyporesponsive to stimuli, Injection site pain, Ischaemic hepatitis, Meningitis, Mental status changes, Nausea, Pancreatitis acute, Platelet count normal, Pyrexia, Scan with contrast abnormal, Sepsis, Ultrasound biliary tract, Ultrasound pancreas abnormal, Vomiting, White blood cell count increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatitis, non-infectious (narrow), Acute pancreatitis (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (narrow), Dementia (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Infectious biliary disorders (narrow), Gallbladder related disorders (narrow), Biliary tract disorders (narrow), Gallstone related disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific dysfunction (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Patient is a 74 year old y.o. female with history of atrial fibrillation, hypothyroidism who presents with acute onset early this a.m. nausea vomiting and change in mental status. History was obtained from the husband as patient is minimally responsive to verbal stimuli at this time. He states she was in her usual state of health until when she awoke this morning. Yesterday in usual state of health that she did have her 2nd COVID vaccine with the Pfizer variant. He states that day she was in her usual state of health with some mild arm pain on the left where she received the vaccine. This morning she awoke with a headache, fever, chills however was ambulating and conversing appropriately. She had no appreciable focal deficits at that time per the husband. She ate breakfast however she subsequently began vomiting. She progressed to a change in mental status with minimal responsiveness. She would say 1 or 2 words and that was it. They then presented emergency department. Diagnosed with severe sepsis, acute encephalopathy, acute meningitis, liver shock, autoimmune hepatitis, ascending cholangitis, acute pancreatitis.

VAERS ID:	1130394 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-28
Onset:	2021-03-03
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 2	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Abdominal pain, Alanine aminotransferase increased, Anion gap normal, Aspartate aminotransferase increased, Atrial fibrillation, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood magnesium normal, Blood sodium decreased, Blood urea increased, Carbon dioxide decreased, Chest X-ray normal, Cholelithiasis, Dehydration, Diabetes mellitus, Diarrhoea, Electrocardiogram abnormal, Escherichia bacteraemia, Feeling abnormal, Fibrin D dimer increased, Haematocrit decreased, Haemoglobin decreased, Headache, Liver abscess, Malaise, Myalgia, Nausea, Procalcitonin normal, Pyrexia, SARS-CoV-2 test negative, Sepsis, Shift to the left, Streptococcus test, Transaminases increased, Troponin, Ultrasound abdomen abnormal, Urine analysis normal, Vomiting, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Liver infections (narrow), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Dementia (broad), Pseudomembranous colitis (broad), Gallbladder related disorders (narrow), Gallstone related disorders (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Dehydration (narrow), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Write-up: The patient initially presented (3/3/21) with headache, fevers, nausea, vomiting, diarrhea, myalgias, malaise. Patient related she was in her normal state of health and only started to feel poorly after she received her second COVID-19 vaccination three days earlier. She interestingly related that after her first Pfizer COVID-19 vaccination she had significant burning in her stomach that she noted but no other major symptoms and notably did not experience this severe burning in her stomach after the second dose. She denied any chest pain, current dyspnea, productive cough, sore throat, urinary symptoms, sick contacts. She has no history of C. difficile, no recent antibiotics, no recent spoiled foods, no recent travel, no history of radiation. She does have a history of GERD and has had gastritis with mild gastrointestinal bleeding in the past and undergone EGD negative for H. pylori infection. She also has undergone colonoscopies with polyps that have been removed and reported as tubular adenomas. As her hospitalization progressed, she was diagnosed with Severe Sepsis due to E. Coli bacteremia in setting of liver abscess, Cholelithiasis without acute cholecystitis, Atrial Fibrillation with rapid ventricular response, Transaminitis (which resolved). Patient was appropriately treated for these conditions. Also, her known uncontrolled diabetes was treated. Per an Infection Disease note on 3/9/21: The patient has had hx of biliary colic (self diagnosis) now with discovery of non-obstructive cholelithiasis on RUQ US it is plausible that the abscess originated from self limiting cholecystitis/cholangitis which would be consistent with recent abdominal pain exacerbated with oral intake. Difficult to state definitively any relation to COVID-19 vaccination, though may have resulted from associated dehydration. Additional COVID vaccine info (both Pfizer): first dose: 2/7/21 lot# EN 5318 second dose: 2/28/21 lot# EN6202

VAERS ID:	1130749 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-14
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-03-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Aortic dilatation, Aortic valve stenosis, Chills, Cough, Dyspnoea, Echocardiogram abnormal, Ejection fraction decreased, Left ventricular dysfunction, Magnetic resonance imaging heart, Mitral valve incompetence, Pericardial fibrosis, Pericarditis, Pyrexia, Right atrial enlargement, Tricuspid valve incompetence, Ventricular dysfunction
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Cardiomyopathy (narrow), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: amLODIPine (NORVASC) 5 MG tablet Take 5 mg by mouth daily. aspirin 81 MG EC tablet Take 81 mg by mouth daily. atorvastatin (LIPITOR) 80 MG tablet Take 1 tablet by mouth daily. B Complex Vitamins (VITAMIN B COMPLEX PO) Take 1 t
Current Illness:
Preexisting Conditions: CAD (status post prior inferior wall STEMI status post RCA and LAD stenting 2014), GERD, Hypertension, Hemachromatosis and Psoriasis
Allergies: NKDA
Diagnostic Lab Data: Echocardiogram 3/15/21 1. Moderately depressed left ventricular systolic function with ejection fraction of 35 to 40%. Possible early apical thrombus. 2. Right ventricular systolic function is moderately depressed. 3. Mild right atrial enlargement. 4. Trace mitral insufficiency. 5. Mild tricuspid insufficiency with upper normal right ventricular systolic pressure 29 mmHg. 6. Aortic valve sclerosis without significant stenosis. 7. Mild dilatation of the ascending aorta at 3.9 cm. Mild dilatation of the aortic root at the sinus of Valsalva at 3.9 cm. 8. Health Center previous echocardiogram on 10/20/2014, left ventricular systolic dysfunction as well as right ventricular systolic dysfunction is seen. The aorta measures 3.9 cm compared to 3.7 cm in the previous study. Atrial measurement is more consistent with normal volume in this present study. Possible apical thrombus seen in this present study. Cardiac MRI 3/16/21: 1. There is minimal thickening of the pericardium, which measures 0.3 cm with abnormal diffuse enhancement of the pericardium seen on postcontrast images. These findings are highly suspicious for mild acute pericarditis. However, there is no discrete MR evidence for constrictive physiology, such as a definite diastolic septal bounce, and correlation with echocardiogram findings is recommended. 2. Incidental note is made of a curvilinear focus of abnormal signal identified in the inferior wall of the left ventricle, extending from the mid cavity to apex, which demonstrates transmural enhancement on postcontrast images and likely represents sequela of prior myocardial infarction. Clinical correlation is recommended. 3. Otherwise, there is no abnormal delayed gadolinium enhancement identified in the left ventricle to represent myocarditis. 4. There is mildly diminished systolic function of the left ventricle with an ejection fraction of 52%. 5. Incidental note is made of small bilateral layering pleural effusions.
CDC Split Type:

Write-up: 3/14/21 complaints of low-grade fever, cough, chills and difficulty with taking in a deep breath after receiving his second COVID vaccine about 5 days prior. New diagnosis of pericarditis given based on symptoms and cardiac MRI

VAERS ID:	1132799 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-23
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-03-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Endotracheal intubation, Intensive care, Respiratory disorder, SARS-CoV-2 test positive
SMQs:, Angioedema (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received 1st COVID-19 vaccine on 3/2/2021 (Pfizer). He was admitted to his local hospital earlier in the week with worsening respiratory status, progressed to needing intubation and was transferred to our hospital for a higher level of ICU care. On 3/23/2020 he tested positive for COVID-19 via SARS-CoV-2 PCR NP swab. He is still currently inpatient.

VAERS ID:	1133511 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-05
Onset:	2021-01-06
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1284 / 2	LA / -

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Eye pain, Fatigue, Headache, Hyperhidrosis, Pyrexia, SARS-CoV-2 test
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Glaucoma (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210127; Test Name: Nasal Swab; Result Unstructured Data: Test Result:Negative
CDC Split Type: USPFIZER INC2021264892

Write-up: Severe sweating; fever; weakness; Worst headache of my life/daily headaches; searing eye pain; fatigue; This is a spontaneous report from a contactable physician (patient). A 50-year-old male patient received his second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: El1284), via an unspecified route of administration in left arm on 05Jan2021 16:00 as a single dose for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. The patient previously received his first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: Ek5730) in the right arm on 16Dec2020 12:00 PM. The patient had no other vaccine in four weeks. The patient had not been diagnosed with COVID prior vaccination. The patient experienced severe sweating, fever, weakness, "worst headache of my life," searing eye pain for the last 2 months, daily headaches and fatigue on 06Jan2021 12:00 AM (also reported as first 48 hours). The events resulted in disability or permanent damage. Treatment was administered for the reported events. Outcome of events was unknown. The patient underwent Covid nasal swab test post vaccination on 27Jan2021 with negative result.; Sender''s Comments: Based on temporal association and known drug profile a contributory role of BNT162B2 to the reported events cannot be excluded. Case will be reassessed if additional information is received. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.

VAERS ID:	1134751 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-14
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-03-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 1	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized within 4 days of getting the vaccine and passed away 6 days after getting the vaccine

VAERS ID:	1135286 (history)
Form:	Version 2.0
Age:	98.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-02-18
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / OT
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER	- / UNK	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Blood pressure measurement, Chills, Consciousness fluctuating, Hypertension, Urinary tract infection
SMQs:, Neuroleptic malignant syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypoglycaemia (broad)

Write-up: in and out of consciousness; blood pressure was 170/112; severe chills; UTI; A spontaneous report was received from a consumer, concerning a 98-year old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced severe chills/ chills, blood pressure was 170/112/ hypertension, was in and out of consciousness/ consciousness fluctuating, chronic heart failure/ cardiac failure chronic and urinary tract infection (UTI). The patient''s medical history included were chronic heart failure and urinary tract infection. Concomitant medication included was apixaban. On 18 Feb 2021, the patient received their second of two planned doses of mRNA-1273 (Lot number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 18 Feb 2021, same day of receiving vaccine, the patient experienced severe chills, blood pressure was 170/112, and was in and out of consciousness. She was hospitalized and remained at the hospital. The patient received both scheduled doses of mRNA-1273 prior to the events; therefore, action taken with the drug in response to the events is not applicable. The outcome of events, were considered as unknown.; Reporter''s Comments: Very limited information regarding the events has been provided at this time. However, advanced age, history of chronic heart failure and concurrent underlying urinary tract infection may remain as risk factors. Further information has been requested.

VAERS ID:	1135521 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-29
Onset:	2021-02-08
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-03-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9262 / 1	LA / -

Administered by: Private Purchased by: ?
Symptoms: Cataract nuclear, Macular oedema, Retinal artery occlusion, Retinal vein occlusion
SMQs:, Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Lens disorders (narrow), Retinal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: OMEPRAZOLE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Acid reflux (esophageal); Allergy to animal (Allergies to medications, food, or other products: mollusks)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021268092

Write-up: Central retinal vein occlusion with macular edema of left; Central retinal vein occlusion with macular edema of left; ophthalmic and retinal artery occlusion left eye; nuclear sclerosis of both eyes; This is a spontaneous report from a contactable consumer (patient). A 72-year-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Formulation: Solution for injection; Lot Number: EL9262) via an unspecified route of administration in the left arm on 29Jan2021 14:45 (at the age of 72-year-old) as a single dose for COVID-19 immunization. Medical history included acid reflux and allergies to mollusks. The patient did not receive other vaccine in four weeks prior to vaccination. Prior to vaccination the patient was not diagnosed with COVID-19. Since the vaccination, the patient has not been tested for COVID-19. Concomitant medication included omeprazole (MANUFACTURER UNKNOWN). On 08Feb2021 at 06:00, the patent experienced central retinal vein occlusion with macular edema of left eye; ophthalmic and retinal artery occlusion, left eye and nuclear sclerosis of both eyes. The seriousness criteria were considered as disability. The event resulted in Doctor or other healthcare professional office/clinic visit. Therapeutic measures were taken as a result of events and included treatment with intraocular injection of anti-VEGF. The outcome of the events was unknown.

VAERS ID:	1135743 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN5318 / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Blood pressure measurement, Electrocardiogram, Erythema, Hypertension
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Hypertension (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: It got to 217/99; I got really red; This is a spontaneous report received from a contactable consumer (Patient). A 79-years-old female patient received first dose bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE; Solution for injection, Lot Number: EN5318), via an unspecified route of administration on 09Feb2021 at single dose for COVID-19 immunization. Patient''s medical history included Cancer, asthma. Concomitant medications included letrozole taken for neoplasm malignant, gabapentin, montelukast taken for asthma. Patient received the first dose after half an hour the patient had such subjective symptoms as red, blood pressure had gotten very high after half an hour of Vaccination. It got to 217/99 having somewhat high blood pressure but not that high. Patient went to the emergency room at a hospital they put me on EKG machine to monitor my heart and took some blood samples. Benadryl was given as treatment. The outcome of the events was unknown.

VAERS ID:	1137348 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-16
Onset:	2021-03-16
Days after vaccination:	28
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	023M20A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1137461 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-25
Onset:	2021-03-25
Days after vaccination:	28
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, COVID-19 pneumonia, Hypoxia, Intensive care
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol, amiodarone, atorvastatin, bumetanide, cholecalciferol, cinacalcet, diltiazem, ferrous sulfate, fluticasone-salmeterol, ipratropium-albuterol, levothyroxine, metolazone, metoprolol, multivitamin, nystatin cream, omeprazole, warf
Current Illness:
Preexisting Conditions: COPD, hyperlipidemia, hypertension, paroxysmal afib, gastric ulcer, CKD stage 4, gout, hyperparathyroidism, spinal stenosis (lumbar), hypothyroidism.
Allergies: Latex (itching/rash), environmental
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received first Moderna COVID shot 2/25/2021. Pt developed acute on chronic respiratory failure with hypoxia, presented to local hospital ED on 3/25 and transferred to our facility for higher level of care. Currently in ICU with covid related hypoxia and pneumonia.

VAERS ID:	1137518 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-17
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1137705 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-18
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6205 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1137817 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-09
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1137863 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-10
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1138067 (history)
Form:	Version 2.0
Age:	28.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-03-21
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / UNK	UN / SYR

Administered by: Unknown Purchased by: ?
Symptoms: Catheterisation cardiac normal, Chest pain, Echocardiogram, Echocardiogram abnormal, Effusion, Ejection fraction, Electrocardiogram ST segment abnormal, Myocarditis, Nausea, Oropharyngeal pain, Pain, Pain in extremity, Pericarditis, Pyrexia, Troponin increased
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: 24 hours following administration patient developed body aches, fever (101), sore throat and nausea. 72 hours after receiving the shot he developed sudden onset substernal chest pain described as sharp and burning with radiation to his bilateral arms.

VAERS ID:	1138122 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-20
Onset:	2021-03-13
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 2	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1138168 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-10
Onset:	2021-03-23
Days after vaccination:	41
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	UN / UN

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

Write-up: Case had both COVID vaccines: 1/20/21 and 2/10/21. Case developed symptoms and had a positive Case rSARS-CoV-2 Ag Resp Ql IA.rapid~COVID19 TEST-positive on 3/23. Hospitalized. 3/26: SARS-CoV-2 RNA Nph Ql NAA+non-probe~COVID19 TEST-positive.

VAERS ID:	1138181 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-03-06
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1138357 (history)
Form:	Version 2.0
Age:	37.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-03-02
Days after vaccination:	26
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1138552 (history)
Form:	Version 2.0
Age:
Sex:	Male
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-03-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Activated partial thromboplastin time, Alanine aminotransferase, Antibody test, Antinuclear antibody, Aspartate aminotransferase, Autoantibody test, Blood albumin, Blood alkaline phosphatase, Blood bilirubin, Blood creatine, Blood fibrinogen, Blood immunoglobulin G, Blood lactate dehydrogenase, Blood urea, Complement factor C3, Complement factor C4, Double stranded DNA antibody, Epstein-Barr virus antibody, Full blood count, Globulin, HIV antibody, Haemoglobin, Haptoglobin, Hepatitis B antibody, Hepatitis C antibody, Immune thrombocytopenia, Investigation, Platelet count, Protein total, Prothrombin time, Rheumatoid factor, SARS-CoV-2 antibody test, SARS-CoV-2 test, Vital signs measurement, White blood cell count
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Upper respiratory symptom (Two months prior to receiving the vaccine)
Allergies:
Diagnostic Lab Data: Test Name: partial thromboplastin time; Result Unstructured Data: Test Result:normal or negative; Test Name: alanine aminotransferase; Result Unstructured Data: Test Result:mildly elevated (90); Test Name: alanine aminotransferase; Result Unstructured Data: Test Result:normalized; Test Name: antibodies for Cyclic Citrullinated Peptide; Result Unstructured Data: Test Result:normal; Test Name: Jo1; Result Unstructured Data: Test Result:normal; Test Name: Scleroderma; Result Unstructured Data: Test Result:normal; Test Name: Sjogren''s syndrome A antibody; Result Unstructured Data: Test Result:2.8 was elevated; Comments: normal <1 AI; Test Name: Sjogren''s syndrome A antibody; Result Unstructured Data: Test Result:1.5; Comments: decreased from 2.8 on day 6 to 1.5 (normal <1 A); Test Name: Sjogren''s syndrome A antibody; Result Unstructured Data: Test Result:<0.2; Comments: day 34; Test Name: Sjogren''s Syndrome B; Result Unstructured Data: Test Result:normal; Test Name: Smith; Result Unstructured Data: Test Result:normal; Test Name: Anti Centromere; Result Unstructured Data: Test Result:Normal; Comments: (<1:80, normal <1:80); Test Name: Anti Centromere; Result Unstructured Data: Test Result:normal; Test Name: Antinuclear Antibody; Result Unstructured Data: Test Result:<1:80; Comments: normal <1:80; Test Name: Ribosomal P Protein; Result Unstructured Data: Test Result:normal; Test Name: Sm/Rnp IgG; Result Unstructured Data: Test Result:normal; Test Name: aspartate aminotransferase; Result Unstructured Data: Test Result:mildly elevated (42); Test Name: aspartate aminotransferase; Result Unstructured Data: Test Result:normalized; Test Name: Ia/IIa platelet autoantibodies; Test Result: Positive ; Test Name: albumin; Result Unstructured Data: Test Result:normal or negative; Test Name: plasma IIb/IIIa; Test Result: Positive ; Test Name: alkaline phosphatase; Result Unstructured Data: Test Result:normal or negative; Test Name: bilirubin; Result Unstructured Data: Test Result:normal or negative; Test Name: creatine; Result Unstructured Data: Test Result:normal or negative; Test Name: fibrinogen; Result Unstructured Data: Test Result:normal or negative; Test Name: Chromatin IgG; Result Unstructured Data: Test Result:normal; Test Name: LDH; Result Unstructured Data: Test Result:normal or negative; Test Name: BUN; Result Unstructured Data: Test Result:normal or negative; Test Name: complement C3; Test Result: 94 mg/dl; Comments: normal; Test Name: complement C4; Test Result: 10.9 mg/dl; Comments: low; Test Name: complement C4; Test Result: 27.6 mg/dl; Comments: day 34; Test Name: dsDNA; Result Unstructured Data: Test Result:normal; Test Name: Epstein-Barr Virus serology; Test Result: Negative ; Test Name: complete blood count; Result Unstructured Data: Test Result:unremarkable; Test Name: globulin; Result Unstructured Data: Test Result:normal or negative; Test Name: hemoglobin; Result Unstructured Data: Test Result:normal; Test Name: haptoglobin; Result Unstructured Data: Test Result:normal or negative; Test Name: Hepatitis B,; Test Result: Negative ; Test Name: Hepatitis C antibody; Test Result: Negative ; Test Name: HIV; Test Result: Negative ; Test Name: electrolytes; Result Unstructured Data: Test Result:normal or negative; Test Name: exam; Result Unstructured Data: Test Result:normal; Test Name: platelet count; Result Unstructured Data: Test Result:2 x10 9/l; Comments: severe thrombocytopenia with a platelet count of 2 x 109/L; Test Name: platelet count; Result Unstructured Data: Test Result:<100 x10 9/l; Test Name: platelet count; Result Unstructured Data: Test Result:normalized to 173 x10 9/l; Comments: on day 11; Test Name: platelet count; Result Unstructured Data: Test Result:145 x10 9/l; Test Name: platelet count; Result Unstructured Data: Test Result:28 x10 9/l; Test Name: total protein; Result Unstructured Data: Test Result:normal or negative; Test Name: prothrombin time; Result Unstructured Data: Test Result:normal or negative; Test Name: Rheumatoid factor; Result Unstructured Data: Test Result:normal; Test Name: SARS-CoV-2 IgG antibody; Test Result: Negative ; Test Name: nasopharyngeal swab; Test Result: Negative ; Test Name: PCR assay for SARS-CoV-2; Test Result: Negative ; Test Name: SARS-CoV-2; Test Result: Negative ; Test Name: Vital signs; Result Unstructured Data: Test Result:normal; Test Name: white-cell count; Result Unstructured Data: Test Result:normal
CDC Split Type: USPFIZER INC2021286072

Write-up: vaccine may be linked to the patient''s ITP/the ITP became clinically apparent following the vaccine; A 22-year-old healthy male with no medication use received the Pfizer-BioNTech BNT16B2b2 mRNA vaccine through his work as an emergency department employee. On day three, post-vaccination, he experienced widespread petechiae and gum bleeding, which prompted his presentation. He was current on his vaccines, including yearly influenza, with no history of adverse reactions. He denied respiratory and gastrointestinal complaints or a history of infection. He had no personal or family history of bleeding or autoimmune disease. Vital signs and the remainder of his exam were normal. Laboratory tests revealed normal white-cell count, hemoglobin, and severe thrombocytopenia with a platelet count of 2 x 109/L. Two months prior to receiving the vaccine, the patient was evaluated at an outpatient clinic for upper respiratory symptoms. His PCR assay returned negative for SARS-CoV-2, and complete blood count was unremarkable with a normal platelet count of 145 x 109/L (reference range, 140-400 x 109/L). The upper respiratory symptoms resolved within a few days, and the patient had no further complaints. However, as a precautionary measure, one-week post outpatient evaluation, he was again tested for SARS-CoV-2, which returned negative. At the emergency department on day 3, post-vaccination, the following labs were normal or negative: prothrombin time, partial thromboplastin time, fibrinogen, BUN, creatine, electrolytes, bilirubin, LDH, alkaline phosphatase, albumin, globulin, total protein, and haptoglobin. The aspartate aminotransferase and alanine aminotransferase were mildly elevated; however, they normalized the next day. Additionally, he tested negative for HIV, Hepatitis B, Hepatitis C antibody, and Epstein Barr Virus serology. A nasopharyngeal swab also returned negative for SARS-CoV-2 antigen. The patient was then admitted and given dexamethasone 40 mg daily for 4 days, a platelet transfusion, and intravenous immunoglobulin at 1 g/kg for 2 days. Immunologic studies performed on day 6 for Rheumatoid factor, antibodies for Cyclic Citrullinated Peptide, Anti Centromere, Chromatin IgG, dsDNA, Jo1 , Ribosomal P Protein, Ribonucleoprotein, Scleroderma, Smith, Sjogren''s Syndrome B, Sm/Rnp IgG, Antinuclear Antibody (<1:80, normal <1:80) were normal. However, Sjogren''s Syndrome A antibody (2.8) was elevated (normal <1 AI). On day six, post-vaccination, petechiae and oral bleeding decreased, and the patient was discharged with a platelet count of 28 x 109/L. Based on the presentation, a platelet count <100 x 109/ L, and the exclusion of alternative causes, a diagnosis of ITP was made. At follow up, on day 11, the patient''s platelet count normalized to 173 x 109/L, and the patient tested positive for plasma IIb/IIIa and Ia/IIa platelet autoantibodies. Sjogren''s Syndrome A antibody decreased from 2.8 on day 6 to 1.5 (normal <1 AI). Moreover, complement C3 (94) was normal (reference range, 79-152 mg/dL), while complement C4 (10.9 mg/dL) was low (reference range, 16-38 mg/dL). On day 34 a repeat of the patient''s abnormal immunologic studies showed a normal value of both Sjogren''s syndrome A antibody (SSA AB: <0.2) and Complement C4 (27.6 mg/dL). Additionally, SARS-CoV-2 IgG antibody testing was performed to rule out that a previous COVID-19 infection elicited the ITP experienced on day 3. However, SARS- CoV-2 IgG was negative. As of 16Feb2021, and since the patient''s discharge on day 6, he remains healthy without any evidence or symptoms of autoimmune disease. [Correction added on 22Feb2021, after first online publication: 11Feb2021]. Previous studies reported only mild or moderate adverse events following the Covid-19 vaccine. To the author''s knowledge, outside of a report in the press, this is the first case published in the medical literature of an individual, with no other cause identified and no associated illness, experiencing ITP after receiving the Pfizer-BioNTech vaccine. The temporal relationship of the patient''s presentation 3 days post-vaccine administration suggests, but does not prove, the vaccine may be linked to the patient''s ITP. Additionally, the rapid and severe drop in platelet count to 2 x 10 9/L is reminiscent of the abrupt onset observed in drug-induced thrombocytopenia, which further suggests a recent etiology. However, it must be noted that the incidence of ITP is about 3.3 per 100 000 adults/year.8 Therefore, it is also plausible that this patient''s diagnosis was purely coincidental, given that over 12 million vaccines administered to date. Additionally, 43 448 participants were included in the Pfizer-BioNTech trial, and no ITP was reported. Moreover, considering the low complement C4 (10.9 mg/dL), mildly elevated SSA Ab (1.5), and 2 months prior, the platelet count (145 x 109/L) was near the lower limit, it is difficult to exclude alternative causes, such as an underlying autoimmune condition with pre-existing ITP. In this scenario, the ITP became clinically apparent following the vaccine, though this patient never manifested symptoms suggestive of autoimmune disease. This case was reported to the FDA''s Vaccine Adverse Events Reporting System (VAERS) and is valuable both for post-approval pharmacovigilance and as a foundation for clinicians to evaluate future patients with suspected ITP. Rare vaccination events are important, but do not diminish the enormous utility of vaccination and the well-documented safety profile of the Pfizer-BioNTech BNT16B2b2mRNA vaccine. No follow-up attempts are needed; information about batch/ lot number cannot be obtained.; Sender''s Comments: The causal relationship between the reported event immune thrombocytopenia and BNT16B2b2 vaccine cannot be excluded based on a plausible temporal association. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to RAs, Ethics Committees, and Investigators, as appropriate.

VAERS ID:	1141878 (history)
Form:	Version 2.0
Age:	45.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-02-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	041L20A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood fibrinogen, Epinephrine, Epistaxis, Haemoglobin, Platelet function test abnormal, Surgery
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: norethindrone daily, zoloft 50mg daily
Current Illness: none3
Preexisting Conditions: endometriosis, scoliosis, chronic sinusitis
Allergies: percocet, vicodin, darvocet, ultram
Diagnostic Lab Data: 2/6 abnormal platelet function tests, fibrinogen, platelet epinephrine test, hemoglobin
CDC Split Type:

Write-up: Sudden unstoppable nasal bleeding that needed emergent surgery to stop it. In 12 hour time span I had to report to ER 3 times to try to stop the bleeding. On the third visit ENT was called in and I had emergent surgery to stop the bleeding. I spent the night in the hospital. I lost about 4 or 5 units of blood. I have never had nose bleeds like this in the past.

VAERS ID:	1142512 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-03-19
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Acute myocardial infarction, Electrocardiogram ST segment normal, Fatigue, Gastrooesophageal reflux disease, Myalgia, Nausea, Sleep disorder, Troponin normal, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: CAD, DM2, obesity, HTN, recurrent PE, RA, hyperlipidemia, CKD3
Allergies: NKA
Diagnostic Lab Data: Troponin 0.07. No ST changes on EKG
CDC Split Type:

Write-up: Pt was hospitalized from 3/19-3/21 for intractable n/v following COVID-19 vaccination and subsequently had a type 2 NSTEMI. Pt states she got her vaccine on Thursday and then developed severe GERD sx that night. She states she normally does not have GERD and she tried antacids and PPI for her sx. She states she tried to sleep but awoke with projective vomiting and was unable to stop this. She also had myalgias and fatigue. She went to ER and hospital notes indicate supportive care was given and sx resolved quickly. Pt never developed any CP or SOB.

VAERS ID:	1143470 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-19
Onset:	2021-03-05
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / -

Administered by: Other Purchased by: ?
Symptoms: Asthenia, Dizziness, Gait disturbance, Hypoaesthesia
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Vestibular disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Bladder cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021273677

Write-up: feel weak; dizzy; acute numbness in both legs running up my feet to my knees - all balance - could not stand without assistance.; acute numbness in both legs running up my feet to my knees - all balance - could not stand without assistance/partial numbness in the face; This is a spontaneous report from a contactable consumer (patient). A 69-years-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection, lot number and expiration date unknown), via an unspecified route of administration in the left arm on 19Feb2021 at 14:00 as a single dose for COVID-19 immunization. Medical history included bladder cancer. The patient had no known allergies. The patient''s concomitant medications were not reported. The patient previously received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration in the left arm on 29Jan2021 at 14:00 for COVID-19 immunization. The patient had no other vaccine in four weeks. Exactly two weeks after the second dose was administered (on 05Mar2021), the patient started to feel weak and dizzy and experienced acute numbness in both legs running up to his feet to his knees - all balance - could not stand without assistance, with partial numbness in the face. These progressively got worse for several days until disappearing on 12Mar2021. The patient had no COVID prior to vaccination and had not tested post-vaccination. No treatment was administered for the events. The patient recovered from the events on 12Mar2021. The adverse events (AE) resulted in: disability or permanent damage. Information on the batch/lot number has been requested.

VAERS ID:	1143598 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-19
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	014M20A / 1	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Dyspnoea, Fibrin D dimer increased, Pulse absent, Resuscitation, Syncope, Troponin increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: amlodipine, donepezil, fluoxetine, rosuvastatin, MVI, calcium/vit D
Current Illness: none
Preexisting Conditions: HTN, HLD, Crohn''s disease, anxiety, depression, Alzheimer''s
Allergies: NKDA
Diagnostic Lab Data: Initial troponin 0.568, d-dimer 13.6
CDC Split Type:

Write-up: Presented at PCP''s office for progressive shortness of breath for the past few days. During visit patient had a syncopal episode regained consciousness then lost pulse for which she received 4 minutes of resuscitative care with chest compressions. She did regain a pulse after about 4 minutes of chest compressions. During that time emergency room physician said he saw a slow narrow complex rhythm. No reports of ventricular arrhythmias. Troponin and d-dimer were elevated. Heparin was started in the ED. During stay she was started on warfarin and bridging with heparin.

VAERS ID:	1143656 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-28
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: COVID-19, Dizziness, Fall, Head injury, Hypoacusis, Loss of consciousness, SARS-CoV-2 test positive, Sinus congestion
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hearing impairment (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first Moderna COVID-19 vaccine on 3/15/21. Starting 3/27, patient began to have acute onset dizziness, muffled hearing, loss of consciousness and sinus congestion. On 3/28, this dizziness lead to a fall in which he hit his head and was sent to the ED. Pt tested positive for COVID 19 while in the ED, and was admitted.

VAERS ID:	1143914 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-03-17
Days after vaccination:	28
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Write-up: Cardiology provider wanted to report that patient experienced an acute CHF exacerbation within 1-3 weeks after vaccine administration. Admitted to hospital for IV diureses.

VAERS ID:	1145128 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-15
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1145290 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-16
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6205 / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Fundoscopy abnormal, Magnetic resonance imaging abnormal, Magnetic resonance imaging head normal, Optic atrophy, Optic nerve sheath haemorrhage, Optic neuritis, Optic perineuritis, Papilloedema, Visual acuity reduced
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Glaucoma (narrow), Optic nerve disorders (narrow), Demyelination (narrow), Lens disorders (broad), Retinal disorders (narrow), Ocular infections (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Pt seen in ophthalmology clinic 3/16/21 for evaluation of c/o bilateral vision loss and admitted to hospital for further evaluation and management based on their findings. She has known history of cataracts, macular thinning of the left eye and bilateral pseudophakia, but no recent vision issues. Pt states that approximately 3 to 4 days after getting her first COVID-19 vaccination (Pfizer) on 2/16/2021 she noted blurred vision in left eye and over the course of the next several days, started to have worsening blurring as well as darkening of her vision to the point where she was only able to see faint outlines of objects. Did also have some associated visual hallucinations with this. Seen in clinic (exact date unknown but sometime between 2/16/21 and 3/8/21) where a visual acuity exam was done, and no further evaluation was recommended. But pt had ongoing issues and was ultimately seen by ophthalmology on 3/8/21 and was then directed to the ED on 3/8/2021 for possible stroke evaluation. In the ED, CT of the brain was negative for acute stroke. MRI was advised, but patient declined during that ED visit and voiced preference to schedule outpatient, however, she was never able to make that appointment. On 3/9/21, pt received her second COVID-19 vaccine, and 1 to 2 days later, she developed the same symptoms in the right eye, though does not feel that her visual acuity decreased by as much in that eye as it had in the left eye. Pt also has had mild associated frontal headache since her first COVID-19 vaccination, but it responds readily to acetaminophen. Pt seen in ophthalmology clinic again on 3/16/21. At that appointment, she had a funduscopic exam which showed mild temporal pallor and ophthalmology felt that this is likely inflammation of the optic nerve or optic nerve sheath, likely secondary to retrobulbar optic neuritis versus perineuritis possibly triggered by recent vaccination. Request was made for admission to Hospital for further evaluation and management. Hospital Course (admitted 3/16/21 ? 3/22/21): MRI of the brain and orbits revealed optic neuritis. In consultation with neurology and neuro-ophthalmology the pt was started on a 5-day course of methylprednisolone 1 g IV daily. The pt noted improvement in her vision rapidly. Primary diagnosis at discharge was optic neuritis, possibly triggered by covid-19 vaccination.

VAERS ID:	1145479 (history)
Form:	Version 2.0
Age:	87.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-27
Onset:	2021-03-27
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	16B21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood gases, Coma scale abnormal, Computerised tomogram, Death, Endotracheal intubation, Extensor plantar response, Full blood count, Haemorrhagic stroke, Liver function test, Metabolic function test, Posturing, Respiratory distress, SARS-CoV-2 test, Tachycardia, Troponin, Unresponsive to stimuli, Urine analysis
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dystonia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol Calcitonin Calcium Acetate Vitamin B-12 Digestive Aids Mixture OR Multivitamin Preservision AREDS Omega 3 Systane Probiotic Tramadol Kenalog 0.1% Cream
Current Illness: none known
Preexisting Conditions: Hyperlipidemia GERD Osteoporosis Nontraumatic hemorrhage of right cerebral hemishere
Allergies: NKA
Diagnostic Lab Data: CT BMP Hemogram liver panel troponin UA COVID-19 swab Atrial Blood gas
CDC Split Type:

Write-up: Patient received vaccine at 10:18am and then went home with no reaction in the vaccination POD. EMS was called to the patients home shortly before 2:30 that afternoon. When EMS arrived patient was posturing with lower extremities extended in plantar flexion. Last seen normal 30 minutes prior. she was also tachycardic and in respiratory distress with sonorous respirations. Cranial nerve deficit present GCS 3.She was unresponsive and intubated. Airlifted after CT to hospital. She died at 1647 at Hospital from hemorrhagic stroke.

VAERS ID:	1146025 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-03-19
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood alkaline phosphatase increased, Chills, Computerised tomogram abdomen abnormal, Diarrhoea, Liver abscess, Neutrophil count increased, Pyrexia, White blood cell count increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Liver infections (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Biliary system related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow)

Write-up: fever/chills/diarrhea x 2 weeks

VAERS ID:	1146696 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-08
Onset:	2021-03-08
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6199 / 1	LA / SYR

Administered by: Unknown Purchased by: ?
Symptoms: Atrial fibrillation, Heart rate increased, Incomplete course of vaccination, Laboratory test
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Medication errors (narrow), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamins
Current Illness: I went to the emergency room the same day that I had the Vaccination. I was in atrial Fib for approx. 1 hr. my blood pressure was 180/150 and remained in the emergency for several hours. My primary Dr. wants me to follow-up with a cardiologist even though I have had no prior heart issues. I will not be taking the 2nd shot today because of this experience.
Preexisting Conditions:
Allergies: Morphine
Diagnostic Lab Data: All labs were done in the ER
CDC Split Type:

Write-up: Fast heart rate/ atial Fib went to the emergency on 3/8/2021 at 8pm

VAERS ID:	1147151 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-12
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-03-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-16
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received email from Public Health Nurse that patient had passed away on 3-16-21. The coroner did not believe it was associated with the vaccine, just reporting the death. Requested VAERS form still be filled out.

VAERS ID:	1147316 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-28
Onset:	2021-03-05
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-03-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Cough, Dyspnoea, Laboratory test, Mental status changes, Pyrexia, X-ray
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: 2/28/2021-received second dose of Moderna COVID Vaccine. 3/1/2021-Emergency Room visit for cough-after labs and xray, and she being at baseline, was discharged back to facility. Return to ED on 3/5/2021 with altered mental status, shortness of breath, wet cough, and fever. Patient admitted to hospital.

VAERS ID:	1147356 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-13
Onset:	2021-03-29
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-03-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1805022 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Bradykinesia, COVID-19, Cough, Mental status changes, Pneumonia, Pyrexia, SARS-CoV-2 test positive, Tachycardia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Parkinson-like events (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received dose of J&J vaccine (Janssen) on 3/13/2021. Symptoms began around 3/27 similar to COVID-19. Pt presented to ED at another local hospital 3/29/2021, tested positive for COVID-19 and was transferred to be admitted to our hospital for treatment of COVID-19. Notes from hospital admission H&P: Patient is a 59 y.o. male with history DM, Who presented to Urgent care then hospital ER with covid positive, PNA, Fever and a cough. Real tachycardic there to 117, temp to 103, confused, moving slow. Altered mental status (slow cognition), 94% on 2L"

VAERS ID:	1148280 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-16
Onset:	2021-03-01
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-03-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	023M20A / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1148539 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-28
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-03-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6199 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Asthenia, Blood pH decreased, Cardio-respiratory arrest, Catheterisation cardiac, Intensive care, Troponin, Urinary tract infection, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Lactic acidosis (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Weakness, coded in ED, sent to cath lab and then ICU

VAERS ID:	1148864 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-08
Onset:	2021-03-16
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-03-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 1	AR / SYR

Administered by: Private Purchased by: ?
Symptoms: Acute respiratory failure, Cardiac septal hypertrophy, Chills, Computerised tomogram thorax abnormal, Condition aggravated, Deep vein thrombosis, Diastolic dysfunction, Dyspnoea, Dyspnoea exertional, Echocardiogram, Echocardiogram abnormal, Exercise tolerance decreased, Fatigue, Loss of personal independence in daily activities, Lung opacity, Myocardial strain, Oxygen saturation decreased, Pain, Peripheral artery thrombosis, Pulmonary embolism, Pulmonary mass, Right ventricular dilatation, Ultrasound Doppler, Ultrasound scan abnormal
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Interstitial lung disease (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad)

Write-up: Pt is a previously healthy 76 year old woman who received her covid vaccine 2 wks ago. She received Moderna vaccine on 3/8/21. On 3/16/21 She developed symptoms of fatigue, chills, body aches, decreased exercise tolerance. 3/19/21 exercised at YMCA as she does regularly. She was not able to do her usual level of activity and was only able to exercise low level for 10 minutes. Yesterday was very sob and after washing 2 windows had to lay down and rest. In my office the nurse rooming the pt noted the pt to be very winded and sob just ambulating from waiting room to the exam room. Pox was down to 89% and took a while to come up to 94%. Transferred to Hospital ED. DiagnosedDiagnosis: Acute hypoxic respiratory failure secondary to massive Pulmonary Emboli, DVT without known precipitating factors. pt without previous history of clotting disorder, no known neoplasm, no recent travel or sedentary period. unprovoked DVT with MASSIVE PE. patient did not have previous pulmonary disease. Additional information for Item 19: studies: PO Chest Final Result Stable chest. No new opacities are identified in this patient with known extensive bilateral pulmonary embolus. US Venous Duplex Lower Extremity Bilateral Final Result 1. Acute DVT involving the right popliteal and posterior tibial veins. 2. No acute DVT involving the left lower extremity. CT PE Protocol WITHOUT legs Final Result 1. Positive exam: Large-volume central pulmonary emboli seen in both main pulmonary arteries with extension bilaterally into all lobes. Dilated right heart chambers suggesting acute right heart strain. 2. Peripheral groundglass opacities in the right upper lobe may represent small area of pulmonary hemorrhage or developing infarct. Red Level 1 findings were entered into the system. | Actionable Findings system for documentation and communications on 3/22/2021 4:31 PM, Message ID 191499. 3. Pulmonary nodules in the right lower lobe measure up to 4 mm maximally. See below consensus guidelines. TTE - INTERPRETATION SUMMARY: Left ventricle is normal in size. There is normal left ventricular systolic function. The quantitative LVEF based on modified Simpson''s method is 62%. There is asymmetric septal hypertrophy with maximal wall thickness of 1.3 cm. There is mild (grade I) diastolic dysfunction with normal left atrial pressure. Right ventricle is normal in size. There is normal right ventricular systolic function. No previous echocardiogram in Froedtert Health system for comparison.

VAERS ID:	1149835 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-27
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-03-31

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	VO1B21F / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Cardiac disorder, Death, Injection site pain
SMQs:, Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-29
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None.
Current Illness: None known.
Preexisting Conditions: According to her family, patient had no known medical history as she refused to go to the doctor. She had no primary physician and had never been hospitalized.
Allergies: None known.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received her first Moderna COVID-19 vaccination on 03/11/2021. She did not have any ill effects directly afterwards. However, starting on 03/27/2021, she began complaining of left arm pain in the area of the injection. She continued to complain of pain in the injection site on 03/28/2021. On 03/29/2021, her roommate found her deceased on her bed due to a probable cardiac event.

VAERS ID:	1149915 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-03
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-31

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9269 / 1	RA / OT

Administered by: Unknown Purchased by: ?
Symptoms: Arthralgia, Computerised tomogram, Pain in extremity, Vaccination site pain
SMQs:, Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: none
Allergies:
Diagnostic Lab Data: Test Date: 20210201; Test Name: CAT Scan of his head and neck; Result Unstructured Data: Test Result:normal
CDC Split Type: USPFIZER INC2021148837

Write-up: her husband''s pain is more in his right elbow and right shoulder/pain is more like a joint pain; right arm pain started with the COVID-19 Vaccine injection site/pain is in his right (dominant) arm; husband is experiencing a sore arm, husband''s arm has been sore as worsened; This is a spontaneous report from a contactable nurse. A 86-year-old male patient received first dose of BNT162B2, (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Batch/Lot Number: EL9269), via intramuscular route of administration, administered in Arm Left on 03Feb2021 14:15 as single dose for covid-19 immunization. Medical history included was none. Concomitant medication was not reported. Upon follow-up (16Mar2021): it was reported that, first dose of Pfizer covid-19 was shot on an unspecified date at 14;15 PM via intramuscular route of administration in right arm of Batch/Lot number: EL9269. She said her husband''s arm has been sore for 8 days. Her husband''s arm has been sore for 8 days was reported as worsened. She said her husband tried Advil, Tylenol, hot packs, cold packs, and nothing seems to help his sore arm, and pain was in his right (dominant) arm, the pain was more in his right elbow and right shoulder, and her husband''s pain is more like a joint pain. She said her husband has a high tolerance for pain, and normally doesn''t take anything for pain. She said her husband can''t put his jacket on because he is unable to lift his arm due to the pain in his right elbow and right shoulder. She said her husband has been trying everything, and nothing seems to help his right elbow and right shoulder pain much. Clarified her husband''s right arm pain started with the COVID-19 Vaccine injection site and then the pain moved into his right shoulder and then into his right elbow. Reported her husband had a CAT scan of his head and neck on 01Feb2021 checking for blood clots. She said the results of the Head and Neck CAT (Computerised tomogram) Scan were normal. Reported her husband''s second COVID-19 Vaccine dose is scheduled for 24Feb2021. The reporter classified the event husband is experiencing a sore arm and husband''s arm has been sore as worsened as disability and other events was not reported and assessed the causality between the event husband is experiencing a sore arm and husband''s arm has been sore as worsened the vaccines as Related. Upon follow-up, it was reported that, the patient has a very sore arm for about 8 days but then it resolved and no trouble since then. His second shot did not have much of a reaction and both are fine now. Therapeutic measures were taken as a result of husband is experiencing a sore arm and husband''s arm has been sore as worsened and included treatment with ADVIL at a dose of 200 mg (Lot Number: W36210, Expiration Date: Nov2019), TYLENOL, at a dose of 500mg, hot packs and old packs. Upon follow-up (16Mar2021), the outcome for the events were recovered on 11Feb2021. Follow up (16Mar2021): This is a follow-up spontaneous report received from a contactable nurse includes, updated information about the first dose of Pfizer vaccine, route of administration for the second vaccine and the outcome for the events. Follow-up attempts are completed. No further information is expected.; Sender''s Comments: Considering temporal relationship and known safety profile, the reported pain in arm was likely causally related to the vaccination with BNT162B2. The case will be reassessed should additional information become available. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.

VAERS ID:	1150753 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-10
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-03-31

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Anion gap decreased, Aortic valve incompetence, Atrial fibrillation, Atrial flutter, Base excess increased, Blood bicarbonate decreased, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood glucose normal, Blood pH increased, Blood potassium normal, Blood sodium decreased, Blood urea normal, Carbon dioxide normal, Cardiomegaly, Chest X-ray abnormal, Defect conduction intraventricular, Dyspnoea, Dyspnoea exertional, Echocardiogram, Ejection fraction decreased, Electrocardiogram abnormal, Fatigue, Fibrin D dimer increased, Haematocrit normal, Haemoglobin normal, Hepatic steatosis, Left ventricular dilatation, Left ventricular dysfunction, Mean cell volume normal, Mitral valve incompetence, N-terminal prohormone brain natriuretic peptide increased, PCO2 decreased, PO2 increased, Platelet count normal, Pleural effusion, Pulmonary congestion, Pulmonary oedema, Right ventricular systolic pressure increased, SARS-CoV-2 test negative, Scan with contrast abnormal, Tachycardia, Tracheomalacia, Tricuspid valve incompetence, Troponin decreased, Ventricular dyskinesia, Ventricular hypokinesia, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Imipramine 150mg nightly. Losartan 100mg daily.
Current Illness: none
Preexisting Conditions: hypertension, obesity, panic disorder, diabetes mellitus type 2, former tobacco use
Allergies: lisinopril
Diagnostic Lab Data: 3/23: Chest x-ray shows enlargement of cardiac silhouette. see additional results below. 3/25: A complete two-dimensional transthoracic echocardiogram was performed (2D, M-mode, Doppler and color flow Doppler). The study was technically difficult. Contrast injection was performed. Patient has breast implants. Patient is in afib/aflutter and is tachycardic during exam. The left ventricle is mildly dilated. Left ventricular systolic function is severely reduced. Ejection Fraction = <25%. There is global LV akiniesis, there is inferoseptal and inferior dyskinesis. The right ventricle is normal size. The right ventricular systolic function is normal. No significant mitral valve stenosis. There is severe mitral regurgitation. No hemodynamically significant valvular aortic stenosis. Trace aortic regurgitation. There is moderate tricuspid regurgitation. Right ventricular systolic pressure is elevated at 40-50mmHg. The aortic root is normal size. There is no pericardial effusion. 3/26:Sodium 135, potassium 4.2, chloride 105, CO2 24, anion gap 6, BUN 20, creatinine 1.11, glucose 141, calcium 8.2 proBNP 2831 WBC 7.5, hemoglobin 12.3, hematocrit 40, MCV 90.7, platelet 350 SARS-CoV-2 PCR negative Twelve-lead ECG: Normal sinus rhythm with nonspecific intraventricular block. Rate 93. Chest x-ray: Stable moderate enlargement of cardiac silhouette compared to previous. Mild pulmonary vascular congestion present. No infiltrate or pleural effusion. ABG: pH 7.47, PCO2 22, PO2 138, arterial bicarb 19.5, base deficit 7.5 Troponin: Less than 0.02 D-dimer: 2588 CTA chest: No evidence for pulmonary embolism. Moderate cardiomegaly and mild pulmonary edema. Moderate right and small left pleural effusions. Tracheomalacia. Fatty liver.
CDC Split Type:

Write-up: Rapidly progressive dyspnea and fatigue, worse with even light exertion, at night and laying down.

VAERS ID:	1151244 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-03-25
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-03-31

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045AZ1A / 1	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Abdominal discomfort, Bell's palsy, Body temperature increased, Chills, Eye swelling, Fatigue, Headache, Hypoaesthesia oral, Injection site erythema, Injection site mass, Injection site pain, Injection site swelling, Malaise, Oral herpes, Peripheral swelling, Pruritus
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Oropharyngeal infections (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hearing impairment (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine 100 MCG tablet
Current Illness: None
Preexisting Conditions: Sleep Apnea
Allergies: Amoxicillin, Cyclobenzaprine, Penicillins, Sulfa Antibiotics
Diagnostic Lab Data: Doctor''s visit Wednesday March 31st.
CDC Split Type:

Write-up: On Wednesday, March 24th my husband and I got our 1st Moderna vaccine at 8:30 am. Felt good the rest of the day. On Thursday, March 25th I woke up and the bag under my right eye was really swollen and I felt like I had a big cold sore coming out on the top right side of my lip. My arm was swollen like a 2x2 area and tender but other than that I felt good. At 9:30 am that same day I started getting a headache and my stomach felt really upset. I didn''t throw up but felt like I was going to. About 10:00 am I really felt sick to my stomach and extremely tired. My headache was more intense and mostly on my right side (same side as my eye and cold sore). By noon I had the chills and was running a temperature over 100. At 3:00 when I got done with work I slept. I was only awake for a total of 1 hour and went to bed for the night at 8:15 pm. I still had a bad headache, upset stomach and chills and my arm was swelling bigger but I slept all night. On Friday, March 26th I woke up and my face looked worse. The cold sore was getting bigger and the bag under my eye was huge making my eye almost shut. I still had a bad headache and the injection site was getting bigger and stuck out far. It was hot to the touch. It was bright red and bumpy and hurt to touch it. I no longer was sick to my stomach and I had no fever. My face was still looking awful and about 2:00 pm I started running a fever again. I still had a headache. I still felt tired. On Saturday March 27th, my bag under my eye looked a little better but the cold sore was getting worse. I had a slight headache, no fever and not sick to my stomach. However, the lump at the injection site got huge. It was the size of the palm of my hand and stuck up about an inch. It was hot to the touch and red. By 9:00 pm my eye and face were worse and the right side of my face was drooping. On Sunday March 28th 8:00 am my face was worse and itchy. The cold sore was spreading up the right side of my drooping face and my eye was almost shut. I called the Teledoc and had a video call. She said that the vaccine triggered a virus in my system. She called in a prescription for Valacyclovier 1GM 4 pills. Took 2 pills at noon and then the last 2 that night before bed. She said to give it 2-3 days and it should clear up. On Monday, March 29th 6:30 am the lump in my arm is a little smaller but my eye is worse. I looked horrible. On Tuesday, March 30th I still had a low grade headache and my lip and right side of my face is kinda numb. I called my doctor and made an appointment for Wednesday, March 31st. On Wednesday, March 31, 2021, I woke up and now had a canker sore inside my top lip on the right side of my face in addition to looking like a monster. I went to the doctor?s office at 7:30 am and she said that I definitely have a virus going on and now I have Bell?s Palsy as a result. The doctor gave me a prescription for Valacyclovier 1GM tablets to take 3 times a day for 7 days. She also prescribed Prednisone 20 MG to take 3 tablets for 7 days to relief the itching and irritability of my face.

VAERS ID:	1151670 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-23
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-03-31

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Chest X-ray abnormal, Chills, Cough, Diarrhoea, Fatigue, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Write-up: Pt admitted to the hospital with fever, cough, chills, diarrhea, and fatigue with an abnormal chest X-Ray.

VAERS ID:	1153968 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Cough, Decreased appetite, Diarrhoea, Fatigue, Gait disturbance, Headache, Oropharyngeal pain, Pain, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Write-up: This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of GAIT DISTURBANCE (Felt her legs start to wobble and needed her cane to walk.), DIARRHOEA (Diarrhea), COUGH (Cough), FATIGUE (Tired), PAIN (Body aches), HEADACHE (Headache), DECREASED APPETITE (Wasn''t hungry), OROPHARYNGEAL PAIN (Sore throat from vomiting often) and VOMITING (Vomiting) in a 79-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 013a21a) for COVID-19 vaccination. The patient''s past medical history included COVID-19 in November 2020. On 26-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced GAIT DISTURBANCE (Felt her legs start to wobble and needed her cane to walk.) (seriousness criterion hospitalization), DIARRHOEA (Diarrhea) (seriousness criterion hospitalization), COUGH (Cough) (seriousness criterion hospitalization), FATIGUE (Tired) (seriousness criterion hospitalization), PAIN (Body aches) (seriousness criterion hospitalization), HEADACHE (Headache) (seriousness criterion hospitalization), DECREASED APPETITE (Wasn''t hungry) (seriousness criterion hospitalization), OROPHARYNGEAL PAIN (Sore throat from vomiting often) (seriousness criterion hospitalization) and VOMITING (Vomiting) (seriousness criterion hospitalization). The patient was hospitalized for 2 days due to COUGH, DECREASED APPETITE, DIARRHOEA, FATIGUE, GAIT DISTURBANCE, HEADACHE, OROPHARYNGEAL PAIN, PAIN and VOMITING. At the time of the report, GAIT DISTURBANCE (Felt her legs start to wobble and needed her cane to walk.), DIARRHOEA (Diarrhea), COUGH (Cough), FATIGUE (Tired), PAIN (Body aches), HEADACHE (Headache), DECREASED APPETITE (Wasn''t hungry) and VOMITING (Vomiting) outcome was unknown. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events a causal relationship cannot be excluded. Noting the history of COVID infection (Nov 2020) may remain as risk factor. Further information has been requested.

VAERS ID:	1155160 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-04
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Asthenia, Atrioventricular block first degree, Blood pressure decreased, Catheterisation cardiac abnormal, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Coronary artery disease, Coronary artery occlusion, Deep vein thrombosis, Dyspnoea, Fatigue, Fibrin D dimer increased, Gene mutation identification test negative, Hyperlipidaemia, Hypertension, Pulmonary embolism, SARS-CoV-2 test negative, Thrombectomy, Thrombosis, Type 2 diabetes mellitus
SMQs:, Anaphylactic reaction (narrow), Dyslipidaemia (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Conduction defects (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Lipodystrophy (broad), Infective pneumonia (broad), Dehydration (broad), COVID-19 (broad)

Write-up: Patient received Moderna vaccine dose #1 on 3/3/21 at approximately 0900. In the afternoon of 3/4/21, patient had sudden onset shortness of breath while at home, as well as fatigue and low energy. Patient knew that a potential side effect of vaccine was fatigue, so he assumed this was just a normal side effect to be expected. States that his difficulty breathing and fatigue continued for about a week. After continued urging from wife to seek medical care, patient visited urgent care center on 3/15/21. The urgent care did a D-Dimer lab, and an x-ray of chest. X-ray "showed something abnormal" so they did a CT scan as well, which showed a "huge pulmonary embolism." D-Dimer lab was elevated. Patient was transported to hospital by ambulance and had immediate surgery to remove blood clot from lungs at approximately 2100 on 3/15/21. Per patient, the surgeon said the clot was about the size of his palm. Surgeon reported that there was "100% blockage to left lung from the aortic artery and 90% blockage to right lung from aortic artery." A DVT in popliteal vein was identified, and the surgeon assumes the clot started in the popliteal vein and broke off and traveled to lungs. Patient was admitted and hospitalized until he was discharged home on 3/18/21. During course of hospitalization, genetic testing was done and it was determined that the "genetic marker for clots was negative, so they think the clot is from a one-time event--patient''s family does not need to be concerned that they have clotting issues." Patient states that he was started on heparin in the hospital, and was discharged home on Eliquis blood thinner, which is being tapered. Patient states that the doctors think he will be on Eliquis for about 6 months and will not need to be on it for life. Doctors say the DVT in leg will dissolve on its own. During hospitalization, an echogram and cardiac cath was performed, which showed "an old heart attack on the left side, but that collateral vessels have built up already." Right side of heart was weaker from having to work so hard due to blood clots in lung, but prior to discharge from hospital, the right side of heart was already showing improvement. A heart cath was done to check vessels and it was determined no stents were needed, although there was a small clot in left anterior descending artery. Patient was also newly diagnosed during course of hospitalization with Type II Diabetes in a non-obese person, HTN (which patient had never had before), Coronary Artery Disease, Hyperlipidemia, 1st degree AV block. Was discharged home with metformin, losartan, chlorthalidone, atorvastatin, and Aspirin. The chlorthalidone was discontinued, due to "blood pressure dropping too low--they think his high blood pressure was situational" per wife of patient. Medical doctors advised against receiving the 2nd dose of Moderna vaccine. Patient being followed by Internist at hospital. Patient''s shortness of breath resolved "immediately after clot was removed" but is continuing to be followed while on new medications and blood thinner dosing. The above information was provided during telephone interview of patient and his wife.

VAERS ID:	1155328 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-03-26
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Atrial fibrillation, Atrial flutter, Fatigue, Malaise, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient admitted to local hospital for new onset atrial fibrillation/flutter with rapid ventricular response. Patient last known well at time of vaccination (no reported complications with 1st vaccination). After 24 hrs, began feeling fatigued, with general malaise, and fever. Presented to hospital ED 4 days after vaccination and found to be in new onset afib/flutter. Required admission and introduction of diltiazem and metoprolol for rate control and started on rivaroxaban for anticoagulation

VAERS ID:	1155927 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-12
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1156161 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-14
Onset:	2021-02-19
Days after vaccination:	36
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1157054 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / UNK	LA / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	01B21A / UNK	LA / -

Administered by: Unknown Purchased by: ?
Symptoms: Ataxia, Cerebrovascular accident, Facial paralysis, Headache, Muscular weakness, Neurological symptom
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hearing impairment (broad)

Write-up: 5 hours after immunization developed head ache and stroke like symptoms with left facial droop, ataxia and left arm and leg weakness. she was given tpa for stroke and transferred to Hospital.

VAERS ID:	1157204 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-03-31
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EP7533 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Chest pain, Electrocardiogram ST segment elevation, Electrocardiogram abnormal, Myocardial infarction, Stent placement, Troponin increased
SMQs:, Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: Patient developed chest pain at about 3:30AM the following morning. Ultimately diagnosed with anterior STEMI requiring stent placement.

VAERS ID:	1158221 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Dyspnoea, Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad)

Write-up: Within 15 minutes of the administration of the 2nd dose of the vaccine, patient experienced dyspnea accompanied with sensation of throat tightness. Appeared as though patient was also suffering from sense of impending doom.

VAERS ID:	1159537 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-02-23
Days after vaccination:	27
Submitted:	0000-00-00
Entered:	2021-04-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks after receiving vaccine

VAERS ID:	1159696 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-10
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012M20A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, COVID-19, Cardiac stress test abnormal, Chest X-ray, Chest discomfort
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Other ischaemic heart disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: 77 yo male with past medical history of diabetes, stroke, aortic valve replacement, sleep apnea and hypertension. Admitted for COVID-19 infection, chest tightness, and acute kidney injury on 2/15/21. COVID was treated with bamlanivimab in emergency room (prior to acute kidney injury finding that led to hospitalization) and supportive care. Acute kidney injury was treated with IV fluids. Diagnosed with NSTEMI with cardiologist consult, outpatient stress test and conservative management. Patient discharged home on 2/18/21 with no change in home medications.

VAERS ID:	1161003 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-03-30
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Atrial fibrillation, Atrial flutter, Dizziness, Echocardiogram abnormal, Ejection fraction decreased, Hepatic enzyme increased, Hyperhidrosis, Nausea, Peripheral coldness
SMQs:, Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (narrow), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: Pfizer-BioNTech COVID-19 Vaccine EUA 72 year old female healthy, not on any medications, came to hospital for her first covid vaccine. After approximately 10 minutes vaccination, she started feeling dizzy, light headed, slightly nauseated. Reports sweating and cold hand. Patient was taken to the emergency department and later admitted to the hospital with new onset afib/aflut with RVR following first dose of Pifzer Covid-19 vaccination. Further workup revealed reduced EF on ECHO and elevated LFTs. Patient was treated and discharged home.

VAERS ID:	1161231 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-12
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6208 / 1	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Cerebral haemorrhage, Dizziness, Gait disturbance, Headache, Intensive care, Pain, Surgery, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Patient stated he is on a blood thinner (patient would not specify which one), metformin, atorvastatin and "blood pressure" medications
Current Illness: None reported by patient
Preexisting Conditions: Patient stated he has history of gout, high blood pressure and diabetes. He has also had a stent put in place several years ago
Allergies: No Known Drug allergies per patient
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient stated he felt fine the day he received the vaccine. However, starting the day after, he developed dizziness, achiness and a headache. These symptoms progressively worsened over the course of several days. On day 6 after receiving the vaccine, the patient stated his right leg started dragging and he had a difficult time functioning. The patient drove himself to the ER where he collapsed. A bleed in the brain was subsequently discovered and the patient underwent surgery, where he spent 3 days in the ICU. The patient was later discharged. As of today, the patient states he has resumed normal function

VAERS ID:	1162094 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-19
Onset:	2021-02-04
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-04-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1293 / 2	LA / -

Administered by: Work Purchased by: ?
Symptoms: Deafness, Tinnitus
SMQs:, Hearing impairment (narrow)

Write-up: Severe bilateral tinnitus; Hearing loss; This is a spontaneous report from a contactable nurse reporting for self. A 38-years-old female patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, administered in left arm on 19Jan2021 (at the age of 38-years old) (Batch/Lot Number: EL1293) as a single dose for COVID-19 immunization. The patient had not received any other vaccines in the 4 weeks prior. Medical history included postural orthostatic tachycardia syndrome (POTS) from an unknown date. The patient had not experienced COVID prior to vaccination. The patient''s concomitant medications were not reported. The patient previously received first dose of BNT 162b2 on 29Dec2020 at 12:00 PM, in left arm for COVID-19 immunization; and previously received CECLOR and experienced allergy. The patient developed severe bilateral tinnitus and hearing loss on 04Feb2021 at 2:00am, 2 weeks after vaccination with 2nd dose. The event resulted in a doctor or other healthcare professional office/clinic visit, Emergency room/department or urgent care visit, and Disability or permanent damage. As treatment for the events, the nurse reported "multiple visits to doctors and medications hearing." The outcome of the events severe bilateral tinnitus and hearing loss were not recovered. The patient wasnot COVID-tested post vaccination.; Sender''s Comments: Based on available information, a possible contributory role of BNT162B2 vaccine can not be excluded for the reported events of tinnitus and hearing loss due to temporal relationship. Case will be re-assessed upon the additional information provided. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.

VAERS ID:	1167817 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-03-30
Days after vaccination:	26
Submitted:	0000-00-00
Entered:	2021-04-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012M20A / 1	RA / IM

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

Write-up: Positive COVID Test 03/30/2021 with signs and symptoms of COVID.

VAERS ID:	1168622 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Chest pain, Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-01
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt started late in the day w/ CP and SOB, was transported to Hospital by EMS . Pt passed away once at the facility. Time of Death was: 2011 on 4/1/21; pt was discharged from ER on 4/2/21

VAERS ID:	1169427 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Blister, Decubitus ulcer, Erythema, Loss of personal independence in daily activities, Mobility decreased, Mucosal disorder, Pain, Skin exfoliation, Urinary incontinence
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Received 2nd dose covid vaccine around noon 4/1/21 and was standing in kitchen some hours later and suddenly felt weak. Eased self to floor. States "I was unable to move." Missed lunch date on Sunday, 4/4/21 and was found on his kitchen floor laying on R side. Arrived via EMS 16:30 weak, incontinent of urine with large, fluid-filled blistering R upper arm, sloughing of skin R ribcage, R axillary, and medial aspect R arm. Stage 2 and 3 pressure ulcers to R shoulder, hip, knee, ankle. Blanchable erythema on his back. Dry oral membranes, lips, tongue. Extreme weakness/pain. AOx4.

VAERS ID:	1169442 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-04-01
Days after vaccination:	42
Submitted:	0000-00-00
Entered:	2021-04-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Private Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, Cardiac failure acute, Cardiac failure congestive, Cardiomegaly, Left ventricular failure, SARS-CoV-2 test positive
SMQs:, Cardiac failure (narrow), Supraventricular tachyarrhythmias (narrow), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient admitted to inpatient at Hospital on 4/1/2021 at 4:30 pm for new acute onset A.Fib with controlled ventricular response, acute on chronic combined diastolic and systolic CHF, and cardiomegaly. Anticoagulation started. Patient was discharged on 4/3/2021. Of note-on 4/1/2021 (date of admission) patient tested positive for "asymptomatic COVID-19". Per physician discharge summary, "patient did not have active COVID by physical exam or history". Also of note, patient was positive for COVID-19 on 8/29/2020, and was vaccinated with Pfizer COVID-19 vaccine on the following dates: 1/28/2021 (1st dose) and 2/18/2021 (2nd dose)

VAERS ID:	1169683 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-25
Onset:	2021-02-25
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	UN / SYR

Administered by: Senior Living Purchased by: ?
Symptoms: Chills, Death, Fatigue, Nausea, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-08
Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus insulin, levothyroxine, losartan, Protonix, potassium, sertraline, spironolactone, vitamin D3, amiodarone, aspirin, atorvastatin, clonidine, plavix, donepazil, iron, and labetolol.
Current Illness: Cerebrovascular disease, vascular dementia with hallucinations, atherosclerotic cardiovascular disease, hypertension, atrial fibrillation, pacemaker placement, Watchman placement (Aug 2020), congestive heart failure, pulmonary hypertension, peripheral vascular disease, diabetes mellitus type II, reflux, anemia, hypothyroidism, osteoporosis, history of compression fracture, anxiety, depression, and history of nicotine use. Hospitalized in November 2020 for fatigue and not eating - was reportedly losing blood but unknown from where. She was given a blood transfusion and fluids. It was a suspected GI bleed but family declined a hematology workup.
Preexisting Conditions: Cerebrovascular disease, vascular dementia with hallucinations, atherosclerotic cardiovascular disease, hypertension, atrial fibrillation, pacemaker placement, Watchman placement (Aug 2020), congestive heart failure, pulmonary hypertension, peripheral vascular disease, diabetes mellitus type II, reflux, anemia, hypothyroidism, osteoporosis, history of compression fracture, anxiety, depression, and history of nicotine use. Hospitalized in November 2020 for fatigue and not eating - was reportedly losing blood but unknown from where. She was given a blood transfusion and fluids. It was a suspected GI bleed but family declined a hematology workup.
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Within 5-10 hours of the second dose: nausea, vomiting, chills, fever, fatigue. Chills, fatigue and nausea continued for 10 days until death

VAERS ID:	1170447 (history)
Form:	Version 2.0
Age:	84.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-25
Onset:	2021-02-25
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	UN / SYR

Administered by: Senior Living Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated, Death, General physical health deterioration, Hepatic failure, Leukaemia, Malaise, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-01
Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: First COVID 19 shot
Other Medications:
Current Illness: Leukemia, congestive heart failure
Preexisting Conditions: Leukemia, congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fully recovered from natural SARS-COV-2 infection in early December 2020. Patient was doing quite well between mid December and mid January. Patient was hospitalized with congestive heart failure in late January 2021. Received first dose of Moderna COVID19 vaccine shortly before being discharged around February 1 (not sure of exact date). Patient was feeling well at that time. Patient became quite ill within 24 hours of Moderna COVID19 vaccine. Patient steadily worsened during February 2021. Was hospitalized in mid February (unsure of date) and diagnosed with kidney failure and liver disease. Congestive heart failure rapidly worsened and previously stable leukemia flared up. Patient was discharged from hospital February 19 and was placed in quarantine at Care Center. Patient was considered terminal and was to go into hospice care. Patient was administered second COVID19 vaccine on February 25, rapidly deteriorated, and died on March 1.

VAERS ID:	1171548 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-08
Onset:	2021-04-06
Days after vaccination:	29
Submitted:	0000-00-00
Entered:	2021-04-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood creatinine increased, Chest X-ray, Chest pain, Chills, Condition aggravated, Dysphagia, Echocardiogram abnormal, Electrocardiogram abnormal, Glomerular filtration rate decreased, Left atrial dilatation, Lip swelling, Mitral valve incompetence, Pharyngeal swelling, Pruritus, Swollen tongue, Troponin normal, Ventricular extrasystoles
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Angioedema (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: amLODIPine 2.5 mg tablet Take 1 tablet every day by oral route. Brilinta 90 mg tablet Take 1 tablet twice a day by oral route. Co Q-10 1 tablet daily 300mg ezetimibe 10 mg tablet Take 1 tablet every day by oral route. fenofibric aci
Current Illness: No acute illnesses at the time of vaccination or up to one month prior, see chronic illnesses below
Preexisting Conditions: anemia cardiac pacemaker in situ Premature ventricular complexes coronary arteriosclerosis in native artery elevated liver enzymes level gastroesophageal reflux disease hypertensive disorder lumbar spondylosis mixed hyperlipidemia paroxysmal atrial fibrillation paroxysmal ventricular tachycardia spinal stenosis of lumbar region
Allergies: cedarwood mold Ragweed
Diagnostic Lab Data: Chest XR 3/9/2021: Stable chest, chronic changes 3/9/2021: Negative troponin, Stable anemia (hx of anemia), normal CMP 3/15/2021 and 3/16/2021: Negative troponin x2, negative covid test, normal hgbA1c, UA, TSH, magnesium. 3/15/2021 CMP showing creatinine at 1.33 and GFR 54 otherwise unremarkable, CMP normalized 3/16/2021 3/15/2021: Stable chest XR. EKG with atrial paced rhythm and nonspecific ST abnormality 3/16/2021 echocardiogram; Left ventricle: The cavity size is normal. Wall thickness is at the upper limits of normal. Systolic function is normal. The estimated ejection fraction is 60-65%. Left ventricular diastolic function parameters are normal for the patient''s age, Right ventricle: The cavity size is at the upper limits of normal. Systolic function is normal. Systolic pressure is mildly increased. RV systolic pressure: 35 mm Hg. Left atrium: The atrium is mildly dilated. Mitral valve: There is mild, 1-2+ regurgitation.
CDC Split Type:

Write-up: Patient had covid vaccine and then 1 day later, developed worsening PVCs. Patient has a history of PVCs and Vtach for which he has a pacemaker. Patient is historically very symptomatic with his PVCs. These worsened over the course of a week which lead to worsening substernal chest pain and he presented to the ER on 3/15/2021 and due to his history of CAD, was hospitalized for observation, discharged on 3/16/2021. He had labs, echocardiogram while in the hospital. His metoprolol was increased to help decrease symptomatic PVCs. On 3/9/2021, patient developed chills, difficulty swallowing and the sensation of his throat and tongue being swollen, along with some generalized itching. He presented to the ER 3/9/2021 due to these symptoms and these symptoms resolved without interventions and he was discharged home. He then developed lower lip swelling on 3/15/2021.

VAERS ID:	1173051 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-12
Onset:	2021-02-26
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	006M20A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Anaemia, Basal ganglia haemorrhage, C-reactive protein increased, Cerebrovascular accident, Dysarthria, Hemiparesis, Laboratory test, Platelet count increased, White blood cell count increased
SMQs:, Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: Pt presented to the ER on 2/26 with hemorrhagic CVA basal ganglia, left sided hemiparesis, dysarthria, WBC elevated to 19,000, platelets elevated 568,000, new anemia, CRP markedly elevated

VAERS ID:	1175166 (history)
Form:	Version 2.0
Age:	49.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-20
Onset:	2021-03-20
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 1	LA / -

Administered by: Private Purchased by: ?
Symptoms: Atrial fibrillation, Electrocardiogram, Heart rate, Heart rate increased, Sinus rhythm
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Dehydration (broad)

Write-up: Atrial Fibrillation / diagnosed with Atrial Fibrillation with RVR; heart rate heightened (topped out at a resting heart rate of over 160 bpm)/ up to 160 (high /bpm)/ continued to have increased; This is a spontaneous report from a contactable consumer (patient). A 49-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; Dose 1) via an unspecified route of administration, administered in the left arm on 20Mar2021 18:15 (batch/lot number: ER2613 and expiry date unknown) at 49 years old at a SINGLE DOSE for COVID-19 immunization. The patient was vaccinated at the Hospital. The patient''s medical history included obesity from an unknown date and unknown if ongoing. Patient had no previous heart issues and had no known allergies. There were no concomitant medications or other medications in two weeks of vaccination. The patient did not receive other vaccination within 4 weeks prior to the BNT162B2. The patient was not diagnosed with COVID-19 prior to vaccination. The patient has not been tested for COVID-19 since the vaccination. On 21Mar2021, 12:00 am, patient went into atrial fibrillation with a high heart rate up to 160 bpm. It was reported that the heightened heart rate started on evening after the vaccine (on 20Mar2021), it topped out at a resting heart rate of over 160 bpm. Patient went to a primary health care physician, he did EKG (results unknown), then ordered patient to Emergency Room (Hospital name). The patient was diagnosed with Atrial Fibrillation with RVR. The patient was prescribed Apixaban (Eliquis) 5 mg oral tablet, 1 tab 2 times a day and Metoprolol (metoprolol succinate 50 mg extended release) 50 mg 1 cap per day. Patient was also given Diltiazem 10 mg via IV push while at the hospital. It was reported that patient continued to have increased heart rate and have not returned to a normal sinus rhythm as of 23Mar2021. The patient underwent lab tests and procedures which included EKG: unknown result on Mar2021; heart rate: heightened (topped out at a resting heart rate of over 160 bpm ) on 20Mar2021, up to 160 (high /bpm) on 21Mar2021 and heart rate: continued to have increased on 23Mar2021; and sinus rhythm: have not returned to normal on 23Mar2021. The events resulted in Doctor or other healthcare professional office/clinic visit, Emergency room/department or urgent care, and patient was hospitalized for one day. The outcome of the events was not recovered.

VAERS ID:	1175483 (history)
Form:	Version 2.0
Age:	49.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-16
Onset:	2021-03-26
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	046A21A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal pain, Guillain-Barre syndrome, Magnetic resonance imaging spinal abnormal, Paraesthesia
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (narrow), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Write-up: Patient was immunized on 3/16/21 shortly after being discharged from the hospital. He was readmitted with abdominal pain and complaints of bilateral hand tingling. Neurology was consulted and working diagnosis was Guillain-Barre Syndrome (GBS). Patient was given a 5 dose series of IVIG 0.4g/kg.

VAERS ID:	1175809 (history)
Form:	Version 2.0
Age:	52.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN, INFO N / 2	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Angiogram, Angiogram cerebral abnormal, Echocardiogram normal, Electrocardiogram normal, Facial paralysis, Headache, Hemiparesis, Hypoaesthesia, Intracranial aneurysm, Magnetic resonance imaging head normal, Ultrasound Doppler normal
SMQs:, Peripheral neuropathy (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad)

Write-up: Patient was observed for 30 min after her second dose of covid-19 vaccine (note patient decided to take diphenhydramine immediately after receiving this dose of vaccine because she experienced a spike in her blood pressure with her first covid-19 vaccine). Patient felt fine and left the vaccine clinic. But about 2 hours after receiving the second dose, patient developed numbness, right upper and lower extremity weakness and headache. Upon presentation to the ED, patient developed right sided facial droop and ongoing right upper and lower extremity weakness and headache. Stroke protocols were initiated including offering tPA for clinical stroke, but patient declined it. At workup, her EKG showed a sinus rhythm, she had not reported recent illness. A CT angiogram showed no significant flow limiting stenosis either in the neck or head and there was no perfusion deficit. However, incidental bilateral aneurysms were discovered at the anterior cerebral arteries at the junction of the A3 segments and pericallosal arteries. There was no evidence that they had hemorrhage and they are small, less than 5 mm in diameter and neurosurgery has evaluated the patient and is not recommending any urgent intervention. The next day the patient was doing well, presenting symptoms/deficits resolved except for ongoing mild headache. An MRI examination of the brain has shown no acute infarct and normal brain morphology was described. She had an echocardiogram, which showed grossly normal left ventricular size and systolic function with an estimated ejection fraction of 65%. Amlodipine was started for elevated blood pressure. Note: patient had a history of hypertension but was not on medications for this prior to admission. Neurology consult = ?This is a peculiar event. It is unclear if the patient had a TIA or COVID reaction to a COVID vaccination or a reaction to headache. She does not exhibit a completed stroke on MRI scan. She has recovered completely except for mild headache. Incidental aneurysms were discovered and at some point she should have follow up for that. She should have a follow up with the stroke service. In the meantime, I think it is reasonable to continue with daily aspirin on this patient. Note that she had a cryptogenic TIA.?

VAERS ID:	1176064 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-03-30
Days after vaccination:	32
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 1	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death within 60 days of receiving a COVID vaccine

VAERS ID:	1176121 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-12
Onset:	2021-03-31
Days after vaccination:	47
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 1	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-31
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death within 60 days of receiving a COVID vaccine

VAERS ID:	1176278 (history)
Form:	Version 2.0
Age:	96.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-04-02
Days after vaccination:	50
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043L20A / 1	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-02
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient within 60 days of receiving a COVID vaccine death

VAERS ID:	1177317 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EP7533 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Abdominal pain, Blood sodium decreased, Cholelithiasis, Haematocrit decreased, Haemoglobin decreased, Lipase increased, Pancreatitis, Red blood cell count
SMQs:, Acute pancreatitis (narrow), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Retroperitoneal fibrosis (broad), Gallbladder related disorders (narrow), Gallstone related disorders (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Abdominal pain, pancreatitis, gall stones

VAERS ID:	1177616 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-04-04
Days after vaccination:	52
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043L20A / 2	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-04
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death within 60 days of receiving the COVID vaccine series

VAERS ID:	1178286 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-15
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / -

Administered by: Private Purchased by: ?
Symptoms: Blood test, Dysphagia, Dysphonia, Throat irritation, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad)

Write-up: My throat was itchy in between that half hour my voice started to change; my throat felt worse; I have wheezing in my lungs; I still have problem swallowing a little bit; My throat was itchy in between that half hour my voice started to change; my throat felt worse; This is a spontaneous report from a contactable consumer (reporting for herself). A 60-year-old female patient received second dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration, administered in Arm Left on 15Mar2021 (Batch/Lot number was not reported) as single dose for COVID-19 immunization. Medical history included anxiety, depression, neuralgia, heart, blood pressure issue and lot of allergies. Concomitant medication included levothyroxine; atorvastatin calcium (CHOLESTAT [ATORVASTATIN CALCIUM]); pantoprazole; ciprofloxacin hydrochloride, tinidazole (FLOXAZOLE); aspirin [acetylsalicylic acid] (ASPIRIN [ACETYLSALICYLIC ACID]); lubiprostone (AMITIZA); thioctic acid (ALPHA LIPOIC ACID); baclofen; linezolid (ZENIX [LINEZOLID]); ascorbic acid, calcium, minerals nos, retinol, tocopheryl acetate, vitamin b nos, vitamins nos, zinc (CENTRUM SILVER [ASCORBIC ACID;CALCIUM;MINERALS NOS;RETINOL;TOCOPHERYL ACETATE;VITAMIN B NOS;VITAMINS NOS;ZINC]); rosuvastatin calcium (CRESTOR); docusate sodium (STOOL SOFTENER); benazepril hydrochloride, hydrochlorothiazide (BENAZEPRIL HYDROCHLORIDE AND HYDROCHLOROTHIAZIDE) taken for heart; desvenlafaxine succinate (PRISTIQ) taken for anxiety, depression; citalopram; venlafaxine hydrochloride (EFFEXOR) taken for anxiety; escitalopram oxalate (LEXAPRO); cyclobenzaprine; gabapentin taken for neuralgia; metoprolol taken for heart; amlodipine taken for blood pressure issue; magnesium oxide. The patient previously took bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE) on 22Feb2021 for COVID-19 immunization and experienced pulse rate would not go down. On 15Mar2021, it was reported that they had it done at the hospital, then after 15 minutes, her throat was itchy the may say another half hour in between that half hour, her voice started to change and her throat felt worse. They walk me down to the ER my throat was hurting then slowly they gave me Epi Pen and they injected in an IV with steroids. The have wheezing in her lungs and spent the night in hospital for observation. They did all kind of blood work, when she was placed in ER. The patient reported that she still have problem swallowing a little bit and voice changes after talking. The outcome of the event "still have problem swallowing a little bit" was not recovered while the outcome of the other events was unknown. Information on the lot/batch number has been requested.

VAERS ID:	1178395 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-03-10
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-04-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6199 / UNK	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood test, Cardiac ablation, Cardiac monitoring, Cardioversion, Electrocardiogram, Heart rate increased
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dehydration (broad)

Write-up: Rapid heart rate requiring hospitalization and cardioversion (and planned cardiac ablation) six days after administration of first vaccine dose.

VAERS ID:	1179306 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-15
Onset:	2021-02-16
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3248 / 1	LA / -

Administered by: Private Purchased by: ?
Symptoms: Anaphylactic reaction, Breast pain, Cough, Dizziness, Drug hypersensitivity, Dysphonia, Dyspnoea, Lymph node pain, Respiratory tract irritation, Respiratory tract oedema, Throat tightness
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Anticholinergic syndrome (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Lipodystrophy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ZYRTEC [CETIRIZINE HYDROCHLORIDE]; SINGULAIR; ADVAIR; FLUTICASONE
Current Illness: Asthma (at 59 she was bumped up to moderate degree asthma); Eczema; Environmental allergy; Epiphora; Eye itching; Food allergy; Hypertension; Obesity (she gains and loses it); Sinus congestion; Sneezing
Preexisting Conditions: Medical History/Concurrent Conditions: Bee sting; Bronchitis (she has a history of getting Bronchitis); Milk allergy; Neck injury; Smoke sensitivity (from the sulfa in the matches, fireplaces, wood burning and firepits.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021321503

Write-up: anaphylactic; reactions are allergic; Terrible airway swelling, it felt like breathing through a straw, narrowing airway; Sensation of throat closure/narrowing of airway; significant shortness of breath/difficult to breath like through a straw; Pain in both lymph nodes, under both the armpit; Pain in both breasts; Dry cough; Itching, airway/trachea itchy; Hoarseness; Dizziness; This is a spontaneous report from a contactable nurse (patient). A 65-years-old female patient received the first dose of BNT162B2 (Pfizer-BioNTech COVID-19 vaccine, lot number: EL3248), via an unspecified route of administration, administered in the left deltoid on 15Feb2021 at 15:30 as a single dose for protection against Covid. Medical history included ongoing obesity as she gains and loses it, ongoing hypertension, ongoing asthma (at 59 she was bumped up to moderate degree asthma), ongoing significant food allergies, was born with and had ongoing eczema so she was allergic to milk (was given soy milk since she could not tolerate milk, when she drank milk, it produced phlegm/caused increase in mucus, ongoing significant environmental allergies wherein she would have allergies in the fall, from August through September and would have sneezing, congestion and itchy watery eyes. The patient also had a history of getting bronchitis but has not had it for a long time. The patient got stung by a bee when she was 40ish and her upper thigh got red, itchy and it lasted for 10 days and she and no other symptoms and was now careful around bees. The patient reacts to the smoky matches that blow out and make smoke, from the sulfa in the matches, fireplaces, wood burning and firepits. Concomitant medications included cetirizine hydrochloride (ZYRTEC) taken for an unspecified indication, start and stop date were not reported; montelukast sodium (SINGULAIR) taken for an unspecified indication, start and stop date were not reported; fluticasone propionate, salmeterol xinafoate (ADVAIR) taken for asthma, start and stop date were not reported and fluticasone (manufacturer unknown) taken for asthma and allergies, start and stop date were not reported. The patient was on significant medications for her asthma, allergies and blood pressure. The patient previously got a flu shot at the end of Oct2020. The patient also previously took Aleve in her early 40''s and was taking them for a neck injury for 2-3 months and at the end of the treatment she broke out in a rash. The patient also previously took aspirin 3 years ago and broke out in a rash. The patient also has an albuterol inhaler but has not taken it for years. The patient was careful, handwashing normally, wipes the shopping carts as they are germy. The patient stated that after receiving the vaccine, one main event was terrible airway swelling, itching and it was difficult to breathe. The terrible airway swelling felt like breathing through a straw and narrowing airway. She stated that it started 18.5 hours after the vaccine, on 16Feb2021 at 10 am and lasted for 4 hours between 10 to 2 pm. The patient also had itching wherein her airway and trachea were itchy which also started on 16Feb2021 at 10 am to 2 pm. The patient experienced narrowing of airway and sensation of throat closure also between 10 am to 2 pm. The patient also experienced that it was difficult to breathe but she did not feel like she needed to go to the hospital. If it got any worse she would gave went to the emergency department. She stated that she was sitting up, walking around and she would have had a significant shortness of breath and she was trying to wait it out. It was difficult to breath like through a straw which also started from 10 am to 2pm. She did not feel like she wanted to walk or do daily activities. She was on the phone with her mother and her mother could hear her difficulty in talking and her heavy breathing. The patient also experienced pain in both lymph nodes, under both armpits and pain in both breasts which started also on 16Feb2021 at 10 am and lasted for 24 hours the 10 am the next day. The patient had dizziness which started about noon and when she woke up the next day it as gone which she considered as medically significant since she is never dizzy and it was not due to her blood pressure and she has been on pills for a long time. The patient had dry cough and hoarseness also on 16Feb2021 from 10 am to 2 pm. The patient was afraid to take the second vaccine and she spoke to her pulmonologist who knows her history and was told that she would benefit. She thought that if she felt bad, she would go to the emergency room if it got worse but it did not. The patient stated that she thinks these reactions are allergic, the itching and narrowing of throat can be anaphylactic. The patient did not require any medical intervention and was not seen in the emergency department and was not hospitalized. The events lasted for 4 hours and stayed at that level. The patient did not get any treatment and it went away. The outcome of the events terrible airway swelling, it felt like breathing through a straw, narrowing airway, Dry cough, Itching, airway/trachea itchy, Hoarseness, Sensation of throat closure/narrowing of airway, reactions are allergic and anaphylactic was recovered on 16Feb2021 at 14:00. The outcome of dizziness was recovered on 17Feb2021 and the outcome of pain in both lymph nodes, under both the armpit and pain in both breasts on 17Feb2021 at 10:00. The patient reported that the events were considered as medically significant. The relatedness of the drug to the reactions from primary source reporter (method of assessment: Global Introspection) for the events was related.; Sender''s Comments: A contributory role of vaccine BNT162B2 to reported events cannot be fully excluded since it is part of the product safety profile. Potential contributors include patient''s advanced age, as well as underlying obesity, hypertension, asthma, eczema, multiple allergies and other co-morbidities. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.

VAERS ID:	1179803 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-03
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	LA / -

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Blood glucose, Malaise, Vomiting
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochorithiazide 12.5 Messelimine Synthroid Fish oil Curcumin Magnesium Vitamin d with vitamin k2
Current Illness: None
Preexisting Conditions: Pre-diabetes
Allergies: Penicillin Bactrim
Diagnostic Lab Data: I do daily blood sugar testing.
CDC Split Type:

Write-up: Very ill day after first dose. Weak, vomiting, fever Not quite as I?ll after second dose. Blood sugar had consistently been running about 15 points higher since receiving the vaccine. Diabetes is no longer in remission.

VAERS ID:	1180818 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-19
Onset:	2021-03-22
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EM9810 / 2	RA / IM

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

Write-up: Recipient of vaccine is a family member (father) of employee of Hospital. Recipient was vaccinated with Dose 2 Pfizer Covid vaccine on 3/19/2021 and observed on-site for 15 minutes after vaccination with no apparent concerns. On 3/23/2021, his daughter (our employee) notified clinic that on 3/22/2021, recipient had died. 4/7/2021 his daughter (our employee) states the medical examiner indicated his autopsy showed evidence of cardiac arrest.

VAERS ID:	1180830 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-02-26
Days after vaccination:	30
Submitted:	0000-00-00
Entered:	2021-04-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	AR / SYR

Administered by: Senior Living Purchased by: ?
Symptoms: Anaemia, Biopsy bone marrow abnormal, Bone marrow reticulin fibrosis, Haemoglobin decreased, Platelet count decreased, Thrombocytopenia, Transfusion
SMQs:, Haematopoietic cytopenias affecting more than one type of blood cell (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Malignancy related conditions (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Malignant lymphomas (broad), Myelodysplastic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Despite patient having long-standing history of ET, she had a completely normal CBC in August of 2020 and was maintained on the same dose of hydrea for more than 10 years. She was found to have an abrupt drop in both hemoglobin (13-$g9g/dl) and platelets (300s-- $g104) 2 days after her 2nd vaccine. Her hydrea dose was lowered and repeat blood work 1 month later demonstrated platelets of 64 and hemoglobin of 6.7. patient was admitted to the hospital and was transfused 2 units of blood. Bone marrow biopsy demonstrated 50% cellular marrow with grade three fibrosis consistent with Post-ET MF. No evidence of hemolysis, vitamin, or iron deficiency. Spleen not enlarged. Hydrea was stopped completely during admission. Today''s blood work (4/8/2021) demonstrates continued thrombocytopenia and anemia - platelets of 54 and hemoglobin of 7.5.

VAERS ID:	1181703 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-26
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-04-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1805031 / UNK	- / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Autoimmune demyelinating disease, Bladder catheterisation, Burning sensation, Chest X-ray normal, Chest pain, Demyelination, Dysuria, Eye pain, Facet joint syndrome, Hypoaesthesia, Intervertebral disc degeneration, Intervertebral disc protrusion, Intervertebral disc space narrowing, Magnetic resonance imaging head abnormal, Magnetic resonance imaging spinal abnormal, Multiple sclerosis, Neurogenic bladder, Pain, Paraesthesia, Peripheral coldness, Scan with contrast abnormal, Sensitive skin, Urinary retention, Vertebral foraminal stenosis, Vertebral osteophyte, White matter lesion
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Glaucoma (broad), Optic nerve disorders (broad), Cardiomyopathy (broad), Demyelination (narrow), Arthritis (narrow), Immune-mediated/autoimmune disorders (narrow)

Write-up: Pt received J&J covid vaccine on 3/15/21 in.presented to the ED on 3/29 for few days of progressive weakness and urinary difficulty. Recently took a trip and returned Thursday evening. That night, she noticed mild sensitivity to her left forearm. On Friday she developed an achy feeling under both arms and across her breasts. Her eyes felt painful as well. Overnight Friday into Saturday her feet began feeling cold and numb and she developed a generalized sensitivity over her entire body that she describes almost as a burning sensation. Also had trouble urinating -. presented with pain, paresthesias and weakness below mid-chest level and urinary retention. MRI brain, C and T spi ~C and T spine c/w demyelination. Neuro consulted and impression = acute demyelinating disease, unclear etiology but may be acute disseminated encephalomyelitis (ADEM) 2/2 COVID vaccine vs. 1st presentation of multiple sclerosis. Sx gradually improved s/p solumedrol IV bid x 5d in hospital -- $g transitioned to PO prednisone taper per neuro (60 mg x2 days then go down by 10 mg every 2 days until off) for discharge. Pt to f/u with neuro post discharge. For neurogenic bladder PT had temporary foley, removed 4/2 and will require CIC QID (teaching done prior to discharge) at home. Outpt f/u Urology.

VAERS ID:	1182144 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-28
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-04-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	010MZ0A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Anxiety, Balance disorder, Blood test normal, Cardiac function test normal, Dehydration, Dizziness, Dysstasia, Gait inability, Magnetic resonance imaging head normal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypoglycaemia (broad), Dehydration (narrow)

Write-up: I experienced this rather immediate unexpected gradually increasing dizziness with impaired balance while walking at accustomed pace over approximately 12-15 minute time period. I was compelled to leave the track and lay down on an exercise mat where fortunately my wife came by t Within half hour of this attack i coiuld not stand and walk independently without support. My first time to a hospital ER in my 78 years of life. Recommended for observation and additional tests I stay overnight in observation unit. Diagnosis appeared to be perplexing for physicians. My wife came by to assist me in standing , walking to the car and driving me to nearby ER. What happened to me was a frightening, anxiety-producing and dangerous situation. I could have easily fallen with substantial head or other bodily injury. Being in excellent health and with nothing else unusual having occurred recently to affect my general health (no changes, no illnesses), I cannot help conclude this episode was a serious adverse reaction to my 2nd Moderna vaccination. I now consider what happened on 3/28/21 a "Vestibular Attack". I think possibly my body for some reason related to the vaccine might have been attacking itself, if that makes sense to scientists. I hope this doesn''t happen to others. I am not anti-vaccination. But individuals should be warned about this possible dangerous reaction or adverse side effect, which in my case did not occur immediately after the 2nd Moderna dose. I''ve complained to the hospital that possibility of severe dizziness with extreme loss of balance being related to recent Moderna 2nd vaccination was NOT discussed or commented.

VAERS ID:	1184977 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-08
Onset:	2021-03-14
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-04-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Chest X-ray abnormal, Chest discomfort, Dyspnoea, Electrocardiogram abnormal, Pain, Pulmonary thrombosis, Thrombosis, Ultrasound chest
SMQs:, Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Oxybutynin 10mg, Simvastatin 40mg, Tamsulosin 0.4mg, Telmisartan 20mg, Turmeric, Aspirin
Current Illness: No
Preexisting Conditions: 7years ago a severe concussion and lost sense of taste and smell
Allergies: No
Diagnostic Lab Data: X-ray and ECHO complete with TTCV, ultrasound of chest, and test showed multiple blood clots in both lungs
CDC Split Type:

Write-up: 3/14/2021 Tightness in chest, attributed to physical work outside, 3/15 still felt tightness, 3/16 getting winded and went to the ER around 5:30pm, they took blood and ran test EKG, X-ray and ECHO complete with TTCV, ultrasound of chest, and test showed multiple blood clots in both lungs; by this time he was having trouble breathing and was admitted because of the blood clots. He was given Heparin and Vicodin through IV, on 3/17 they ran more test to see where blood clots came from and where they came from but nothing was found in legs. he was in a lot of pain Wednesday and he was sent home on 3/19.

VAERS ID:	1185115 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-03-05
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EM9810 / 1	LA / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8727 / 2	RA / SYR

Administered by: Work Purchased by: ?
Symptoms: Bacterial test, Gram stain, Implant site extravasation
SMQs:, Extravasation events (injections, infusions and implants) (narrow)

Write-up: Accumulation of fluid in left breast area. I do have a breast implant from a reconstruction after breast cancer August 2016.

VAERS ID:	1190219 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-04-03
Days after vaccination:	57
Submitted:	0000-00-00
Entered:	2021-04-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011L20A / UNK	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / UNK	LA / IM
VARZOS: ZOSTER (SHINGRIX) / GLAXOSMITHKLINE BIOLOGICALS	- / UNK	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Tinnitus
SMQs:, Hearing impairment (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norestradiol HRT
Current Illness: Also Shingrix vaccine on 03/18/21
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Appt 4-12-21
CDC Split Type:

Write-up: Tinnitus

VAERS ID:	1192450 (history)
Form:	Version 2.0
Age:	30.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-18
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL8982 / UNK	LA / IM

Administered by: Work Purchased by: ?
Symptoms: Impaired quality of life, Lacrimation increased, Sinus congestion, Sleep disorder, Sneezing
SMQs:, Anaphylactic reaction (broad), Lacrimal disorders (narrow), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clindamycin 1% gel
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: As a person who has never had any kind of allergies--including seasonal allergies--as of the week I received the vaccine, I appear to have developed a new allergy to dust mites. When resting my head against a pillow (especially near the open end of the pillow case), I develop sneezing, complete sinus congestion (to the point I am not able to breathe from either nostril), runny eyes, and similar histamine responses. The symptoms have responded well to diphenhydramine and loratadine, as well as use of allergen-resistant pillowcases, but they have reduced my sleep quality in the weeks since they developed, and I feel this new allergy has negatively impacted my quality of life.

VAERS ID:	1192691 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-19
Onset:	2021-02-05
Days after vaccination:	17
Submitted:	0000-00-00
Entered:	2021-04-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1283 / 2	LA / IM

Administered by: Work Purchased by: ?
Symptoms: Audiogram abnormal, Deafness, Tinnitus
SMQs:, Hearing impairment (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fetzima, Lamotrigine, Montelukast, Advair
Current Illness: N/A
Preexisting Conditions: Asthma, POTS, Cardiomyopathy
Allergies: Ceclor
Diagnostic Lab Data: Audiogram showing hearing loss. April 5th 2021.
CDC Split Type:

Write-up: Acute onset of tinnitus and hearing loss.

VAERS ID:	1193195 (history)
Form:	Version 2.0
Age:	30.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-09
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	008B21A / 2	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Chest pain, Myocarditis, Troponin increased
SMQs:, Myocardial infarction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Chest pain, highly elevated troponin, no ACS; likely Myocarditis

VAERS ID:	1193520 (history)
Form:	Version 2.0
Age:	29.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-31
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	10805031 / UNK	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Abnormal behaviour, Blood test normal, Computerised tomogram normal, Delusion, Hallucination, Insomnia, Poor quality sleep, Psychotic behaviour, Screaming, Speech disorder, Urine analysis abnormal
SMQs:, Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Depression (excl suicide and self injury) (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 7 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: No Prescription drugs Takes alavert on occasion for allergies Tums
Current Illness: None
Preexisting Conditions: Patient is cognitively disabled, but functions fairly well with day to day activities and routines. She has not experienced any incidents or conditions that she displayed beginning on March 31st 2021.
Allergies: None
Diagnostic Lab Data: Given a Urine Test and Blood Test on Sunday, April 4th. Urine test for UTI was inconclusive and blood test was normal Given a Urine Test and Blood Test on Monday, April 5th, as well as a CT scan. Urine test for UTI continued to be inconclusive, blood test was normal and CT was scan was normal. Patient was placed on anti-psychotic medication while in the psychiatric ward. After about three days of non-sleep, she finally began to sleep. She is doing well under the medication but is very sedated.
CDC Split Type:

Write-up: My daughter, although has cognitive issues, has not ever displayed any adverse behavior. We first noticed some unusual behavior on March 31st 2021. Three days later, on April 3rd, her behavior became more noticeable and unusual for her. She was saying things that didn''t make any sense and wasn''t sleeping well or not at all. On Sunday April 4th, her behavior intensified into delusions and hallucinations. She was talking to people not there and making bizarre statements. She was taken to emergency hospital late Sunday night and given a blood and urine test and sent home. By Monday morning, she had not slept the entire night and was shouting out, trying to leave the house and her hallucinations and delusions had intensified. We took her to Emergency room, where she was diagnosed with psychotic behavior and was admitted to the psychiatric ward. She is expected to be released today, April 11th, 2021.

VAERS ID:	1195170 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-19
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-04-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Anaemia, Biopsy bone marrow, Chest scan, Computerised tomogram abdomen, Full blood count, Haemoglobin decreased, Haemoperitoneum, Immune thrombocytopenia, Immunoglobulin therapy, Petechiae, Platelet count decreased, Platelet transfusion, Purpura, Serology negative, Vaginal haemorrhage
SMQs:, Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Severe acute immune thrombocytopenia, now refractory to steroids and IVIG developed 10 days after second dose of vaccine. Patient developed spontaneous wet purpura, petechiae and vaginal bleeding on 3/19/2021. CBC showed undetectable platelet count. Normal hemoglobin and platelets. Did not respond to dexamethasone 40md daily x 4 or multiple IVIG doses. Started romiplostim on 3/25/21 and is currently on dose escalations with platelets persisting undetectable. On 3/28 developed acute anemia with a 2 to 3 g/dL hemoglobin drop and was found to have a spontaneous hemoperitoneum . Treated with tranexamic acid, multiple platelet transfusions and an additional dose of romiplostim. Bleeding has since resolved but platelets remain undetectable.

VAERS ID:	1195435 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-23
Onset:	2021-03-24
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 1	LA / SYR

Administered by: Other Purchased by: ?
Symptoms: Abdominal pain, Computerised tomogram abdomen abnormal, Crohn's disease, Haematemesis, Small intestinal obstruction
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal premalignant disorders (narrow), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Crohn?s flared up causing a small bowel obstruction. Vomiting blood, abdominal pain.

VAERS ID:	1195632 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-04-11
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Chest pain, Pleuritic pain, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Infective pneumonia (broad)

Write-up: right sided pleuritic chest pain started 04/11/2021.

VAERS ID:	1196190 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-15
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Dehydration, Headache, Myalgia, Tremor
SMQs:, Rhabdomyolysis/myopathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Dehydration (narrow)

Write-up: Headache, muscle aches, shakes, weakness, dehydration

VAERS ID:	1196226 (history)
Form:	Version 2.0
Age:	44.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-03-19
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808609 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Anti-muscle specific kinase antibody negative, Antiacetylcholine receptor antibody, Antibody test normal, Asthenia, Asthma, Blood creatine phosphokinase normal, Blood immunoglobulin G normal, Blood thyroid stimulating hormone normal, Borrelia test negative, C-reactive protein normal, Chest X-ray normal, Computerised tomogram thorax normal, Condition aggravated, Dyspnoea, Dyspnoea exertional, Echocardiogram normal, Electrocardiogram normal, Electromyogram normal, Electrophoresis protein normal, Fatigue, Fibrin D dimer normal, Full blood count normal, Immunoelectrophoresis, Magnetic resonance imaging head normal, Metabolic function test normal, Obstructive airways disorder, Prothrombin time normal, Pulmonary function test abnormal, Red blood cell sedimentation rate normal, Respiratory distress, SARS-CoV-2 test negative, Troponin normal
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Write-up: Fatigue , SOB (shortness of breath), Dyspnea on exertion, Generalized weakness, Respiratory distress, COVID-19 vaccine administered Asthma exacerbation Possible COVID-91 allergic reaction Nebs, inhalers, IV and oral steroids, oxygen Symptoms ongoing

VAERS ID:	1196273 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-04-11
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8733 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, COVID-19, Chest X-ray normal, Cough, Fatigue, Hypokalaemia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Guillain-Barre syndrome (broad), Infective pneumonia (broad), Hypokalaemia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first dose of the Pfizer COVID 19 vaccine on 3/30/2021. She presented to the ED on 4/11/2021 with fatigue, cough, hypokalemia, and generalized weakness. She was admitted to an inpatient unit and tested for COVID-19 which came back positive. Anticipated discharge is today, 4/12/2021

VAERS ID:	1196802 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-04-07
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Diarrhoea, Dyspnoea, Nausea, Pain, Pyrexia, Treatment noncompliance, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Is a 54-year-old female who presents today with nausea vomiting and diarrhea as well as body aches and a fever after taking her first Covid vaccination 2 days ago. She went to urgent care at first and they transfer her to the ER here. She has been out of her insulin for at least 3 weeks. She has had a refill of her glipizide and has not picked up a refill. She denies any chest or abdominal pain. She has had times where she is short of breath. She has had 3 episodes of nausea and vomiting and 3 episodes of diarrhea since midnight or in the last 19 hours.

VAERS ID:	1197242 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-03-31
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808980 / 1	LA / SYR

Administered by: Public Purchased by: ?
Symptoms: Acoustic stimulation tests, Tinnitus
SMQs:, Hearing impairment (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clomiphene, tamsulosine, omeprazole
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Hearing test (04/12/2021).
CDC Split Type:

Write-up: Developed very bad tinnitus in both of my ears within six hours of receiving the vaccine.

VAERS ID:	1197275 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Abdominal pain, Blood albumin, Blood calcium increased, Chest pain, Computerised tomogram abnormal, Diarrhoea, Hyperhidrosis, Nausea, Oesophagram, Pneumomediastinum, Protein total increased, Protein urine present, Pulmonary interstitial emphysema syndrome, Red blood cells urine positive, Urine analysis, Urine ketone body present, Vomiting
SMQs:, Acute renal failure (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Proteinuria (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: 22 Y male with past medical history of environmental allergies presents with a chief complaint of abdominal pain and nausea/ vomiting. He states that on 4/7 he had some nausea and one episode of non bloody nonbilious emesis that morning. He had previously received his first dose of the Moderna COVID vaccine on 4/6. He states this morning he awoke and had significant nausea and abdominal pain and then had approximately 10 episodes of non bloody emesis that eventually became bilious. He did have some diaphoresis. He states that he eventually did have some chest pain that he attributed to all of the vomiting. He went to urgent care and did receive Zofran but this did not alleviate his symptoms. He denies shortness of breath, cough, fever, chills, diarrhea, melena, hematochezia, genitourinary symptoms, or other pain. He states that he has been having a few episodes of loose stools, but did not have any bowel movements today. In urgent care CT was performed and was suspicious for pneumomediastinum within the partially imaged lower chest and a CT esophagram was recommended. Patient presented here for CT esophagram. He is admitted for further treatment, and required a three day admission with IVF, and IV narcotics and antiemetics to control his nausea and Abd symptoms. He denied dyspnea. On 4/11 the patient was tolerating a diet and stable to dc home.

VAERS ID:	1198196 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-10
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 2	AR / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Asthenia, Behaviour disorder, Cerebral haemorrhage, Constipation, Death, Fall, Fatigue, Gait disturbance, Hypersomnia, Pyrexia, Restlessness, Vomiting
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Akathisia (broad), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Depression (excl suicide and self injury) (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Blood thinner Clopidogrel
Current Illness: None
Preexisting Conditions: Hyperlipidemia; dementia; anxiety disorder; essential hypertension
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: On 3/10/2021 around 2 pm reported more fatigue, low-grade fever, and weak; treated w/ Tylenol; 3/13/2021 refused medications; 3/16/2021 became constipated; 3/20/2021 gait unsteady and reported feeling as though she''d fall; more fatigued; 3/20/2021 refused medications and slept excessively; 3/20/21 vomited in bed; 3/22/2021 restless and exit seeking; 3/25/2021 packed belongings and exhibited exit seeking; 3/26/2021 transported to hospital 5:15 am due to falling while attempting to pick up something off of the floor; 3/29/2021 hospital reported she had a brain bleed and had chosen hospice care at her daughter''s home; resident passed away on 3/30/2021.

VAERS ID:	1198211 (history)
Form:	Version 2.0
Age:	34.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-10
Onset:	2021-02-10
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / -

Administered by: Private Purchased by: ?
Symptoms: Acute respiratory failure, C-reactive protein increased, Cardiac arrest, Computerised tomogram abnormal, Cough, Death, Hypoxia, Lung infiltration, Pneumonia, Pneumonia bacterial, Pyrexia, Resuscitation, SARS-CoV-2 test negative, Viral test negative, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Fluoxetine, methenamine, gabapentin, baclofen, clonazepam, seroquel
Current Illness: Bilateral community acquired pneumonia
Preexisting Conditions: quadriplegic spinal cord paralysis secondary to remote MVA autonomic dysreflexia depression/anxiety neurogenic bladder
Allergies: None
Diagnostic Lab Data: 2/10/21: WBC 15.1, CRP 32. COVID19 negative. Viral respiratory panel negative.
CDC Split Type:

Write-up: The patient received his 2nd dose of Moderna (LOT#, site, time unavailable) at an outside clinic the morning of 2/10/21 and presented to the ED with coughing and hypoxia (sp02 occasionally dropping into 70''s) at 8 PM that day. He had quadriplegic spinal paralysis as a result of a remote MVA and has been hospitalized and critically ill in the past due to recurrent UTI''s and pneumonia with associated sepsis. CT negative for pulmonary embolism and showed bilateral infiltrates. Clinical presentation consistent with bilateral pneumonia and started on Rocephin/azithromycin. He was initially stable in the hospital on 1-2 LPM 02. The following evening he became febrile and acutely developed asystole without any pre-existing arrhythmia. Resuscitation was attempted for 45 minutes but unsuccessful. Overall, I suspect his death was related to bacterial pneumonia and resulting acute respiratory failure, complicated by his quadriplegia and autonomic dysreflexia but reported this event as it did occur within 2 days of receiving his 2nd Moderna vaccination.

VAERS ID:	1198406 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-25
Onset:	2021-01-26
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Military Purchased by: ?
Symptoms: Asthenia, Condition aggravated, Confusional state, Depressed mood, Depression, Fatigue, Feeling abnormal, Headache, Impaired work ability, Mobility decreased, Muscular weakness, Pain, Vision blurred, Visual impairment, Vitreous floaters
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (narrow), Depression (excl suicide and self injury) (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Trintellix and Wellbutrin
Current Illness: None
Preexisting Conditions: Depression
Allergies: none
Diagnostic Lab Data: Clinical exam
CDC Split Type:

Write-up: Patient was previously healthy and got her second injection in the right arm on 1/25/2021. She had severe weakness of the right arm starting the day after the immunization, headaches across the whole head, severe fatigue, confusion (brain fog), worsening depression, body aches, and these all progressed and got worse for at least 14 days. She was unable to work any of those days due to weakness, confusion, and body aches. She saw me in the clinic on March 2 as she was still feeling weak, tired, confused. The clinic notes that day record: "On the next day, the 26th, she had severe pain and couldn''t do much. Then she got super depressed and could not get out of bed for 2 weeks, had a lot of fatigue, body aches, and felt down. She tried going to the store one day and by the time she got done she could not get into her truck because she was in so much pain. That would have been about 2 weeks ago. She went back to work last week and was at work the whole week. She was told she does have leave time and that it did not cover the absence of work. She now needs new leave time forms completed. Currently she is in a lot of pain. She has her endocrine appointment on March 15th. The pain is getting worse. The cold is really hard on her. She is barely able to move her right arm at the end of the day, and that is the arm where she had the COVID shot. She is having a lot more weakness. She can not even take one flight of stairs now because everything hurts her. This is a huge difference than before. She used to be able to do several flights, and she can''t do that anymore. She has also had vision changes. She has floaters but she is having a harder time focusing. She feels like no one would believe her, but she feels like this is all part of the reaction to COVID. She has a hard time focusing. She feels like she is going insane."

VAERS ID:	1198445 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-04-09
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Acute pulmonary oedema, Acute respiratory failure, Anaphylactic reaction, Angiogram pulmonary abnormal, Bilevel positive airway pressure, COVID-19, COVID-19 pneumonia, Cardiomegaly, Condition aggravated, Dyspnoea, Hepatic steatosis, Hypersensitivity, Lung opacity, SARS-CoV-2 test positive, Wheezing
SMQs:, Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: ascorbic acid-multivit-min-MSM 1,000-1,000 mg pwep aspirin 81 mg tablet atenoloL (TENORMIN) 25 mg tablet blood sugar diagnostic (BLOOD GLUCOSE TEST) strip blood sugar diagnostic (BLOOD GLUCOSE TEST) strip Blood-Glucose Meter (ACCU-CHEK GUID
Current Illness: Ear pain, Sinus pain, cough, sinus drainage on 3/4/21
Preexisting Conditions: Obesity, unspecified Depressive disorder, not elsewhere classified Paroxysmal supraventricular tachycardia (HC) Unspecified sinusitis (chronic) Influenza with other respiratory manifestations Balanoposthitis Impotence of organic origin Contact dermatitis and other eczema due to plants (except food) Primary localized osteoarthrosis, lower leg Other disorders of synovium, tendon, and bursa(727.89) Palpitations Family history of other digestive disorders Knee joint replacement by other means TIA (transient ischemic attack) Encounter for screening colonoscopy Dysphagia Retinal detachment Diabetic eye exam (HC) SVT (supraventricular tachycardia) (HC) Atrial fibrillation (HC)
Allergies: Statins-hmg-coa Reductase Inhibitors Vicodin [Hydrocodone-acetaminophen] Morphine Doxycycline
Diagnostic Lab Data: INDICATION: PE suspected, high pretest prob, Covid positive. Hypoxic. COMPARISON: CT abdomen and pelvis from 12/30/2017. TECHNIQUE: CT chest pulmonary angiogram during arterial phase injection of IV contrast. Multiplanar reformats and MIP reconstructions were performed. Dose reduction techniques were used. CONTRAST: IOHEXOL 350 MG IODINE/ML IV 75 ML: 75mL FINDINGS: ANGIOGRAM CHEST: No pulmonary artery filling defects. The aorta is normal in caliber. LUNGS AND PLEURA: Patchy groundglass and consolidative opacities. There are interspersed areas of interlobular septal thickening within these groundglass opacities compatible with a "crazy paving" pattern. No effusions or pneumothorax. Similar 3 mm micronodule in the right middle lobe dating back to at least 2017 and statistically benign. Otherwise, no convincing new pulmonary nodules. MEDIASTINUM/AXILLAE: Mild cardiomegaly. Enlarged left AP window lymph node measuring 1.3 x 1.3 cm (series 4/54). No enlarged right hilar lymph node measures 2.1 x 2.2 cm (series 4/71). CORONARY ARTERY CALCIFICATION: Moderate. UPPER ABDOMEN: Hepatic steatosis. Scattered hepatic hypodensities percent characterized as cysts are seen on series 4 image 106, 154, and 164. Partially visualized simple or benign left renal cyst is again seen. No dedicated follow-up is required. MUSCULOSKELETAL: Degenerative changes of the spine. IMPRESSION: 1. No pulmonary embolus. 2. COVID pneumonia. There may be a component of superimposed pulmonary edema. 3. A few mildly enlarged mediastinal lymph nodes are favored to be reactive. 4. Mild cardiomegaly. 5. Hepatic steatosis.
CDC Split Type:

Write-up: He tested positive for COVID-19 on April 7 2021. He qualified for monoclonal antibody therapy and presented for that therapy 4/9/2021. After starting the infusion he developed sudden onset shortness of breath. He is noted to be wheezing. He was given Solu-Medrol and benadryl prior to transfer to ED. Acute hypoxic respiratory failure in patient with recent Covid diagnosis with sudden worsening during monoclonal antibody infusion. Differential includes allergic reaction/anaphylaxis, flash pulmonary edema, worsening Covid. Given the wheezing he was given a DuoNeb with no significant improvement but may be slightly decreased wheezing. Patient was placed on BiPAP given concern for pulmonary edema and increased work of breathing. We were able to titrate down the FiO2 to 40%. He was transitioned to high flow nasal cannula. Will admit to the hospital for further supportive cares given Covid and hypoxic respiratory failure.

VAERS ID:	1199403 (history)
Form:	Version 2.0
Age:	27.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-20
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025A21A / 2	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Asthenia, Gait disturbance, Laboratory test normal, Magnetic resonance imaging normal, Mobility decreased, Muscular weakness
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Write-up: Weakness that started shortly after receiving 2nd dose moderna. Usually able to walk 3 miles daily. Also able to run with her dog. Now barely able to get out of bed. Feeling unbalanced. Weakness bilateral hips with jerky gait. Weak BLE. Neurologically intact. CMS intact.

VAERS ID:	1199455 (history)
Form:	Version 2.0
Age:	17.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-02
Onset:	2021-04-10
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-04-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-10
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: fluoxetine, fesoterodine, ortho-tricyclen, oxybutynin
Current Illness: NA
Preexisting Conditions: spina bifida, spinal meningocele, VP shunt, scoliosis, neurogenic bladder, constipation
Allergies: bananas, cephalexin, kiwi, mango, pineapple, latex
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reported difficulty breathing and chest pain; suffered cardiac arrest and death

VAERS ID:	1201211 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-09
Onset:	2021-04-09
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Angioedema, Endotracheal intubation, Intensive care, Swelling, Swollen tongue
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient received Janssen COVID vaccine 4/9/21 around 9 am. Patient reported to emergency department around 10 pm that day (4/9)- says tongue began swelling since 7pm, he took a benadryl at 8pm with no improvement. Per ED physician, patient had "tremendous amount of tongue swelling, I am not even able to visualize the palate he has fullness to his left neck as well". Patient intubated in emergency room to protect airway. Patient admitted to ICU where he is still today (4/13). Per chart, the edema subsided on 4/12 and patient was extubated today (4/13). Patient received IV steroids from 4/9- 4/13 (discontinued this morning). Of note: patient does take lisinopril 20mg daily (start date July 2020). There is concern the angioedema was caused by this medication. Patient received tranexamic acid and Berinert in the emergency department to assist in treating this potential etiology.

VAERS ID:	1201760 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Deep vein thrombosis, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril 10mg Atorvostatin 20mg
Current Illness: None
Preexisting Conditions: Hypertension Hypercholesteroemia OSA CVA
Allergies: Wasp Stings
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed bilateral DVT with right sided PE within 2 days of vaccine. Clinically stable.

VAERS ID:	1201794 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-02
Onset:	2021-04-03
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	0284214 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Disorientation, Headache, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: vitiligo
Allergies: None
Diagnostic Lab Data: None, I took Acetaminophen until 4/12/2021 when I switched to Ibuprofen
CDC Split Type:

Write-up: headache, disorientation, nausea all from 4/3/2021 continuing to this date. Yesterday the headache was so bad I did vomit.

VAERS ID:	1202354 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-06
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Blood gases, Cerebral infarction, Computerised tomogram head abnormal, Computerised tomogram neck, Condition aggravated, Diabetes mellitus, Dizziness, Drug screen, Encephalomalacia, Full blood count, Headache, Laboratory test, Magnetic resonance imaging head abnormal, Neurological symptom, Speech disorder, Subdural hygroma, Urine analysis, Visual impairment
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Drug abuse and dependence (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Vestibular disorders (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: On 4/8/21 patient reported increased difficulty speaking, increased dizziness, and vision changes. Reports new headache rated 8/10 that started at 11am 4/8. Hx of stroke 2018 with residual right side symptoms. BP 162/104, HR 80, O2 sat 97% room air at 1740. Sent to a Medical Center ER and admitted with stroke symptoms and new onset diabetes.

VAERS ID:	1202374 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-05
Onset:	2021-04-03
Days after vaccination:	29
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / 1	RA / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / 2	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Computerised tomogram abnormal, Dyspnoea, Myocardial strain, Pain, Peripheral embolism, Pulmonary embolism, Ultrasound scan abnormal
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Write-up: Acute pulmonary embolus with mild right heart strain. Woke at 3am on 4-3-21 with severe pain and difficulty breathing, went to emergency room and was given a CT scan, diagnosed and treated with Heparin IV. drip and admitted to the hospital. Later an ultrasound test showed another clot in my left leg so I was started on Apixaban (Eliquis) 5 milligram . Released and sent home on 4-5-21

VAERS ID:	1202715 (history)
Form:	Version 2.0
Age:	41.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-04-13
Days after vaccination:	68
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012M20A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood culture, Cerebral haemorrhage, Computerised tomogram head abnormal, Headache, Impaired work ability, Magnetic resonance imaging head abnormal, Scan with contrast abnormal, Venogram
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Malignancy related therapeutic and diagnostic procedures (narrow)

Write-up: I developed a sudden, sharp stabbing pain in the left side of my head while at work. I had not fallen nor had any injuries/illness. I went to ER; CT scan was concerning for clot in sinus so I was sent via ambulance to inpatient neurology where further MRI/MRV scans determined it was not in fact a clot, but a small bleed of unknown origin. Again, I had no injuries. I was hospitalized while multiple scans were completed along with lab work. Home now following up with neurology, still have head pain, unable to fully work, etc. Hematoma is still there but not growing.

VAERS ID:	1203721 (history)
Form:	Version 2.0
Age:	44.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-03-31
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808978 / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Anaphylactic reaction, Chest discomfort, Lip pruritus, Lip swelling, Pruritus, Rash macular
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: I started having an annaphylaxis reaction a short time after i left. At first it was intense all over body itching that felt like it was from the inside out. By the time i got home i was getting red blotchy patches over my face, neck, and chest. I took benedryl which did nothing to subside the reaction. When my chest started feeling tight i went to the emergency room. My lips were itching and puffy. At the er i received treatment for annaphylaxis once and about a half hour to forty minutes before i was to be discharge i had a reoccurance of symptoms and was treated for it a second time and admitted to the hospital. This was from the March 31st clinic held at the fire department.

VAERS ID:	1203894 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-05
Onset:	2021-04-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Amnesia, Blood pressure abnormal, Chest X-ray normal, Computerised tomogram head normal, Computerised tomogram neck, Echocardiogram normal, Electrocardiogram normal, Fibromuscular dysplasia, Magnetic resonance imaging head normal, Ultrasound Doppler, Ultrasound kidney normal
SMQs:, Neuroleptic malignant syndrome (broad), Dementia (broad), Noninfectious encephalopathy/delirium (broad), Hypertension (broad)

Write-up: Two hours after I had memory loss and couldn?t remember what I did that day, my husband called the nurse hotline and they had me raise my arms and speak and smile but because of the memory loss they said to call the paramedics and my blood pressure was 230/105 and they thought I was having a stroke. My husband took me to the hospital ER and that evening I was checked in because my BP was 225/105 they thought I was have a stroke. At the hospital, I had the first CT head w/o contrast, then a head neck CT scan and I was admitted into the hospital. The follow day they did an electrocardiogram, then an echocardiogram, renal and duplex test, chest x-Ray MRI brain w/o contrast. There was no pain headache or body aches, then I was starting to remember what I had done the day before. A neurologist came into explain the results and all tests were negative, but I was diagnosed with Fibral Muscular Dysplasia, but because they didn?t have enough data, he couldn?t say that it was because of the Moderna vaccine. I was released 24 hours later. My BP went back to normal 120/70 3 days later.

VAERS ID:	1204502 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-30
Days after vaccination:	27
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-30
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized and died within 60 days of receiving a COVID vaccine series

VAERS ID:	1204759 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-04-01
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / OT

Administered by: Unknown Purchased by: ?
Symptoms: Chest pain, Malaise, Nasopharyngitis, Treatment noncompliance
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: really sick; chest pains; will not take the second shot; pretty bad cold; This spontaneous case was reported by a consumer and describes the occurrence of MALAISE (really sick) and CHEST PAIN (chest pains) in an 83-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Asthma. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 01-Apr-2021, the patient experienced NASOPHARYNGITIS (pretty bad cold). On an unknown date, the patient experienced MALAISE (really sick) (seriousness criterion hospitalization), CHEST PAIN (chest pains) (seriousness criterion hospitalization) and TREATMENT NONCOMPLIANCE (will not take the second shot). At the time of the report, MALAISE (really sick), CHEST PAIN (chest pains), TREATMENT NONCOMPLIANCE (will not take the second shot) and NASOPHARYNGITIS (pretty bad cold) outcome was unknown. Not provided The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. The patient''s weight is 170 (units not reported). Whilst hospitalized, all laboratory tests (unspecified) were normal. Concomitant medication included unspecified medication for asthma. Treatment information was not provided. Based on the current available information and temporal association between the use of the product and the start date of these events, a causal relationship cannot be excluded.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of these events, a causal relationship cannot be excluded.

VAERS ID:	1205905 (history)
Form:	Version 2.0
Age:	87.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-02
Onset:	2021-04-04
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	AR / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Abdominal pain upper, Colonoscopy, Diarrhoea, Endoscopy, Faeces discoloured, Haematochezia
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Noninfectious diarrhoea (narrow)

Write-up: Started to have stomach cramps. Had black diarrhea due to blood in stool.

VAERS ID:	1207663 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-03-31
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 1	RA / IM

Administered by: School Purchased by: ?
Symptoms: Abdominal pain, Back pain, Blood test, Chills, Computerised tomogram, Dehydration, Diarrhoea, Large intestine infection, Pyrexia, Rash
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Omeprazole, famotidine, clopidigrel, ezetimibe, rosuvastatin, repatha, baby aspirin, vitamin D, multi-vitamin, zinc
Current Illness: Possibly contracted lyme disease while vacationing on Cape Cod two days earlier. No rash at the time of vaccination -- but bulls eye rash developed two days after vaccination on leg (not at site of vaccination, which was arm). Never saw any ticks on myself, but had walked in the woods -- could have been a nymph.
Preexisting Conditions: coronary artery disease; reflux; lactose intolerance; occasional migraine; seasonal allergies
Allergies: paradoxical reaction to benzodiazepines; lactose intolerance
Diagnostic Lab Data: Blood tests and CT scan at Hospital Emergency Department, on 4/4/21.
CDC Split Type:

Write-up: Received 2nd dose of vaccine on Wednesday. About 5 hours after 2nd dose, chills and fever. Part-way through night (about 12 hours after) started with violent diarrhea and intense abdominal pain. Fever continued for about 65 hours. 2 X 3 inch rash appeared on thigh on Friday, 2 days after receiving vaccine. Liquid diarrhea continued despite fever breaking, as did intense abdominal and back pain. Pain medication helped temporarily with pain. Immodium tried on Saturday but only made things worse. Became dehydrated. Visited emergency department on Sunday morning, 4 days after receiving vaccine. Was diagnosed with infectious colitis and possibly Lyme disease. Treated with doxycycline and metronidazole. Received 2 liters of IV fluid for dehydration.

VAERS ID:	1208285 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-03-05
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

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

Write-up: Blood clot in brain caused stroke

VAERS ID:	1208600 (history)
Form:	Version 2.0
Age:	52.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-04-14
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808978 / 1	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Angiogram, Brain natriuretic peptide, Chest X-ray, Dyspnoea, Electrocardiogram, Fibrin D dimer, Full blood count, Metabolic function test, Pulmonary embolism, SARS-CoV-2 test, Troponin
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), COVID-19 (broad)

Write-up: Patient suffered from SOB 4 days after receiving injection, was diagnosed on 4/14/21 with bilateral PE''s. Admitted to hospital.

VAERS ID:	1208654 (history)
Form:	Version 2.0
Age:	87.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-15
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 2	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram pulmonary, Anticoagulant therapy, Asthenia, Cardiolipin antibody positive, Chest X-ray abnormal, Chest pain, Computerised tomogram thorax abnormal, Dizziness, Dyspnoea, Embolism venous, Pneumonia, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Immune-mediated/autoimmune disorders (broad)

Write-up: Patient presented 3 days after her second DuoNeb vaccine with weakness dizziness chest pain or shortness of breath and was initially diagnosed with a pneumonia by chest x-ray obtained with antibiotics without improvement. Subsequently she was hospitalized and CT of the chest showed left lower lobe segmental pulmonary embolism. The patient never had history of venous thromboembolism in the past. She had weakly positive anticardiolipin antibody of IgG type of unknown significance. She was treated initially with antibiotics but after diagnosis of the blood clot she was started on anticoagulation with apixaban with improvement

VAERS ID:	1209252 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Death, Myocardial infarction, Pulmonary embolism
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-11
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Reported being immunocompromised or on a medication that affect your immune system and note of pituitary gland.
Preexisting Conditions: Reported being immunocompromised or on a medication that affect your immune system and note of pituitary gland.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 4/13 patient''s daughter in law called public health department to report that patient was found by EMS on 3/12/21. They believe patient had passed away over night. No autopsy was done. Family member reported that EMS believed the cause to be heart attack or pulmonary embolism.

VAERS ID:	1209422 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-03-26
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Private Purchased by: ?
Symptoms: Condition aggravated, Death, Diabetes mellitus, Diabetic complication, Dyspnoea, Electrolyte imbalance, Impaired driving ability, Myocardial infarction, Nausea, Unresponsive to stimuli, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-28
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Insulin, albuterol, metoprolol, trazodone, duloxetine, cephdinir
Current Illness: Unknown
Preexisting Conditions: Asthma, obesity, insulin-dependent DM
Allergies: Unknown
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 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. On 03/28/2021, she was short of breath before vomiting a small amount. She then became 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.

VAERS ID:	1209641 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-04-09
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Deep vein thrombosis, Dyspnoea, Fibrin D dimer increased, Pulmonary embolism, Pulmonary infarction, Ultrasound Doppler abnormal
SMQs:, Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Pantoprazole, Pravastatin, Paroxetine
Current Illness: None
Preexisting Conditions: Chronic lymphocytic leukemia, History of prostate cancer--s/p prostatectomy, Hyperlipidemia, depression with anxiety
Allergies: None
Diagnostic Lab Data: D-dimer 9800 Lower extremity ultrasound positive for femoral vein DVT. CTA of chest- positive for bilateral lung pulmonary emboli in each lung lobe with left lower lobe infarction
CDC Split Type:

Write-up: patient was administered Moderna vaccine (initial shot) and within 48-72 hours became short of breath. He presented to my office for evaluation 4/14/2021 and found to have right leg DVT and massive bilateral pulmonary emboli with left lung infarction.

VAERS ID:	1209680 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-09
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 1	RA / IM

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

Write-up: Patient was admitted to hospital with positive covid diagnosis after 1 shot of moderna vaccine

VAERS ID:	1210267 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-02-03
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Death, General physical health deterioration, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-07
Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: SCA 6
Preexisting Conditions: SCA 6
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dad became very sleepy the day after. He quickly declined and died on Feb. 7 th. I feel the vaccine may have had something to do with his death.

VAERS ID:	1211381 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-05
Onset:	2021-04-06
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Chest pain, Computerised tomogram thorax abnormal, Dyspnoea, Musculoskeletal chest pain, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: patient developed chest pain, right rib pain and dyspnea 1 day following vaccine

VAERS ID:	1211991 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-22
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / -

Administered by: Private Purchased by: ?
Symptoms: Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Write-up: Clots Ongoing

VAERS ID:	1212773 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-08
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	028A21A / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood test normal, Deafness unilateral, Dizziness, Magnetic resonance imaging head normal, Tinnitus
SMQs:, Anticholinergic syndrome (broad), Hearing impairment (narrow), Vestibular disorders (broad)

Write-up: Extreme ringing in the ears woke me up at 4 am on day 7 after vaccination. Shortly after, I lost hearing in my left ear. Went to the ER where I was prescribed prednisone. I have been on it for a week now with no relief thus far. I am very dizzy, still have extreme ringing, and hearing loss in the left ear.

VAERS ID:	1212983 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-01-30
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: stroke
Other Medications: prednisone, amlodipine., aspirin, calcium, vit b, Symbicort, Spiriva, albuterol, metoprolol,
Current Illness:
Preexisting Conditions: COPD
Allergies: hydroclorothiazide,
Diagnostic Lab Data:
CDC Split Type:

Write-up: stroke

VAERS ID:	1213423 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-04-02
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Chills, Cough, Decreased appetite, Diarrhoea, Dyspnoea exertional, Headache, Pyrexia, SARS-CoV-2 test positive, Vomiting, Wheezing
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client received the vaccine on 3/30. She started having symptoms on 4/2. (Vomiting, diarrhea, bad cough). She believed that she was getting better, then on 4/12, she went to the hospital due to cough, shortness of breath with exertion, diarrhea, fever decreased appetite, headaches, intermittent wheezing and chills. She was admitted for oxygen therapy and further assessment. She had a positive Covid test on 4/4.

VAERS ID:	1213490 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-10
Onset:	2021-04-13
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalized secondary to PE 4 days post vaccination.

VAERS ID:	1214422 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-29
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	LA / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER	- / UNK	- / IM

Administered by: Public Purchased by: ?
Symptoms: Pulmonary thrombosis, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Write-up: Blood clots in left leg, hip, bilateral lungs; treated with blood thinners; was admitted to hospital from 4/1-4/3; discharged to home, stable

VAERS ID:	1214713 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-29
Onset:	2021-04-12
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8734 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Acute myocardial infarction, Arterial stent insertion, Cardiac arrest, Catheterisation cardiac, Culture urine negative, Endotracheal intubation, Fibrin D dimer increased, Mechanical ventilation, Neurological symptom, Platelet count normal, SARS-CoV-2 test negative, Troponin I increased, Ventricular fibrillation, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: obesity BMI 47.4 kg/m2, heavy smoker
Allergies: Penicillin
Diagnostic Lab Data: Troponin I 2.25 on 4/12/21 2215; & 9.2 on 4/13/21 0538; D-dimer 7.77 on 4/12/21 2215; plt 290 4/12/21 2215; WBC 18.7 4/12/21 urine culture-no growth, COVID-19 not detected 4/12/21
CDC Split Type:

Write-up: 50 yo female with no medical history known to our system presents with Inferior STEMI with ventricular fibrillation cardiac arrest. Unknown initial downtime without CPR. Arrived by rescue squad and taken emergently to Cardiac Catheterization Lab, required mid-LAD stenting. Therapeutic temperature management (TTM), now rewarmed. Currently intubated on mechanical ventilation, on norepinephrine, poor neurological responses, consider neurology consult for brain evaluation/prognostic recommendations. There is a progress note written by ED RN on 4/12/21 that states family reports she had "her 2nd COVID shot 1 week ago," but per Immunization Registry, only 1 COVID vaccine is recorded.

VAERS ID:	1214879 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-04-14
Days after vaccination:	27
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Respiratory distress, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Hospitalized on 4/14/2021 with respiratory distress - history of COPD

VAERS ID:	1214912 (history)
Form:	Version 2.0
Age:	37.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-04-09
Days after vaccination:	50
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	023M20A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Retinal artery occlusion
SMQs:, Embolic and thrombotic events, arterial (narrow), Retinal disorders (narrow)

Write-up: Patient had a branch retinal artery occlusion

VAERS ID:	1214953 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-02
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Blood thyroid stimulating hormone, Brain natriuretic peptide, Chest X-ray abnormal, Computerised tomogram thorax, Echocardiogram, Fibrin D dimer, Full blood count, Hypertensive crisis, Metabolic function test, Pulmonary embolism, Troponin
SMQs:, Embolic and thrombotic events, venous (narrow), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Infective pneumonia (broad)

Write-up: Acute Pulmonary Embolism-Bilateral , Hypertensive Crisis

VAERS ID:	1217884 (history)
Form:	Version 2.0
Age:	27.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-21
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 1	LA / IM

Administered by: Work Purchased by: ?
Symptoms: Arteriogram carotid, Blood cholesterol normal, Blood magnesium decreased, Blood magnesium normal, Blood potassium decreased, Blood triglycerides increased, C-reactive protein increased, Catheterisation cardiac, Chest pain, Echocardiogram normal, Ejection fraction, Electrocardiogram normal, Feeling abnormal, High density lipoprotein normal, Left ventricular dysfunction, Low density lipoprotein normal, Magnetic resonance imaging abnormal, Magnetic resonance imaging heart, Myocardial oedema, Myocarditis, Nausea, Pain in extremity, Pain in jaw, Red blood cell sedimentation rate increased, Total cholesterol/HDL ratio normal, Troponin increased
SMQs:, Cardiac failure (broad), Acute pancreatitis (broad), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Myocardial infarction (narrow), Dementia (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Lipodystrophy (broad), Osteonecrosis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (narrow), Immune-mediated/autoimmune disorders (broad)

Write-up: Woke with up chest, arm and jaw pain on 03/21/2021. Presented to the ED. Her initial EKG was negative for any acute changes but her troponin was elevated. Cardiology was consulted. Her echo was negative for cardiomyopathy or hypertrophy. But after her troponin continued to rise she was taken to the cath lab to look for ischemia. Her cardiac angiography was negative for obstructive disease, and coronary arteries were completely normal. Had low magnesium and potassium- so started on oral supplementation. Discharged on 03/22/2021 with nitroglycerin (which was not helpful and made her feel worse/nauseated) and to follow up with outpatient cardiac MRI and cardiology. This imaging revealed significant myocardial edema consistent with myocarditis. 04/01/2021 Per Cardiology: -Given that the patient had covid 19 back in November 2019 I believe she may have had a low yield subacute myocardial infection at that time that was somehow exacerbated by her 1st covid vaccine. Therefore, after some consideration and careful discussion I am advising against the 2nd vaccine at this time. -No physical exercise for 6 months given her current myocarditis and family hx of sudden cardiac death -May trial PRN NSAIDS for pain relief -Recommend birth control and no pregnancy until at least after her follow up cMRI -Follow up in 6 months with cMRI prior

VAERS ID:	1218044 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-03
Onset:	2021-04-03
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / UNK	RA / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / UNK	RA / SYR

Administered by: Public Purchased by: ?
Symptoms: Arthralgia, Atrial fibrillation, Dyspepsia, Fatigue, Heart rate increased, Pain in jaw, Supraventricular tachycardia
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Gastrointestinal nonspecific dysfunction (narrow), Osteonecrosis (broad), Arthritis (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? Yes
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Premarin .3 mg twice daily Vitamin D3 5000 IU Vitamin b12 1000 mcg Wal-tin 24 hr allergy loratadine tablets 10 mg
Current Illness: None
Preexisting Conditions: Biopsy diagnosis of sarcoidosis - non-symptomatic Wolff-Parkinson_-White Syndrome osteoarthritis ankle and hip replacement
Allergies: Epinephrine - tachycardia WPW Syndrome Lupron - same as above Nasal allergy sprays - same as Epi Latex tape - welts hives redness
Diagnostic Lab Data: 4/12/21 went to urgent care they took me to ER. During the testing in ER I went into Supraventricular tachycardia then heart cardioverted itself out then went into Afib
CDC Split Type:

Write-up: First COVID19 shot felt fast heartbeat but seemed to subside in couple hours Second COVID19 shot same fast heartbeat seemed to subside but I was tired. Next day it felt as if someone threw a fast pitch softball at my chest took my breath away seemed to last several minutes then extreme heartburn set in. Very fatigued, heart burn lasted 9 days. Starting on 4/5/21 joint pain also started in my new hip. On 4/12/21 jaw pain set in at which point went to urgent care.

VAERS ID:	1218352 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-04-07
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Intensive care
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt tested positive for COVID-19 as part of routine screening for a procedure at a local hospital on 4/7/2021. Pt began to have symptoms and was given monoclonal antibodies near where she lives on 4/12/2021. Symptoms grew worse overnight and she was admitted to her local hospital on 4/13/2021 with acute hypoxic respiratory failure and started on O2. O2 demands continued to increase during the day and she was transferred to our ICU. Currently on high flow nasal canula, but not intubated.

VAERS ID:	1218567 (history)
Form:	Version 2.0
Age:	44.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-29
Onset:	2021-01-05
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025L20A / 1	LA / OT

Administered by: Unknown Purchased by: ?
Symptoms: Pruritus, Vaccination site erythema, Vaccination site pruritus, Vaccination site swelling
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: full body itch; Injection site itchy; Injection site redness/swelling and itchy; Injection site redness/swelling and itchy; This spontaneous case was reported by a nurse (subsequently medically confirmed) and describes the occurrence of PRURITUS (full body itch) in a 44-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 025L20A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Drug allergy and Allergy to vaccine (Moderna vaccine). On 29-Dec-2020, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 05-Jan-2021, the patient experienced VACCINATION SITE PRURITUS (Injection site itchy), VACCINATION SITE ERYTHEMA (Injection site redness/swelling and itchy) and VACCINATION SITE SWELLING (Injection site redness/swelling and itchy). On 13-Jan-2021 at 2:00 PM, the patient experienced PRURITUS (full body itch) (seriousness criterion hospitalization). The patient was hospitalized from 13-Jan-2021 to 14-Jan-2021 due to PRURITUS. On 14-Jan-2021, PRURITUS (full body itch) had resolved. At the time of the report, VACCINATION SITE PRURITUS (Injection site itchy), VACCINATION SITE ERYTHEMA (Injection site redness/swelling and itchy) and VACCINATION SITE SWELLING (Injection site redness/swelling and itchy) had resolved. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter considered PRURITUS (full body itch) to be possibly related. No further causality assessments were provided for VACCINATION SITE PRURITUS (Injection site itchy), VACCINATION SITE ERYTHEMA (Injection site redness/swelling and itchy) and VACCINATION SITE SWELLING (Injection site redness/swelling and itchy). The patient took Diphenhydramine orally for a week for injection site redness, swelling and itch. The patient was administered epinephrine and methylprednisolone in ER (interpreted as Emergency room) in hospital. The doctor instructed the patient to avoid taking the second dose of vaccine. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Concomitant product use was not provided. Most recent FOLLOW-UP information incorporated above includes: On 26-Mar-2021: Follow-up included patient details, vaccine information and treatment details of the reported events.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.

VAERS ID:	1218781 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-04
Onset:	2021-04-15
Days after vaccination:	101
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025L20A / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: COVID-19, Cardiac failure congestive, Chronic obstructive pulmonary disease, Condition aggravated, Encephalopathy, Hypoxia, Intensive care, Respiratory symptom, SARS-CoV-2 test positive
SMQs:, Cardiac failure (narrow), Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Write-up: Previously diagnosed with Covid PNA in 11/2020 that was treated with course of Remdesivir and steroids, has 2 negative covid tests in the interim. He received his first Moderna COVID vaccine on 1/4/2021, but did not get the second dose. He had recently been hospitalized at a healthcare provider for COPD/CHF exacerbation was discharged 4/13/2021, returned this morning with URI symptoms, found to by hypoxic with O2 sats in the 80s, encephalopathic, and Covid test was subsequently positive (4/15/2021). Pt transferred that evening to our hospital for ICU level care.

VAERS ID:	1218816 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-02
Onset:	2021-04-08
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Diarrhoea, Headache, Injection site bruising, Nausea, Oropharyngeal pain, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Lightreaction same day. After 6 days, symptoms worsened: nausea, diarrhea, vomitting (wouldn''t hold anything) , headache, sore throat, bruising all over the arm where shot was given, and fever . Patient was admitted twice to the hospital ( on 4/12/2021 and on 4/15/2021)

VAERS ID:	1218829 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-03-28
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Anal incontinence, Anxiety, Catheterisation cardiac abnormal, Cerebrovascular accident, Confusional state, Coronary artery disease, Culture negative, Disorientation, Electroencephalogram abnormal, Fatigue, Feeling abnormal, Haemangioma, Hallucination, Hypoaesthesia, Left ventricular end-diastolic pressure, Leukocytosis, Lumbar puncture normal, Magnetic resonance imaging head abnormal, Mental status changes, Pain, Seizure like phenomena, Troponin increased, Viral test
SMQs:, Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Noninfectious diarrhoea (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ibuprofen 200mg every 6 hours prn for pain (hasn''t used in 1 month). May have also been taking "curry powder" supplement.
Current Illness: N/A
Preexisting Conditions: hypertension (mild) Osteoarthritis with chronic hip pain
Allergies: No known allergies
Diagnostic Lab Data: MRI (3/29/21): 1. No abnormal diffusion restriction to suggest acute or subacute infarction. 2. Single 8 to 9 mm lesion noted at the right temporal lobe along its superior margin with imaging features most consistent with a benign cavernoma.3. Punctate focus of susceptibility artifact within the right globus pallidus likely reflecting sequela of previous microhemorrhage. EEG (3/29/21):This 24 hour EEG performed on a 73 yr old is abnormal with right hemispheric slowing as well as frequent runs of right hemispheric spikes which were pseudoperiodic at times. Multiple brief electrographic seizures were aso seen in this segment evolving form the right side. Findings suggest a right sided structural abnormality and epileptogenic focus. EEG (4/2/21): This EEG obtained on a 73 yr old is abnormal due to right hemispheric slowing as well as spikes which suggest a likely structural abnormality and a seizure focus. Compared the EEG monitoring done earlier in this admission, this record looks much improved. Lumbar puncture (3/31/21): No viral or bacterial infection. Cardiac Catheterization (4/1/21): 1. Single vessel coronary artery disease involving proximal to mid, large, bifurcating OM1 branch with mild diffuse disease elsewhere. 2. Normal LVEDP. 3. No aortic valve stenosis.
CDC Split Type:

Write-up: Patient reports she started to experience feeling a sense of doom, stool incontinence, left-sided numbness, altered mental status in the early hours of 3/28/21. Of note, patient received her second dose of the Moderna vaccine on 3/25/2021 and felt poorly the day after with body aches and fatigue. The patient was admitted to ED with suspected stroke, but no ischemia or hemorrhage was shown on MRI. In addition, her blood pressure at the ER was 196/104 and her troponin was elevated and reached a peak of around 5. Cardiac Catheterization showed no acute disease but chronic and unsubstantial changes that did not require intervention. An EEG from 3/29 was concerning for subacute seizure like activity and She was started on IV Keppra. MRI at the same time, also revealed a right-sided cavernoma. During her hospital stay, she had ongoing confusion and disorientation with hallucinations, concerning for an encephalitis. She also received 3 days of ceftriaoxone for a potential unseen infection, but cultures were negative and PCR for viral pathogens was also normal. She was seen to have leukocytosis but the cause was not determined. Eventually, she regained her baseline mentation with no residual deficits and was discharged on Keppra to follow up with neurology.

VAERS ID:	1219054 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-24
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Brain stem infarction, Confusional state, Magnetic resonance imaging head abnormal, Meningioma
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Write-up: Upon waking the morning of 3/24/2021, client experienced confusionMRI did show punctate acute/subacute infarct identified within the pons in the cortex of the left temporal/left parietal lobe. She was also noted to have stable moderate chronic ischemic microvascular changes and a stable old lacunar infarct, as well as a 8 x 6 x 6 mm meningioma arising from the right lateral anterior falx.

VAERS ID:	1219355 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-09
Onset:	2021-04-09
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0158 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood test, Chest X-ray, Computerised tomogram, Dizziness, Loss of consciousness, Pain
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Write-up: Felt dizzy 15 minutes after the shot and dizzy throughout the day on Friday, April 9, 2021 On Saturday, April 10, 2021 felt extremely dizzy in morning and passed out in a back room. Fell backwards on the floor and couldn''t get up. Was yelling and screaming from the pain. Husband called 911 for an ambulance. I was taken to the Hospital and was admitted to hospital. Was very dizzy. Was not allowed to even get up for 2 days in the hospital because I was considered a serious fall risk. Stayed in hospital until Wed., April 14, 2021 when I was released to go home.

VAERS ID:	1219873 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-20
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Computerised tomogram thorax, Fibrin D dimer increased, Pulmonary embolism
SMQs:, Haemorrhage laboratory terms (broad), Embolic and thrombotic events, venous (narrow), Pulmonary hypertension (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: aspirin, celexa, lisinopril, simvastatin, melatonin, omeprazole
Current Illness:
Preexisting Conditions: HX of DVT.
Allergies: atorvastatin - headache
Diagnostic Lab Data: Elevated d-dimer, CTA + for PE.
CDC Split Type:

Write-up: Hx of DVT not on blood thinners. 3 days after 2nd moderna vaccine developed symptoms of pulmonary embolism, but not diagnosed until a month later.

VAERS ID:	1220359 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-05
Onset:	2021-04-15
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808980 / 1	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Cerebral venous sinus thrombosis, Cerebrovascular accident, Computerised tomogram abnormal, Intensive care, Muscular weakness
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Central nervous system vascular disorders, not specified as haemorrhagic or ischaemic (narrow)

Write-up: Patient admitted 4/14/2021 to the ICU from ED. Patient was experiencing hand weakness. Patient given TPA as treatment for a potential stroke. Patient with known stroke on CT imaging, unable to further verify with MRI imaging. Upon further investigation/discussion with the patient, he reports receiving the Johnson & Johnson Vaccine 10 days prior to admission. Patient with known comorbidities which increase his risk of an embolitic stroke however with recent findings from the CDC, unsure if this needs to be further investigated. Patient had 2 head CT scans, showing no intracranial abnormalities and MRI was unable to be completed due to patient''s size. Neurology states high probability of stroke within their consult note. Patient''s risk factors for stroke include: uncontrolled hyperlipidemia (LDL 132 on Crestor 40 mg daily PTA), hypertension (as high as 182/92 mmHg in ED), physical inactivity (BMI 76 kg/m^2), and male. Low suspicion of CVST based on patient''s platelet count of 212 on admission and no abnormality on head CT. MRI would have been beneficial in potentially diagnosing CVST, as well. Our recommendation is to submit this information to the VAERS database as a possible ADR from the vaccine. The patient fits the timing of an ADR, within 6-13 days of vaccine administration, and CDC recommends watching for neurological symptoms based on their most recent press release.

VAERS ID:	1221268 (history)
Form:	Version 2.0
Age:	33.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-13
Onset:	2021-04-15
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8733 / 2	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Appendicectomy, Appendicitis
SMQs:

Write-up: Appendicitis

VAERS ID:	1222021 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-16
Onset:	2021-02-16
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007MA20A / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Dizziness, Malaise
SMQs:, Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-19
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lisinopril,gabapentin,budesonide,albuterol,oxycontin, tramadol
Current Illness: dental visit for amoxillin
Preexisting Conditions: hypertension, Coronary Artery Disease
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client became ill approximately one hour after COVID immunization. Symptoms include weakness, light headed, general malaise. Client refused wife''s offer for medical assistance.

VAERS ID:	1221739 (history)
Form:	Version 2.0
Age:	18.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-16
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / UNK	UN / IM

Administered by: Unknown Purchased by: ?
Symptoms: Chest pain, Echocardiogram abnormal, Electrocardiogram ST segment elevation, Electrocardiogram abnormal, Magnetic resonance imaging heart, Myocarditis, Pericardial effusion, Troponin I increased
SMQs:, Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Patient developed mild chest pain roughly 24 hrs after receiving 2nd Moderna Vaccine injection. He initially managed this with ibuprofen, but pain intensified and he presented to the ED approximately 1.5 days after 2nd injection with severe chest pain, diffuse ST elevations on EKG and elevated Troponin I measurement of 6 ng/ml. Patient transferred to hospital for further management and remains under inpatient care at time of report. Testing initially suggested pericarditis but cardiac MRI consistent with myocarditis. Troponin I peaked @ 75 ng/ml on 4/16/21.

VAERS ID:	1222051 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-15
Onset:	2021-04-17
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	042B21A / 2	UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Antiphospholipid antibodies, C-reactive protein increased, Contusion, Gingival bleeding, Immune thrombocytopenia, Immunoglobulin therapy, Petechiae, Platelet count decreased, Platelet transfusion, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (narrow), Gingival disorders (narrow), Accidents and injuries (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Patient a 46 yo female with a history of Bechet''s presenting to the ED yesterday due to a history of progressive bruising with later appearance of petechiae and gum bleeding. CBC yesterday revealed an isolated thrombocytopenia with platelets of 19k ($g340k all previous checks), suspected ITP. She was given 1 unit of platelets, solumedrol x 1 and IVIG. Platelets this morning have responded but more likely related to the platelet transfusion. Today I discussed continuation of IVIG and transitioning over to pulse dexamethasone 40 mg x 4 days q 14 days for 4 cycles in order to put the ITP in remission. Considerations for precipitating event leading to the ITP include autoimmune condition recently undergoing dose adjustment, history of recent infection (viral gastroenteritis), and post Covid 19 vaccination induced ITP-currently described incidence between 1 in 100,000 to 1 in 1,000,000 and seen between 1-3 wks after vaccination. This is unlikely to be related to vaccine induced thrombotic thrombocytopenia (VITT) as there is no sign of clotting. In addition she received an mRNA vaccine (Moderna) which has not been reported to cause VITT. A HIT antibody was sent.

VAERS ID:	1223510 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-15
Onset:	2021-02-16
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Alanine aminotransferase normal, Albumin globulin ratio normal, Albumin urine absent, Anion gap, Aspartate aminotransferase normal, Asthenia, Bacterial test negative, Basophil count normal, Basophil percentage decreased, Bilirubin urine, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium decreased, Blood chloride decreased, Blood creatine phosphokinase increased, Blood creatinine normal, Blood culture negative, Blood folate normal, Blood glucose increased, Blood lactic acid normal, Blood magnesium normal, Blood potassium decreased, Blood sodium decreased, Blood thyroid stimulating hormone normal, Blood urea normal, Carbon dioxide normal, Chromaturia, Eosinophil count normal, Eosinophil percentage decreased, Fall, Globulin, Glomerular filtration rate normal, Glucose urine absent, Haematocrit normal, Haemoglobin normal, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume decreased, Monocyte count normal, Monocyte percentage, Myalgia, Neutrophil count increased, Neutrophil percentage increased, Nitrite urine absent, Platelet count normal, Protein total normal, Pyrexia, Red blood cell count normal, Red blood cells urine negative, Red cell distribution width normal, SARS-CoV-2 test negative, Specific gravity urine decreased, Troponin increased, Urinary casts, Urinary occult blood negative, Urinary sediment present, Urine ketone body, Urine leukocyte esterase, Urobilinogen urine, Vitamin B12 normal, White blood cell count normal, White blood cells urine negative, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Hyponatraemia/SIADH (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypokalaemia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Current Outpatient Medications Medication Sig Dispense Refill ? ALPRAZolam (Xanax) 1 MG tablet TAKE 1 TABLET BY MOUTH AT BEDTIME AS NEEDED 44 tablet 5 ? Synthroid 50 MCG tablet Take 1 tablet by mouth daily before breakfast. 90 tablet 1 ? li
Current Illness: none
Preexisting Conditions: Past Medical History: Diagnosis Date ? Blind left eye ? Depression ? DJD (degenerative joint disease) of lumbar spine ? H/O cold sores ? Hypothyroid ? Low grade mucinous neoplasm of appendix 02/27/2020 ? Mass of colon 02/2020 ? Migraine ? Personal history of malignant melanoma of skin stage I no progression ? Personal history of other malignant neoplasm of skin see surgical other ? Post-operative nausea and vomiting WITH LONG WAKE UP TIME ? Trigeminal neuralgia s/p microvascular decompression in PA in 2007 now stable
Allergies: Allergies Allergen Reactions ? Sulfa Antibiotics Rash ? Augmentin [Amoclan] Gastrointestinal Intolerance ? Dilantin [Phenytoin] Rash
Diagnostic Lab Data: Component Latest Ref Rng & Units 2/16/2021 2/16/2021 2/16/2021 2/16/2021 2/16/2021 2/16/2021 9:35 PM 9:40 PM 9:44 PM 10:10 PM 10:57 PM 11:30 PM White Blood Cells 3.8 - 10.8 K/uL 9.2 Red Blood Cells 3.90 - 5.11 M/uL 4.78 Hemoglobin 11.7 - 15.7 g/dL 14.2 Hematocrit 35.1 - 45.6 % 42.7 MCV 80 - 97 fL 89.3 MCH 26.4 - 33.0 pg 29.7 MCHC 31.8 - 35.3 g/dL 33.2 RDW 11.2 - 15.6 % 14.2 Platelet Count 140 - 390 K/uL 239 MPV 6.7 - 10.6 fL 7.3 Neutrophil % % 90.0 Lymphocyte % % 5.0 Monocyte % % 4.6 Eosinophil % % 0.0 Basophil % % 0.4 Absolute Neutrophils 1.8 - 7.1 K/uL 8.3 (H) Absolute Lymphocytes 0.9 - 3.5 K/uL 0.5 (L) Absolute Monocytes 0.2 - 0.9 K/uL 0.4 Absolute Eosinophils 0.0 - 0.5 K/uL 0.0 Absolute Basophils 0.0 - 0.2 K/uL 0.0 Source Urine Cath . . . Color, Urine Yellow Appearance, Urine Clear Glucose, Urine NEG Negative Bilirubin, Urine NEG Negative Acetone, Urine NEG Trace (A) Specific Gravity, Urine 1.003 - 1.035 1.003 Occult Blood, Urine NEG Negative pH, Urine 4.6 - 8.0 6.0 Albumin, Urine NEG Negative Urobilinogen, Urine NORM Normal Nitrite, Urine NEG Negative Leukocyte Esterase, Urine NEG Negative White Blood Cells, Urine 0 - 2 /hpf 0 Red Blood Cells, Urine 0 - 2 /hpf <1 Squamous Epithelial Cells, Urine 0 - 10 /hpf <1 Casts, Hyaline 0 - 6 /lpf 0 Bacteria NEG Negative Reflex Request No culture per provider criteria Sodium 133 - 144 mEq/L 132 (L) Potassium 3.5 - 5.0 mEq/L 3.2 (L) Chloride 95 - 107 mEq/L 97 Carbon Dioxide 22 - 32 mEq/L 24 Anion Gap 6 - 15 mEq/L 11 BUN 8 - 24 mg/dL 11 Creatinine 0.50 - 1.20 mg/dL 0.73 Glomerular Filt Rate $g60 mL/min 77 Glucose 70 - 100 mg/dL 155 (H) Albumin 3.5 - 5.2 g/dL 3.8 Calcium 8.6 - 10.4 mg/dL 8.8 AST 11 - 41 IU/L 18 ALT 9 - 40 IU/L 9 Alkaline Phosphatase 35 - 121 IU/L 64 Bilirubin, Total <1.5 mg/dL 0.5 Total Protein 6.2 - 8.5 g/dL 6.7 Globulin 1.8 - 3.7 g/dL 2.9 A:G Ratio 1.2 - 2.7 1.3 Specimen Description BLOOD Drawn from Right hand. BLOOD DRAWN FROM IV SITE NO VP CHARGE 6 mL each . . . Culture No growth 6 days Report Status Final 02/23/2021 SARS-CoV-2 Source NASOPHARYNGEAL . . . SARS-CoV-2 by PCR NOTD Not detected Vitamin B12 232 - 1,245 pg/mL 763 Folate $g4.8 ng/mL 11.5 COVID-19 Antigen NOTD Not detected CK 26 - 192 IU/L 361 (H) Troponin, High Sensitivity <12 ng/L 14 (H) 13 (H) Lactate 0.4 - 2.0 mmol/L 1.2 Magnesium 1.8 - 2.3 mg/dL 1.6 (L) TSH 0.60 - 5.40 uIU/mL 0.73
CDC Split Type:

Write-up: patient hospitalized secondary to fever, generalized weakness and myalgias and had a fall. she was hospitalized for 2 days.

VAERS ID:	1223679 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-15
Onset:	2021-04-17
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Chest pain, Computerised tomogram thorax abnormal, Dyspnoea, Echocardiogram abnormal, Infarction, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: Acute right lower lobe subsegmental pulmonary embolism. Patient presented with right-sided, intercostal chest pain and shortness of breath. CT angiogram revealed a PE with small infarct, no heart strain. Patient started on pain medication and anticoagulation. Anticipate full recover and discharge the day after hospital admission. This is hospital day 1.

VAERS ID:	1223845 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-01
Submitted:	0000-00-00
Entered:	2021-04-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6205 / 2	LA / SYR

Administered by: Public Purchased by: ?
Symptoms: Ligament sprain, Lymphadenopathy, Magnetic resonance imaging, Meniscus injury, Osteoarthritis, Pain in extremity, Peripheral swelling, X-ray
SMQs:, Cardiac failure (broad), Angioedema (broad), Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Arthritis (narrow), Tendinopathies and ligament disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin, Trazodone, Losartan/HCTZ 100/25mg, Duloxitine DR 90mg, Metformin 1000 x2, Simvastatin 20 mg, Omeprazol 20 mg x3
Current Illness: None
Preexisting Conditions: Osteoarthritis, degenerative disc disease, Barrett?s Esophagus,
Allergies: Oxicodone, Bee venom
Diagnostic Lab Data: X-Ray, MRI
CDC Split Type:

Write-up: I have a very swollen left leg. It began slowly and became worse. I thought that I sprained my left knee on March 13th. (I had my first vaccine shot in my left arm on March 11th. ) I thought that I would let it heal. My second shot was April 1st and my left leg became very painful after that. I went to the Doc. for a knee sprain, was sent to Orthopedic. I received an X-ray and an MRI. There is tricompartmental osteoarthritis, with 2 degenerative meniscus tears. It occurred to me today that my knee joint may be reacting to the vaccination. I did have swollen lymph nodes on my left side in neck and under my arm after the second shot. My knee has had arthritis and possibly the degenerative meniscus tears but it has never become swollen and inflamed. The swelling and pain has persisted for over 2 weeks now. I?m not sure if it is related but I thought that I should share this with you. If there is anything that you can help with, please do. I have been so very grateful for the vaccination. Thank you!

VAERS ID:	1224094 (history)
Form:	Version 2.0
Age:	28.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-03-26
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 1	LA / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Chills, Dysphagia, Eye swelling, Feeling abnormal, Hypoaesthesia oral, Pyrexia, Tremor, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: Swelling my eyes significantly; Having my tongue go somewhat numb; Difficult to swallow; Feeling worse; Some feverish feelings; Hives all over my body, especially on my face; Chills; Couldn''t stop shaking; This is a spontaneous report from a contactable consumer (patient, self-reported). A 28-year-old female patient (who was not pregnant at the time of vaccination), received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection, lot number: ER8732 and expiry date was not provided), via an unspecified route of administration, in arm left, on 26Mar2021, at 14:00 as single dose for COVID-19 immunisation. Patient medical history was not reported. She did not have any known allergies. Concomitant medications included estradiol valerate, progesterone and cyanocobalamin (VITAMIN B12). Patient stated that she first experienced some feverish feelings, chills and hives 30 minutes following her vaccination. She drove home from the hospital and was feeling a bit off, but mostly okay. By the time she got back, she was feeling worse, around 4 PM. By 5 PM she had broken out in hives all over her body, especially on her face, swelling her eyes significantly and having her tongue go somewhat numb, starting to make it difficult to swallow. She also had significant chills, and couldn''t stop shaking, and ended up being admitted to the ER. After being given antihistamines, the swelling went down and eventually the chills stopped after monitoring in the hospital. The patient was hospitalized for the events on an unknown date in Mar2021. Treatment received for the events. The patient was not diagnosed with COVID prior vaccination. The patient had not been tested for COVID post vaccination. The patient did not receive any other vaccine in four weeks of vaccination. Outcome of the events was recovered on an unknown date in Mar2021.

VAERS ID:	1224257 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-02-18
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Carpal tunnel syndrome, Condition aggravated, Headache, Hypoaesthesia, Incomplete course of vaccination, Paraesthesia
SMQs:, Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: No prescriptions taken within 12 hours
Current Illness:
Preexisting Conditions: Arthritis, brain injury, herd, ataxia
Allergies: Erythromycin , hydrclotroizide , penicillin
Diagnostic Lab Data: I have seen my regular doctor, 2 rheumatology doctors, one in person one on television, one neurologist in person, one chiropractor who is giving me cold laser treatment, , two allergy doctors. no one knows how to treat the nerve flare up from the Moderna injection what will calm down the nerve or make it worse......no one knows?. Moderna?s. Consumer hotline is in another country the person I spoke to did not speak English very well but she was very polite. There is not documentation and how to treat nerve problems caused by their vaccine. NO ONE CAN TELL ME IF THIS IS PERMANENT OR NOT, NO ONE CAN HELP ME.....CAN YOU HELP ME?
CDC Split Type:

Write-up: I had the Covid 19 shot number 1. They cancelled shot number 2 it has been almost 60 days. I now have long term parethenesia. A main nerve condition that I never has before caused by the Covid 19 vaccine. In my quest of many doctors to find help, I have met many people along the way also suffering from long term nerve problems from this vaccine. No one know how to treat any of us. I have tried my main doctor, that was initially treated with prednisone pack. That lasted 10 days. It came back at2/3 less than it was, but it is still there. From the knees down, to my feet...pins needs, prickly feeling numbness. The same for my arms and hands from the elbow down and my cheeks. It has flared up my carpal tunnel nerve in both my hands and headaches.

VAERS ID:	1225566 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-02-18
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	38077727399 / 1	LA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Blood pressure increased, Death, Hyperhidrosis, Pain, Tachypnoea
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Hypertension (narrow), Eosinophilic pneumonia (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 2021-02-27
Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metoprolol succinate, apixaban, clopidogrel, sertraline, tamsulosin, finasteride, famotidine, senna, ducolax
Current Illness: paronychia, dental caries
Preexisting Conditions: fronto-temporal dementia with motor neuron disease, ischemic cardiomyopathy, benign prostatic hypertrophy
Allergies: quinolone antibiotics
Diagnostic Lab Data: None, due to hospice status. Received symptom management at home only.
CDC Split Type:

Write-up: Patient had a sudden change in status one week after receiving his first Moderna Covid 19 vaccine. He had sudden onset of tachypnea RR = 40/min, apparent severe pain, greatly elevated blood pressure, with normal heart rate (on beta blocker), diaphoresis. had been enrolled in hospice for 14 months prior to this episode, but had experienced only slow decline prior to this acute event. He died at home under hospice care on 2/27/2021.

VAERS ID:	1225719 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-08
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Public Purchased by: ?
Symptoms: Amnesia, Computerised tomogram, Encephalitis, Headache, Hunger, Loss of consciousness, Lumbar puncture, Nausea, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Noninfectious encephalitis (narrow), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: I would say these dates would be around the ninth through the 13th. I?m sorry I don?t know all the things they tested me for.
CDC Split Type:

Write-up: Bad headache developed on April 8th at 11 AM. By 2:30, needed to sleep. Unconscious for 3 and 1/2 days. I have no recollection of any of this time. I?m only listening to what have told by the medical field and my family. My husband started calling MEDICAL CENTER Friday morning and A called the helicopter by Friday afternoon at three. They were ruling out a stroke. By the time they landed the helicopter they knew it was not a stroke and started doing testing like CAT scans , lumbar punctures. From what I?ve been told they ran four antibiotics IVs. I remember waking up Sunday morning and someone was sitting in the chair next to me and all I kept saying was that I was hungry. The lady started crying and said that I had been unconscious. She tried to tell me who I was and that I was something called married and that I had children. She tried to explain what had happened but I wasn?t able to comprehend. I didn?t know what it meant that I lived on a farm or that I had animals. Or that we had a vet practice. I remember medical people asking me who I was and what the date was and if I remember how I got there and all I could do was smile. It?s like the words just would not come. And they diagnosed it as an cephalitis over the next couple days. Where the brain swells up and you have memory loss and I had a high fever. I had a lot of nausea after they put me on oral anabiotic?s. I kept hearing from nurse reports that I had almost died. These were hard things to here. I?m forever thankful for all the people that have gone before me for doing the drug trials. I am a energetic lady and I?m slowly getting back to myself. I feel very thankful for the great care at the medical center. I appreciate everything that you do every day. I would not recommend getting vaccinated with this drug. I am one of the healthiest people that I know. No I can?t believe this is happened to me. I take good care and eat healthy and have no bad habits. I meditate and pray and have a joy filled life.

VAERS ID:	1225942 (history)
Form:	Version 2.0
Age:	16.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-19
Onset:	2021-03-28
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Cardiac arrest, Death, Laboratory test, Lung assist device therapy, Oral contraception, Pulmonary embolism, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-30
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Reported to be on Drospirenone-Ethinyl Estradiol 3-0.02 MG per tab
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was a 16yr female who received Pfizer vaccine 3/19/21 at vaccine clinic and presented with ongoing CPR to the ED 3/28/21 after cardiac arrest at home. Patient placed on ECMO and imaging revealed bilateral large pulmonary embolism as likely etiology of arrest. Risk factors included oral contraceptive use. Labs have since confirmed absence of Factor V leiden or prothrombin gene mutation. Patient declared dead by neurologic criteria 3/30/21.

VAERS ID:	1225969 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-17
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Aphasia, Blindness transient, Neurological symptom, Photopsia
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad)

Write-up: Patient developed stroke-like symptoms (right flashing light/temporary vision loss, word-finding difficulty) 24 hours after completion of Moderna COVID vaccination requiring hospitalization for stroke workup.

VAERS ID:	1228430 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-31
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Hospitalization within 6 weeks of receiving the first COVID vaccine dose. Second dose received 4/7/2021.

VAERS ID:	1228684 (history)
Form:	Version 2.0
Age:	2.17
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-04-07
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1805031 / 1	- / -

Administered by: Public Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Anticoagulant therapy, Back pain, Computerised tomogram thorax normal, Leukocytosis, Oropharyngeal pain, Pelvic venous thrombosis, Pyrexia, Ultrasound Doppler abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Thrombophlebitis (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient admitted to Hospital 4/6-4/9 for bilateral lower back pain, fever, sore throat and leukocytosis. Diagnosed with a R iliofemoral nonocclusive thrombus present on admission. Ultrasound was performed and there was no evidence of an occlusive thrombus, there was evidence of flow through her previously placed stent. She was placed on a heparin drop and converted back to Xarelto at the time of discharge. Chest CT showed no evidence of PE. Of note, patient went on spring break and was out her Xarelto, missed approximate 4 days worth of medical. She was also diagnosed and treated for an acute strep throat infection.

VAERS ID:	1228935 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-05
Onset:	2021-04-19
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Angiogram cerebral abnormal, Aphasia, Asthenia, Carotid artery occlusion, Computerised tomogram head abnormal, Facial paralysis, Haematocrit normal, Haemoglobin normal, Hemiparesis, Infarction, Platelet count normal, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Myocardial infarction (broad), Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Presented to emergency department for evaluation of weakness and aphasia. The patient has her eyes open on arrival. She does follow commands with mild weakness to the right upper and lower extremities. Mild right facial droop is noted on physical exam. The patient does not speak otherwise. Initial CT concerning for ischemic stroke. CTA with perfusion was then obtained that shows evidence of a small area of core infarct with a large area of penumbra. Carotid occlusion from the bifurcation LP is noted on the left side with collateral circulation coming from the Act. Patient transfered from this emergency department to tertiary care center for possible thrombectomy.

VAERS ID:	1229011 (history)
Form:	Version 2.0
Age:	35.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-14
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Cold sweat, Dizziness, Dyspnoea, Eye movement disorder, Hyperhidrosis, Malaise, Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Ocular motility disorders (narrow), Hypersensitivity (broad), Hypoglycaemia (broad)

Write-up: Client vaccinated around 1135-1140 am with her first dose of Moderna. Around 1145 am , client walked up to staff stating she did not feel well and felt like she was going to pass out. Visibly sweaty and rapid breathing. Client continued to state that she felt like she was going to die and pass out. Stated she was having difficulty breathing and throat tightness. Eyes began rolling back, diaphoretic and clammy. Epinephrine 0.3mg IM injection given at 1148 am into her left thigh and 911 called. BP 104/42, Pulse 50, O2 sat 99%, Respirations 24. Within 5 minutes of Epinephrine administration, clients breathing was improved. Paramedics arrived on scene within 6 minutes and took over care. Client transported to Hospital.

VAERS ID:	1229104 (history)
Form:	Version 2.0
Age:	45.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-04-19
Days after vaccination:	38
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	NA / 1	- / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	NA / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient has been diagnosed covid positive after completing moderna series

VAERS ID:	1229134 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-29
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Ammonia, Asthenia, Blood cortisol, Blood creatine phosphokinase, Blood folate, Blood magnesium, Blood thyroid stimulating hormone, Borrelia test negative, C-reactive protein, Computerised tomogram head normal, Computerised tomogram thorax normal, Dyspnoea, Dysstasia, Electrocardiogram, Electrophoresis protein, Fatigue, Full blood count, Gait inability, Laboratory test, Liver function test, Magnetic resonance imaging head normal, Magnetic resonance imaging spinal normal, Metabolic function test, Procalcitonin, Red blood cell sedimentation rate, SARS-CoV-2 test negative, Tremor, Treponema test, Troponin, Vitamin B12
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Gabapentin, Duloxetine, Atorvastatin, Tamsulosin, Tylenol, Ibuprofen
Current Illness: none
Preexisting Conditions: polyneuropathy, shortness of breathe, hyperlipidemia
Allergies: None
Diagnostic Lab Data: EKG and basic labs done during first ED visit. Went to ED again on 4/12/15. Seen by neurology and had MRI that was unremarkable. Transferred from local ED to second hospital for inpatient admission. Head CT, CT chest, PE study, brain MRI and MRI cervical spine negative. Lyme ab negative, CBC, CMP, LFTs, Mg, ESR, CRP, procal, trop, ammonia, TSH, cortisol, CK, SPEP, trepnema, folate, B12, COVID negative. Tests done during hospital stay.
CDC Split Type:

Write-up: Not able to leave bed for 3 days after vaccine and very fatigued. Felt mostly back to normal the weekend of 4/3/21 then fatigue returned around 4/6/21 accompanied by generalized weakness, tremor or upper and lower extremities and increased shortness of breathe. Then became dependent on someone else to get up, stand. Was unable to walk due to severity of tremor in upper and lower extremities. Continues to have tremor in rehab facility where he is residing at this time after hospitalization.

VAERS ID:	1229560 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-17
Onset:	2021-04-07
Days after vaccination:	49
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031L20A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	036A21A / 2	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, COVID-19, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: COVID-19 infection & hospitalization after completed vaccine series. First dose of Moderna 2/17/21, second dose received 3/17/21. Pt hospitalized 4/7 for shortness of breath and generalized weakness.

VAERS ID:	1230292 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-25
Onset:	2021-03-31
Days after vaccination:	34
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 1	AR / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Acute megakaryocytic leukaemia, Acute myeloid leukaemia, Fatigue, Flow cytometry, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Immunophenotyping, Platelet count decreased, White blood cell count normal
SMQs:, Haematopoietic erythropenia (broad), Haematopoietic leukopenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Haematological malignant tumours (narrow)

Write-up: Severe fatigue after first dose. 1 week after 2nd dose 3/18/21, developed worsening fatigue with 43% blasts on peripheral CBC indicating a transformation from CMML to AML.

VAERS ID:	1231003 (history)
Form:	Version 2.0
Age:	39.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-06
Onset:	2021-04-01
Days after vaccination:	85
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1284 / 1	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood test, Chest X-ray, Laboratory test, Peripheral swelling, Thrombosis, Ultrasound Doppler abnormal
SMQs:, Cardiac failure (broad), Angioedema (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Multivitamin
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Urgent care exam, blood tests, labs, ultrasound. Pcp visit, chest xray. 3rd visit ro E.R. lab work, ultrasound.
CDC Split Type:

Write-up: Blood clot left arm, arm swelling

VAERS ID:	1231050 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-23
Onset:	2021-04-06
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Balance disorder, Chills, Fatigue, Hypersomnia, Mobility decreased, Respiratory tract congestion, Rhinorrhoea
SMQs:, Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad)

Write-up: Client went to Urgent Care on 4/16 complaining of excessive fatigue, excessive sleeping, unsteadiness and fatigues easily when mobile. He was having trouble getting up and down the stairs. States he had a runny nose and congestion and started taking Mucinex since approximately 4/6. He had some chills on 4/15. When he wakes up in the morning he still feels tired and could go back to sleep. After his initial assessment he was admitted to hospital for treatment and further evaluation.

VAERS ID:	1231568 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-03-27
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 2	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Cardiac disorder, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-27
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril, simvastatin, levothyroxine, ropinirole, inhaler
Current Illness: None known
Preexisting Conditions: Hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, restless leg syndrome, obesity
Allergies: None known
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Unknown onset of adverse events. PT received second COVID vaccine on 3/26/21. She was found deceased in her residence (where she lives alone) by family on 3/28/21. She was found in bed, appropriately covered with blankets. Son last spoke with PT around 17:30 hours on 3/26 after receiving the vaccine, and reported the PT did not complain of any symptoms, did not sound short of breath, and did not complain of any breathing difficulty. Based on postmortem presentation, believed PT died late night of 3/26/early morning of 3/27. Suspect death is likely due to PT''s heart disease, Medical Examiner agreed with the assessment.I spoke with the clinic that administered the second dose, and was informed that the PT did not exhibit any signs/symptoms during the observation period immediately following the vaccine being given. PT''s PCP was contacted, and agreed to certify DC based on known medical history. PCP also agreed that the death did not sound related to the vaccine based on lack of symptoms as reported by the administering clinic and family.

VAERS ID:	1232001 (history)
Form:	Version 2.0
Age:	23.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-15
Onset:	2021-04-16
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	044B21A / 1	- / IM

Administered by: Other Purchased by: ?
Symptoms: Arteriogram coronary normal, Chest discomfort, Chest pain, Chills, Echocardiogram normal, Electrocardiogram ST segment elevation, Myocarditis, Pain, Pyrexia, Troponin increased
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Per patient, he developed chills, subjective fevers, body aches few hours after the vaccine on 04/15. Also developed chest discomfort that progressively got worse over the next 1-2 days which prompted him to visit the ED on 04/18. He was found to have troponin elevation with diffuse J-point elevation. He received aspirin and was started on heparin drip. Chest pain completely resolved by the next day. Coronary angiogram was negative. Cardiology attributed stroke elevation and chest pain to myocarditis secondary to vaccine. Echo was normal with no evidence of pericardial effusion.

VAERS ID:	1232118 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-04-02
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808978 / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Full blood count, SARS-CoV-2 test negative, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), COVID-19 (broad)

Write-up: Continuous vomitting started Friday 4/2-went to Urgent Care Saturday 4/4. recieved IV fluids-Vomiting continued at home, went to Emergency room later that day Saturday, kept me overnight with IV/meds and went home Sunday 4/4

VAERS ID:	1232258 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-04-18
Days after vaccination:	34
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026A21A / 2	RA / IM

Administered by: Military Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Aortic stenosis, Asthenia, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium decreased, Blood chloride decreased, Blood creatinine increased, Blood glucose increased, Blood potassium normal, Blood sodium decreased, Blood urea increased, COVID-19, Cardiac failure congestive, Cardiomegaly, Chest X-ray, Coronary artery disease, Cough, Dyspnoea, Dyspnoea exertional, Haematocrit decreased, Hyperlipidaemia, Hypertension, International normalised ratio normal, Mean cell volume normal, Peripheral vascular disorder, Platelet count normal, SARS-CoV-2 test negative, SARS-CoV-2 test positive, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Dyslipidaemia (narrow), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hyponatraemia/SIADH (narrow), Hypertension (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Lipodystrophy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen (Tab) Tylenol 325 MG TAKE TWO TABLETS BY MOUTH TWICE A DAY AS NEEDED Allopurinol (Tab) Zyloprim 100 MG Take 100 mg by mouth daily with breakfast. Alprostadil (Vasodilator) (Kit) EDEX 40 MCG 40 mcg intracavitary as needed for
Current Illness: N/A
Preexisting Conditions: Severe aortic stenosis,S/P TAVR May 2018. diffuse coronary artery disease, status post bypass surgery on two occasions with graft failure to the RCA.,Unsuccessful attempt to intervene on the RCA due to diffuse calcific disease,TChronic renal insufficiency.,Carotid vascular disease, status post left carotid endarterectomy,Peripheral vascular disease: History of tobacco use, currently refraining.,Metabolic syndrome,Hypertension
Allergies: Allergies: COLCHICINE - Intolerant
Diagnostic Lab Data: Complains of occasional cough and dyspnea on exertion, occasional shortness of breath at rest. No other complaints except for generalized weakness. OBJECTIVE: Patient Vitals for the past 24 hrs: BP Temp Pulse Resp SpO2 Weight 04/20/21 0744 130/75 97.8 ?F (36.6 ?C) 94 20 96 % ? 04/20/21 0600 ? ? ? ? ? 198 lb (89.8 kg) 04/20/21 0500 92/54 97.4 ?F (36.3 ?C) 88 20 94 % ? 04/20/21 0441 ? ? 87 20 90 % ? 04/19/21 2244 108/64 97.5 ?F (36.4 ?C) 90 20 98 % ? 04/19/21 2029 ? ? 86 20 96 % ? 04/19/21 1928 119/63 97.7 ?F (36.5 ?C) 89 20 94 % ? 04/19/21 1546 113/69 97.6 ?F (36.4 ?C) 87 20 94 % ? 04/19/21 1530 ? ? 90 20 97 % ? 04/19/21 1200 120/67 97.7 ?F (36.5 ?C) 90 18 96 % ? 04/19/21 1137 ? ? 91 18 97 % ? I/O: Intake/Output Summary (Last 24 hours) at 4/20/2021 1043 Last data filed at 4/20/2021 1000 Gross per 24 hour Intake 1580 ml Output 1900 ml Net -320 ml PHYSICAL EXAM: Last Recorded Vital Signs: BP: 130/75 Pulse: 94 Resp: 20 SpO2: 96 % Temp: 97.8 ?F (36.6 ?C) Height: 177.8 cm (5'' 10") Weight: 198 lb (89.8 kg) GENERAL: Alert, oriented x3, and in no acute distress on room air HEAD: Normocephalic. No masses, lesions, tenderness or abnormalities EYES: conjunctivae/corneas clear. PERRL, EOM''s intact. ENT: Moist mucus membranes NECK: supple, no adenopathy LUNGS: decreased BS throughout. CVS: S1, S2 normal, no murmur, click, rub or gallop, regular rate and rhythm ABD: abdomen is soft without significant tenderness, masses, organomegaly or guarding EXTREMITIES: Ted''s in place, no edema NEURO: exam reveals no focal deficits PSYCH: Affect is normal LABS AND CULTURES: All recent labs have been reviewed. Pertinent labs include: Lab Results Component Value Date WBC 5.65 04/20/2021 HCT 27.3 (L) 04/20/2021 PLT 167 04/20/2021 MCV 89.1 04/20/2021 RDW 17.2 (H) 04/20/2021 Lab Results Component Value Date NA 132 (L) 04/20/2021 K 4.5 04/20/2021 CL 96 04/20/2021 CREA 2.47 (H) 04/20/2021 BUN 57 (H) 04/20/2021 GLUC 160 (H) 04/20/2021 CA 8.9 04/20/2021 MG 2.2 04/20/2021 CO2 20 (L) 04/20/2021 AST 12 04/20/2021 ALT 10 (L) 04/20/2021 ALKP 48 04/20/2021 TBIL 0.5 04/20/2021 ALB 4.0 04/20/2021 PALB 27 04/25/2018 Lab Results Component Value Date PTT 29 02/08/2020 INR 1.1 (L) 02/08/2020 COVID antigen negative COVID PCR positive Procalcitonin 0.12 IMAGING: All recent imaging has been reviewed. Pertinent images include: Chest x-ray April 18; Cardiomegaly. Patchy interstitial edema and pulmonary opacities. Chest x-ray April 20 Stable cardiomegaly and patchy mild interstitial edema ASSESSMENT: Active Problems: CHF (congestive heart failure) (HCC) PLAN: 77 years old male with past medical history significant for hypertension, hyperlipidemia, coronary artery disease, peripheral vascular disease, aortic stenosis status post TAVR, COPD, CKD stage 3, osteoarthritis, GI bleed, carotid stenosis status post carotid endarterectomy, history of tobacco abuse, was admitted with acute on chronic combined heart failure, hypoxia, COVID-19 pneumonitis. The developed acute kidney injury on CKD stage 3. Acute on chronic combined systolic and diastolic heart failure, secondary to noncompliance with medications. Three weeks ago with taking Bumex, subsequently gained 15 -17 pound, presented with hypoxia and wheezing. Chest x-ray showed increased pulmonary congestion, proBNP elevated. Placed on telemetry, daily weight, intake output, 2 gram sodium diet, 1500 milliliters fluid restriction, Bumex bolus and drip, frequent BMPs, potassium supplement as needed, albumin added, due to worsening BUN creatinine Bumex drip discontinued this morning until the next basic metabolic panel. Limited echo ordered. COVID-19 infection, rapid antigen negative PCR positive, symptoms has been ongoing for at least 3 weeks, not a candidate for remdesivir, started on dexamethasone, airborne isolation. The patient received COVID-19 vaccine. Acute hypoxia secondary to decompensated congestive heart failure and possibly COVID-19 pneumonitis. Treat underlying illnesses, oxygen was weaned to room air this morning. Continue to monitor pulse oximetry Coronary artery disease stable, down trending troponins could be secondary to demand ischemia from congestive heart failure. Continued on Plavix, carvedilol, atorvastatin and Ranexa. Dose of Imdur reduced due to normal blood pressure. Placed on telemetry. Acute kidney injury on CKD stage 3; worsening BUN creatinine on the Bumex. The Bumex drip was held, recheck basic metabolic panel, may consider to restart the drip if BUN creatinine stable. Continue the albumin. Keep MA P above 65, frequent BUN creatinine, bladder scan, pharmacy consult for renal dosing of all the meds. Hyperlipidemia was continued on home dose of atorvastatin History of peripheral vascular disease was continued on Plavix and Pletal BPH was continued on finasteride and Flomax History of gout continued on allopurinol at home dose History of tobacco use ; given albuterol, Combivent per home regimen History of GERD and GI bleed continued on PPI DVT prophylaxis with Lovenox Code status full code Disposition still active issues. ED to Hosp-Admission (Current) on 4/18/2021 Revision History Detailed Report Note shared with patient Note filed date Tue Apr 20, 2021 11:13 AM
CDC Split Type:

Write-up: Positive COVId-19 PCR test and hospital admission on 4/18/21 for Sob

VAERS ID:	1232304 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-01
Onset:	2021-03-09
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	010L20A / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Hospitalisation, Unevaluable event
SMQs:

Write-up: PT hospitalized within 6 weeks of receiving COVID vaccine on 3-9 for 7 hours and on 3-23 for one day

VAERS ID:	1232535 (history)
Form:	Version 2.0
Age:	18.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-04-11
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Angiocardiogram, Blood magnesium, Blood phosphorus, Blood thyroid stimulating hormone, Brain natriuretic peptide, C-reactive protein increased, Chest X-ray, Chest pain, Dyspnoea, Echocardiogram, Electrocardiogram, Full blood count, Lipids, Magnetic resonance imaging heart, Metabolic function test, Myocarditis, Red blood cell sedimentation rate increased, Right atrial pressure increased, Right ventricular hypertrophy, SARS-CoV-2 test, Troponin increased
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Clindamycin gel Tretinoin cream
Current Illness: NA
Preexisting Conditions: Acne
Allergies: NKA
Diagnostic Lab Data: 4/11 ESR, Magnesium, BNP, Troponin, BMP, COVID, 4/12 CRP, Troponin, TSH, Lipid, ESR, phosphate, Magnesium, CBC, CMP, CXR, ECG, MRA chest, CTA coronary arteries 4/13 BMP, CBC, ESR, CRP, Transthoracic resting echocardiogram 4/14 MRI cardiac 4/19 BMP, CBC, CRP, ESR
CDC Split Type:

Write-up: He was admitted to Cardiovascular Medicine on 4/11/21 with acute idiopathic myocarditis, the etiology was unclear but considered due to recent COVID vaccination vs viral infection. He presented with elevated troponin and initially elevated ESR and CRP. CTA of coronary arteries was on done on 4/12 and showed normal coronary arteries. TTE was done on 4/13 and showed a normal LVEF of 65% and normal LV size and wall thickness. His RV size was mildly enlarged and has mildly elevated right atrial pressure. There was no significant valvular disease. Cardiac MRI was done prior to discharge and he will follow up with cardiology for the final results. He was having some intermittent chest pain and SOB and was recommended to use OTC ibuprofen 600 mg BID per cardiology. Reports that his chest pain and shortness of breath is slowly resolving. His symptoms are mild and infrequent.

VAERS ID:	1232588 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-18
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Fatigue, Lymph node pain, Lymphadenopathy, Ocular hyperaemia, Pain, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Glaucoma (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Pt reported she noticed fatigue and achiness about 12 hours after vaccine. The next day, she noticed a bump on her hairline by her lymph node with pain radiating to under her jaw. A few days late she reported a fever, red eye, and increased blood pressure. She went to the emergency room and ended up being admitted and checked for a heart attack or blockage. The cardiologist who cared for her said she did not have a heart attack. He could not conclude that the symptoms were a result from the vaccine, but advised her against getting the second dose out of an abundance of caution.

VAERS ID:	1233604 (history)
Form:	Version 2.0
Age:	104.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-04-14
Days after vaccination:	47
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 2	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-14
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was in ED x 2 and died within 60 days of receiving a COVID vaccine series

VAERS ID:	1233912 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-27
Onset:	2021-04-19
Days after vaccination:	23
Submitted:	0000-00-00
Entered:	2021-04-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Myocardial strain, Palpitations, Peripheral embolism, Presyncope, Thrombosis, Ultrasound Doppler abnormal
SMQs:, Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Write-up: Intermediate Risk PE-diagnosed due to symptoms of pre-syncope, palpitations. Clinical history includes long car ride

VAERS ID:	1235527 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-03-01
Submitted:	0000-00-00
Entered:	2021-04-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / OT

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Dyspnoea, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Short of breath; Tested positive for COVID-19; This spontaneous case was reported by a consumer and describes the occurrence of DYSPNOEA (Short of breath) in a 78-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 045A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included No adverse event (No reported medical history). On 18-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. In March 2021, after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced COVID-19 (Tested positive for COVID-19). On 10-Apr-2021, the patient experienced DYSPNOEA (Short of breath) (seriousness criterion hospitalization). The patient was hospitalized on 10-Apr-2021 due to DYSPNOEA. At the time of the report, DYSPNOEA (Short of breath) and COVID-19 (Tested positive for COVID-19) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): In March 2021, SARS-CoV-2 test: positive (Positive) positive. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. Two weeks after her first dose she got tested at the hospital and tested positive for COVID. Patient was short of breath and went to the emergency room on 10APR2021.; Sender''s Comments: Based on the current available information and the temporal association between the product use and the start date of the events a causal relationship cannot be excluded.

VAERS ID:	1236733 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-24
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Chest X-ray abnormal, Computerised tomogram, Pain in extremity, Peripheral swelling, Thrombosis, Ultrasound Doppler
SMQs:, Cardiac failure (broad), Angioedema (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: CANCER SURVIVOR FOR 18 YEARS, HX OF NON HODGKINS LYMPHOMA.
Allergies: NKA
Diagnostic Lab Data: ULTRASOUNDS AND CT SCANS PER PATIENT REPORT
CDC Split Type:

Write-up: PER PATIENT REPORT, PAIN A WEEK LATER MY LEG WAS ACHING. I USED ICY HOT, MASSAGER. STARTED SWELLING, WENT TO WALK IN. THEY DID AN ULTRASOUND AND SAID I HAD A BLOOD CLOT IN MY LEG AND IT WAS TRAVELING TO MY LUNGS. THERE WERE A COUPLE SPECKS ON LUNG PER XRAY.

VAERS ID:	1237719 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-01
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Aphasia, Cerebral infarction, Cerebrovascular accident, Chest X-ray, Computerised tomogram abnormal, Echocardiogram
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad)

Write-up: 04/11/21 stroke event --unable to speak and not consistent with actions, CT 04/11/21 L MCA infarct no midline shift

VAERS ID:	1238251 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-28
Onset:	2021-03-30
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	AR / IM

Administered by: Private Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Dyspnoea, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Valacyclovir prn
Current Illness: None
Preexisting Conditions: No significant history. Impaired fasting blood sugar
Allergies: Morphine
Diagnostic Lab Data: CT chest
CDC Split Type:

Write-up: Acute bilateral pulmonary emboli without known risk factors for this condition. Onset of symptoms consistent with acute pulmonary embolism started 2 days after vaccination. Formal diagnosis made on CT chest on 4/13/2021 after worsening symptoms of shortness of breath with exertion prompted evaluation in ER

VAERS ID:	1241954 (history)
Form:	Version 2.0
Age:	39.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-08
Onset:	2021-04-11
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	042A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Computerised tomogram, Feeling abnormal, Headache, Hypoaesthesia, Magnetic resonance imaging, Neck pain, Paraesthesia, Tremor
SMQs:, Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Arthritis (broad), Hypoglycaemia (broad)

Write-up: severe headache, neck pain, numbness and tingliness on right side , foggybrain, tremors

VAERS ID:	1242001 (history)
Form:	Version 2.0
Age:	37.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-04-13
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Echocardiogram, Electrocardiogram, Exposure during pregnancy, Injection site pain, Tachycardia foetal, Ultrasound foetal
SMQs:, Congenital and neonatal arrhythmias (broad), Extravasation events (injections, infusions and implants) (broad), Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow), Foetal disorders (narrow)

Write-up: After the vaccine, I just had pain that evening and the next day on the injection site. But I went to my midwifery appt and my baby was SVT - I got admitted to hospital last Tuesday 13th and I''ve been here since. I had COVID virus in August 2020. Pregnancy History - this is my first pregnancy; estimated date of delivery - it was June 18th originally. I''m 32 weeks tomorrow.

VAERS ID:	1242588 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-05
Onset:	2021-04-21
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	030B21A / 1	LA / IM

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

Write-up: Pt received the first dose of the Moderna COVID-19 vaccine on 4/5/2021. On 4/14/2021, he tested positive for SARS-CoV-2 via PCR. On 4/21/2021 he was ill enough to go to the ED due to COVID symptoms and was admitted to the general medicine floor of our hospital.

VAERS ID:	1243081 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-10
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	- / -

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

Write-up: Pt came down with COVID and is now admitted to the hospital with COVID

VAERS ID:	1243148 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-04-04
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: pt received vaccine and then became hospitalized with COVID

VAERS ID:	1243206 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-07
Onset:	2021-04-07
Days after vaccination:	31
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 2	- / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized and died within 60 days of receiving a COVID vaccine series

VAERS ID:	1243360 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-03-27
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-27
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received first Moderna Vaccine on 02/26/2021 and second Moderna Vaccine on 03/26/2021. Health Department was notified of patients death on 03/27/2021, today 04/22/2021. Any further information is unknown by the health department for patients cause of death that occurred on 03/27/2021.

VAERS ID:	1243488 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-04-02
Days after vaccination:	24
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED on 4/2/21 and was subsequently hospitalized for 5 days.

VAERS ID:	1243588 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-18
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0164 / 2	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-18
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: clonazepam, mirtazapine, oxycodone/apap, atorvastatin, diltiazem, eliquis, furosemide, hydrochlorothiazide, levetiracetam, lisinopril, metformin, metoprolol, nigtroglycerin, omeprazole, miralax, KCL, tamsulosin,
Current Illness: suffered from chronic pain and mentioned having discomfort . His breathing was labored and had an audible low sounding wheeze. He was otherwise in good spirits and excited to get his second vaccination. He didn''t have a fever and pain and loud breathing was pretty normal for him.
Preexisting Conditions: diabetes, chronic pain, high blood pressure, high cholesterol, BPH, GERD, seizure disorder? clotting disorder, obesity
Allergies: penicillin, pregabaliln, aspirin
Diagnostic Lab Data:
CDC Split Type:

Write-up: not sure if related, but he passed away on 4/18/2021

VAERS ID:	1243737 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-07
Onset:	2021-02-09
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Deafness bilateral
SMQs:, Hearing impairment (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: many and on-going
CDC Split Type:

Write-up: loss of hearing in right ear after first shot and loss of hearing in left ear after second shot. two other males in our small community have same issue that I know of

VAERS ID:	1245359 (history)
Form:	Version 2.0
Age:
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-04
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Cardiac murmur, Feeling abnormal, Gout, Incoherent, Meningitis viral, Pain in extremity, Psychotic disorder, Weight decreased
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Arthritis (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Write-up: Viral meningitis; Replies but is not very coherent; Heart murmur (did a stress test and found his heart paused 4 times); Psychosis; Every time his leg is touched, it hurts him; Gout; Lost about 20lbs; Did not look like himself; Looked like he was dying; This spontaneous case was reported by a consumer and describes the occurrence of MENINGITIS VIRAL (Viral meningitis), GOUT (Gout), PSYCHOTIC DISORDER (Psychosis), CARDIAC MURMUR (Heart murmur (did a stress test and found his heart paused 4 times)), INCOHERENT (Replies but is not very coherent), WEIGHT DECREASED (Lost about 20lbs) and PAIN IN EXTREMITY (Every time his leg is touched, it hurts him) in a 69-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 013A21A and 001B21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Viral meningitis in 1971. On 02-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 29-Mar-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular). On 04-Mar-2021, the patient experienced FEELING ABNORMAL (Did not look like himself) and FEELING ABNORMAL (Looked like he was dying). On 04-Apr-2021, the patient experienced MENINGITIS VIRAL (Viral meningitis) (seriousness criteria hospitalization and medically significant), GOUT (Gout) (seriousness criterion hospitalization), PSYCHOTIC DISORDER (Psychosis) (seriousness criteria hospitalization and medically significant), CARDIAC MURMUR (Heart murmur (did a stress test and found his heart paused 4 times)) (seriousness criterion hospitalization), INCOHERENT (Replies but is not very coherent) (seriousness criterion hospitalization), WEIGHT DECREASED (Lost about 20lbs) (seriousness criterion hospitalization) and PAIN IN EXTREMITY (Every time his leg is touched, it hurts him) (seriousness criterion hospitalization). The patient was hospitalized on 04-Apr-2021 due to CARDIAC MURMUR, GOUT, INCOHERENT, MENINGITIS VIRAL, PAIN IN EXTREMITY, PSYCHOTIC DISORDER and WEIGHT DECREASED. At the time of the report, FEELING ABNORMAL (Did not look like himself), FEELING ABNORMAL (Looked like he was dying), MENINGITIS VIRAL (Viral meningitis), GOUT (Gout), PSYCHOTIC DISORDER (Psychosis), CARDIAC MURMUR (Heart murmur (did a stress test and found his heart paused 4 times)), INCOHERENT (Replies but is not very coherent), WEIGHT DECREASED (Lost about 20lbs) and PAIN IN EXTREMITY (Every time his leg is touched, it hurts him) had not resolved. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. Wife reports her husband received his first dose on 02March2021 and his second dose on 29March2021 (lot 001B21A) in the unknown arm (deltoid) at HealthCare. She reports that on 04March2021, she saw the family picture and her husband did not look like himself and looked like he was dying. She states that he was completely healthy, lively until the first shot. Her husband was admitted to the hospital on 4April2021 in Hospital and has been there since. Patient discloses that they both went out of town and his friends gave him a corner of a THC gummy and when he was admitted to the hospital she disclosed that to the doctor, and they jumped to conclusion and said her husband is an alcoholic and a drug addict, which she states, was outrages because he is not. Patient states that due to this reason (doctors wanting to dry him out), the doctors ended up delaying the antibiotic for 5 days (for his viral meningitis). After being wrong, they now have diagnosed him with viral meningitis, he has gout, and now psychosis. She states that every time his leg is touched, it hurts him. They also diagnosed him with heart murmur (did a stress test and found his heart paused 4 times). He replies but is not very coherent and has lost about 20lbs while in the hospital. These symptoms have started from the first vaccination and have been continuous throughout and after the second vaccination. Patient discloses that her husband has had meningitis at age 20 years old before and she is now wondering if this jumpstarted anything that was either lying dormant or any previous illnesses. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments.; Sender''s Comments: Although a temporal association exist, based on the known etiology of viral meningitis being of an infective etiology, a causal relationship between the event and the administration of mRNA-1273 is unlikely. However, the relationship between the other events and mRNA-1273 cannot be excluded based on temporal association.

VAERS ID:	1246334 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-05
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 1	RA / SYR

Administered by: Other Purchased by: ?
Symptoms: Cerebral thrombosis, Cerebrovascular accident, Hypoaesthesia, Ischaemic stroke
SMQs:, Peripheral neuropathy (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 19 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Volnea Fluticasone Propionate Montelukast Sodium
Current Illness: NA
Preexisting Conditions: NA
Allergies: Penicillian
Diagnostic Lab Data: 3/5 - 3/6 -- Healthcare 3/6 - Present --Hospital and Rehab Centers
CDC Split Type:

Write-up: Suffered blood clotting leading to three strokes. Started with numbness in limbs and face on 3/5 at 8:30AM and led to Ischemic stroke in three parts of the brain.

VAERS ID:	1246380 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-11
Onset:	2021-04-20
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Public Purchased by: ?
Symptoms: Troponin increased, Vascular occlusion
SMQs:, Myocardial infarction (narrow)

Write-up: right radial occlusion, elevated troponin

VAERS ID:	1246575 (history)
Form:	Version 2.0
Age:	27.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-08
Onset:	2021-04-17
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Blood calcium normal, Blood creatinine normal, Blood fibrinogen increased, Blood potassium normal, Blood sodium normal, Epistaxis, Fatigue, Fibrin D dimer, HIV test negative, Haematocrit normal, Haemoglobin normal, Hepatitis C test negative, Immunoglobulin therapy, International normalised ratio normal, Mean cell volume normal, Mouth haemorrhage, Myalgia, Petechiae, Platelet count decreased, Pyrexia, Vaginal haemorrhage, White blood cell count increased, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient presented on 4/17 to urgent care afer significant vaginal bleeding (soaking through a pad every 1 hour to 1.5 hours) and petechia on multiple extremeties. She also had a nose bleed and bleeding in mouth earlier in the day that resolved spontaneously. After obtaining CBC, platelets were <1000. She was on oral contraceptives. She is a non smoker. She received work up for thrombosis, not indication of thrombosis. She did have some muscle aches and fever and fatigue the day after vaccine. Histroy notable for mild diffuse petechiae on all 4 extremeties. As inpatient received solumedrol 125 mg (then switched to prednisone 80 mg daily), IVIG 1 g/kg x 2 doses. she was discharged on 4/19 d/t rising platelets, Vaginal bleeding slowing and Petechia much fainter.

VAERS ID:	1247552 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-04-02
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	046A21A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1247646 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-04-13
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	046A21A / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Blood potassium increased, Blood test abnormal, Cerebrovascular accident, Haemoglobin decreased, Headache, Magnetic resonance imaging abnormal, Malaise, Visual impairment, Vomiting
SMQs:, Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Multivitamin Acetaminophen PRN Allopurinol (100 mg) Alprazolam (0.5 mg) Calcitrilo (0.25 mg 3 times/week) Tums, TID cyanocobalamin, B12 shot q21 days Levothyroxine (50 mg) Magnesium Oxide (400 mg) Metoprolol (50 mg, daily) Sodium Bicarb 650
Current Illness: None reported, to the best of her knowledge
Preexisting Conditions: CKD, stage 4 blood disorder, unspecified (MDS?, but not official diagnosis) Bariatric surgery, 20 years ago Hypertension
Allergies: None known
Diagnostic Lab Data: MRI on 4/15/21 which revealed stroke in occipital region Blood work on 4/16/21 and 4/17/21, revealed high potassium and low Hgb which were both treated.
CDC Split Type:

Write-up: On April 13th, patient noted a black spot in her vision with her right eye. As the day progressed, she began experiencing a headache which worsened in severity despite treating with medication. She started treating with Tramadol; when that didn''t help, she took her prescription oxycodone (5mg/325mg) 3 hours later, q6 hours x 2. That evening, patient experienced 1 episode of emesis and thought she may not be feeling well, so went to bed. When she woke the next morning, she felt better, but still noted the black spot in her vision. She sought care with her Ophthalmologist, who evaluated her, and he did not believe it was related to her vision. He referred her for an MRI, immediately. MRI revealed a stroke in the occipital region. She was admitted and given IV fluid along with another panel of testing. She was seen by Neurologist and Hospitalist; more testing was completed on Friday, including bloodwork which revealed high potassium levels which was treated. She was also given 1 unit of blood. She discharged on Friday and was started on Clopidogrel (75 mg). Follow up appointments are scheduled with eye doctor, neurology, internist. Right eye was affected and vision will not likely return, per her doctors.

VAERS ID:	1247764 (history)
Form:	Version 2.0
Age:	35.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-17
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 2	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Angiogram, Cerebral haemorrhage, Computerised tomogram, Dyskinesia, Epistaxis, Fall, Head injury, Mouth haemorrhage, Seizure
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Convulsions (narrow), Dyskinesia (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Write-up: Was at the golf course. His arms flew up and he had a seizure falling to the ground and striking head on ground. Blood from nose and mouth. He was transported to hospital. Diagnosed a brain bleed.

VAERS ID:	1247852 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-18
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	NLCC HAY MED PC / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient was admitted to hospital on 3/18/2021, within 6 weeks of receiving COVID vaccination.

VAERS ID:	1248353 (history)
Form:	Version 2.0
Age:	34.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-10
Onset:	2021-04-10
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / N/A	- / IM

Administered by: Private Purchased by: ?
Symptoms: Arthralgia, C-reactive protein, Chills, Dysphagia, Feeling abnormal, Joint swelling, Muscle swelling, Musculoskeletal stiffness, Myalgia, Oropharyngeal pain, Rash, Rash erythematous, Rash pruritic, Red blood cell sedimentation rate increased, SARS-CoV-2 test negative, Urticaria, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Dystonia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Write-up: patient was treated with the Janssen/Johnson & Johnson COVID-19 adenovirus vaccine on Saturday April 10, 2021 and she relates having had symptomatic problems since that time stating prior to administration of the vaccine she was in her normal state of health. She relates that on the evening of April 10 she had chills but otherwise no other major symptoms and the next day felt fine as well as during that week. However she states that starting 1 week later on Saturday, April 17 she began feeling poorly characterized by a recurrence of hives that she has had in the past along with a sore throat. She states this occurred while she was at work and describes the sore throat as unusual from prior sore throat she has had in the past with a description of a globus-like sensation along with some difficulties swallowing for more pressure than overt pain. She attempted salt water gargles without benefit. The rash was the characteristic hives rash that she has had on 2 prior occasions with rapid development of itchy red lesions scattered throughout especially in her proximal extremities and torso region. She relates the hives worsened on Sunday, April 18 essentially from "head to toe" although not actually involving her face. She also related new accompanying symptoms including diffuse arthralgias, stiffness and swollen painful muscles and joints. This was throughout her entire body and somewhat of a migratory nature involving all of her major joints including the hands, wrists, shoulders, feet, ankles, knees and hips. She states that because of the severity of symptoms she had an urgent care appointment on Sunday, April 18 and felt to have a exacerbation of urticaria for which she was prescribed montelukast, loratadine cimetidine and a Solu-Medrol Dosepak. She states she was unable to fill the Solu-Medrol Dosepak initially but took the other medications without relief and then presented to the emergency room here at Hospital on Monday, April 19 where she had an evaluation which was largely unremarkable other than laboratory testing with a nonspecific elevation in inflammatory markers including a CRP of 5.7, ESR 34 and white blood count 15.92. She was notably COVID-19 negative at that time as well as Monospot negative. She was discharged home and ended up filling the Solu-Medrol Dosepak which she took and noted some improvement in her hives but has been continue to experience this ongoing sore throat, arthralgias, myalgias and diffuse swelling which is quite painful. She specifically relates "every time I use a muscle it seems to inflame."

VAERS ID:	1248523 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-21
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID hospitalization.

VAERS ID:	1248561 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-19
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1249132 (history)
Form:	Version 2.0
Age:	29.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-03-31
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	10805031 / UNK	- / -

Administered by: Other Purchased by: ?
Symptoms: Blood test, Computerised tomogram, Fatigue, Insomnia, Psychotic disorder, Urine analysis
SMQs:, Systemic lupus erythematosus (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad)

Write-up: PSYCHOTIC EPISODES; MINIMAL SLEEP FOR AT LEAST 50 HOURS; TIREDNESS; This spontaneous report received from a consumer concerned a 29-year-old white female. The patient''s height, and weight were not reported. The patient''s concurrent conditions included cognitive disability, but she was not on medication for anything. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: 10805031 expiry: UNKNOWN) dose was not reported, administered on 17-MAR-2021 in left arm around 4:40 pm for prophylactic vaccination. No concomitant medications were reported. On 31-MAR-2021, the patient exhibited bizarre behaviors that raised eyebrows but not red flags, as her father thought she was goofing around, she was talking loudly and laughing to herself with nobody around. She seemed very tired, taking a long time in the bathroom (about an hour/an hour and a half). On 03-APR-2021, she was saying things that did not make sense and people could not make sense of what she was talking about. On 04-APR-2021, she started experiencing really bizarre behavior. She was hearing voices, talking to herself and seeing people that were not there, insisting that people were coming over to the house and she had to go there. By the evening, she experienced hallucinations and delusions. She was taken to emergency hospital. She had been awake for about 12 hours, possibly longer. She was tested for a urinary tract infection, but the result was negative. In the emergency room, she had a blood test and computed tomography (CT) scan that did not show anything. In the night on same day, her condition was bad. She was trying to get out of the house. On 05-APR-2021, at 6am, she went back to the hospital room and was admitted to the psych ward for psychotic behaviors. She had been there for 7 days. She had been on unspecified medications, which was helping the symptoms. She was examined by a doctor and admitted to the psychiatric ward. In the evening on same day, her behavior became more severe, showed signs of aggression, flipping furniture, throwing things, saying a light on the wall was watching her. On 06-APR-2021, the psychiatrist stated that she was experiencing psychotic episodes and she was put on antipsychotic medication and examined her. She did not sleep for almost 3 days, started 04-APR-2021 morning at 7:00 am until 06-APR-2021 night (about 50 hours with minimal sleep). Then she was sedated, and she finally slept. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient recovered from minimal sleep for at least 50 hours on 06-APR-2021, was recovering from psychotic episodes, and the outcome of tiredness was not reported. This report was serious (Hospitalization Caused / Prolonged).; Sender''s Comments: V0-20210420207- Covid-19 vaccine ad26.cov2.s-psychotic episodes. This event is considered unassessable. The event has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event.

VAERS ID:	1249139 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-23
Onset:	2021-02-01
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-04-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EK4176 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Thrombophlebitis superficial, Ultrasound Doppler abnormal
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (narrow), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril, sildenafil, methylcellulose
Current Illness: None.
Preexisting Conditions: Hypertension, erectile dysfunction, hyperlipidemia.
Allergies: No known drug allergies.
Diagnostic Lab Data: Venous duplex ultrasound confirmed.
CDC Split Type:

Write-up: Thrombosis of left greater saphenous vein at the knee and proximal leg. Thrombosed superficial veins in the calf. Thrombosed peroneal vein of calf on 2/1/21

VAERS ID:	1254039 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-28
Onset:	2021-01-29
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9264 / 1	LA / -

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

Write-up: Developed symptoms and tested positive for COVID; This is a spontaneous report from a contactable nurse and consumer. A 61-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; batch/lot number: EL9264; expiration date: May2021), dose 1, via an unspecified route of administration, administered in left deltoid on 28Jan2021 08:00 (at the age of 61-year- old) as single dose for COVID-19 immunization. Medical history included type 2 diabetes mellitus diagnosed a couple years ago and total lung capacity decreased from asbestos scarring diagnosed about 15-20 years ago. Concomitant medication included metformin for type 2 diabetes mellitus. The patient received the first dose of the COVID-19 vaccine on 28Jan2021 08:00 AM. The patient developed symptoms on 29Jan2021 and tested positive for COVID on 01Feb2021. The patient mentioned that he has no idea what type of COVID-19 virus test was used when he tested positive. The patient received bamlanivimab (BAM) monoclonal antibody infusion therapy at 700 mg in 270 ml normal saline (lot number: D332489A; expiration date: 08Nov2021) in the infusion clinic of the hospital on 02Feb2021. It was reported that the hospital contacted the patient after he tested positive for the COVID-19 virus to let the patient know he was eligible for the BAM monoclonal antibody therapy based on his past medical history. The BAM therapy would have been physician ordered for the patient. The nurse reported that she looked at the information on the CDC''s website for the COVID-19 vaccine, and the CDC website stated people who have the COVID-19 virus antibodies should wait 90 days before getting the COVID-19 vaccine. The nurse was wondering what is the company''s guidance is on the patient getting his second COVID-19 vaccine dose, since patient had his first COVID-19 vaccine dose, and then tested positive for the COVID-19 virus, and then had the COVID-19 virus monoclonal antibody therapy. The nurse asked does the CDC''s 90-day wait time apply to the patient''s situation. The patient also wanted to know how he should go about getting the second dose, should he wait 90 days. The outcome of the event was unknown. No follow-up attempts are needed. No further information is expected.

VAERS ID:	1255809 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-04-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0158 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Death, Fatigue, Headache, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: simvastatin
Diagnostic Lab Data:
CDC Split Type:

Write-up: -Patient died unexpectedly on Thursday, April 22, 2021 at her home (found unresponsive by spouse) -No reactions were observed at the pharmacy (within 15 min waiting period) following either covid-19 vaccine (1st dose administered 8am on 3/26/21 -Left Deltoid) -When asked (4-16-21) how she tolerated the 1st dose, Patient reported minor side effects (mild Headache, tiredness) but had no reservations about receiving the 2nd dose. No additional information.

VAERS ID:	1255702 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-08
Onset:	2021-04-10
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	LA / -

Administered by: Private Purchased by: ?
Symptoms: SARS-CoV-2 test, Seizure
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Write-up: Generalized seizures without ever having a seizure before; This is a spontaneous report from a contactable consumer (patient). A 50-year-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; Lot number and expiry date not available), via an unspecified route of administration, Left arm on 08Apr2021 at 09:00 AM (at the age of 50-years-old) at a single dose for COVID-19 immunization. The patient''s medical history was reported as none. The patient had no known allergies. Concomitant medication included celecoxib (CELEXA). The patient was vaccinated at a hospital. No other vaccine was given in four weeks. Prior to vaccination, the patient was not diagnosed with COVID-19. The patient experienced generalized seizures without ever having a seizure before on 10Apr2021 at 15:00. The event caused hospitalization in Apr2021 and was also reported as life-threatening. The patient underwent lab tests and procedures which included nasal swab test: negative on 10Apr2021. Therapeutic measures taken as a result of the event included hospitalization and med flight, as reported. The outcome of the event was not recovered. Information about lot/batch number has been requested.

VAERS ID:	1255740 (history)
Form:	Version 2.0
Age:	39.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-04-02
Days after vaccination:	65
Submitted:	0000-00-00
Entered:	2021-04-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 2	LA / -

Administered by: Private Purchased by: ?
Symptoms: Vaccination site thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021434897

Write-up: Blood clot in injection arm; This is a spontaneous report from a contactable Other-HCP. A 39-years-old female patient received at hospital bnt162b2 (BNT162B2), dose 2 via an unspecified route of administration, administered in Arm Left on 27Jan2021 (Batch/Lot Number: El3249) as SINGLE DOSE for covid-19 immunisation . No other vaccine in fours weeks. Other medications in two weeks: Multivitamin.The patient received the first dose on 06Jan2021 at 10:30 AM (lot number=El1284) on left arm via IM The patient medical history was not reported. The patient experienced blood clot in injection arm (vaccination site thrombosis) (life threatening) on 02Apr2021 15:15 with outcome of not recovered. The event was treated wth Xarelto. No Covid prior vaccination; No Covid tested post vaccination; Sender''s Comments: Based on chronological connection to the vaccine a causal relationship between event "blood clot in injection arm" and BNT162B2 vaccine cannot be excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.

VAERS ID:	1256687 (history)
Form:	Version 2.0
Age:	43.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-23
Onset:	2021-04-23
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0169 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest, Computerised tomogram head, Echocardiogram, Electrocardiogram, Seizure, Troponin
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Write-up: Patient experienced a seizure resulting in cardiac arrest. Witnesses described patient "began convulsing and then tipped over". AED applied with no shock advised. Unknown down time prior to initiation of CPR. Rhythm PEA upon arrival of EMS. 7 mins CPR before ROSC obtained. Initial troponin 12. 12 lead EKG without ischemic changes, arrhythmia, etc. Transthoracic echo without regional wall abnormalities or significant findings. CT of head negative for acute intracranial process. No history of seizure, cardiac issues, drug use, etc.

VAERS ID:	1258311 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-19
Onset:	2021-04-20
Days after vaccination:	60
Submitted:	0000-00-00
Entered:	2021-04-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram pulmonary, COVID-19, Pulmonary embolism, SARS-CoV-2 test positive
SMQs:, Embolic and thrombotic events, venous (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient presented to the hospital with 2 week illness prior on 4/20/2021 Patient tested positive for Covid-19 despite receiving second dose on 2/19/2021 Patient also had Pulmonary Embolism in right pulmonary vasculature

VAERS ID:	1258389 (history)
Form:	Version 2.0
Age:	43.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-23
Onset:	2021-04-23
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	0471321A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood test, Dizziness, Headache, Mouth swelling, Peripheral swelling, Swelling, Swelling face, Swollen tongue, X-ray
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (narrow), Anticholinergic syndrome (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Vestibular disorders (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Ozempic
Current Illness: Diabetes, IBD, and sleep apnea
Preexisting Conditions: Diabetes, IBD and sleep apnea
Allergies: Erythromycin and copper
Diagnostic Lab Data: Blood work taken at all ER visits and X-Rays taken at ER event on Sunday
CDC Split Type:

Write-up: Slight dizziness followed by Allergic reaction to include swelling of feet, hands, chest, face, mouth, tongue and throat and slight headache. Dizziness occurring at 10:40 am and swelling starting at 10:40 am with ER visit at 12:45 pm. Given steroids, antihistamines and anti itch medication, sent home with instruction to take Benadryl. Allergy broke through by next morning, patient took pepcide and claritin, allergy got worse, went to ER. Given steroids, two epinephrine shots and albuterol and released with prescription for Epinephrine and Steroids. Sunday, allergy broke through medications again at 8:30pm patient returned to ER after taking steroids, all allergy medications, and one shot of ephinephrine. Hospital gave second shot of epinephrine and albuterol treatment. Patient''s allergy calmed down and patient was sent home with albuterol to be used as necessary.

VAERS ID:	1258481 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-02
Onset:	2021-04-19
Days after vaccination:	17
Submitted:	0000-00-00
Entered:	2021-04-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Computerised tomogram abnormal, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: penicillins
Diagnostic Lab Data: CT
CDC Split Type:

Write-up: pulmonary embolism, developed about 2.5 weeks after vaccination

VAERS ID:	1258878 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-08
Onset:	2021-04-24
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-04-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	038B21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Arteriogram coronary abnormal, Cardiac ventricular thrombosis, Chest X-ray, Chest discomfort, Computerised tomogram thorax abnormal, Deep vein thrombosis, Dyspnoea exertional, Fibrin D dimer normal, Induration, International normalised ratio normal, Limb discomfort, Peripheral swelling, Prothrombin time prolonged, Thrombosis, Troponin, Ultrasound Doppler abnormal
SMQs:, Cardiac failure (broad), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage laboratory terms (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (broad)

Write-up: Received Moderna Covid Vaccine on 3/3/21 and 4/8/2021. Nted onset 4/24 of right calf discomfort, swelling and firmess and at same time began to have exertional dyspnea with chest heaviness. U/S RLE - extensive DVT. CTA - multiple segmental vessels with clot, dilated right ventricle

VAERS ID:	1259028 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-04-08
Days after vaccination:	29
Submitted:	0000-00-00
Entered:	2021-04-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031AZ1A / 2	LA / SYR

Administered by: Public Purchased by: ?
Symptoms: Dyspnoea, Pulmonary embolism, Pulmonary thrombosis
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Write-up: Short of breath 4/20/21 hospitalization for blood clots in both lungs

VAERS ID:	1259775 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-17
Onset:	2021-04-17
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	MODERNS 0421321 / UNK	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Blood test, Chest pain, Computerised tomogram, Echocardiogram, Electrocardiogram, Endoscopy upper gastrointestinal tract, X-ray
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Wellbutrin, seroquel, atavan, atorvestatin, carvadilol, spirolactone, lamictal, Protonix, flow max, vitamin b and vitamin d
Current Illness: Complete proctoctomy surgery on March 18,2021
Preexisting Conditions: Cardiomyopathy, colectomy, oral cancer
Allergies: None
Diagnostic Lab Data: Blood draw on 04/17, x-ray on 4/19, ekg on 4/18 ct scans one on 4/17 and one on 4/19 echocardiogram, upper gi endoscope 4/21. Problem was difference cult to pin down by echocardiogram showed a 15 point drop in ejection fraction after adminitence
CDC Split Type:

Write-up: Chest pain in less than 10 hours of shot administered

VAERS ID:	1261744 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-03-01
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 2	LA / -

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Fall, Lethargy, Pain in extremity, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Write-up: Minimally responsive; Severe left arm pain; systemic weakness and lethargy resulting in 5 falls within the week after the shot; systemic weakness and lethargy resulting in 5 falls within the week after the shot; systemic weakness and lethargy resulting in 5 falls within the week after the shot; This is a spontaneous report from a contactable nurse. An 86-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) at the age of 86-year-old, via an unspecified route of administration, administered in left arm on 24Mar2021 (Lot Number: ER2613) as single dose for COVID-19 immunisation. Medical history included cerebrovascular disease, HTN, DMII, dementia. Concomitant medications included metformin, glimepiride, amlodipine, acetylsalicylic acid (ASPIRIN (E.C.)), senna alexandrina leaf, and vitamin D. The patient was not diagnosed with COVID-19 prior vaccination and was not tested post vaccination. The patient has no known allergies. The patient was previously vaccinated with the first dose of BNT162B2 (lot number: EN6206) at the age of 86-year-old, on 03Mar2021 11:00 AM, intramuscular at the left arm for COVID-19 immunisation. On 25Mar2021 06:00 AM, the patient experienced severe left arm pain, systemic weakness and lethargy. This resulted in 5 falls within the week after the shot on 24Mar2021. Minimally responsive on 05Apr2021 and transferred with full assist to hospital bed. Gathered family for goodbyes on 06Apr2021 as appeared terminal. On 07Apr2021 some alertness in afternoon and strength has been slowly improving as of today 12Apr2021. No treatment was received for the events. The patient was hospitalized due to the event minimally responsive on 05Apr2021. The outcome of the events was recovering.; Sender''s Comments: Based on the available information, the Company considers the reported event minimally responsive is unrelated to BNT162B2 vaccination but more likely an inter-current medical condition in this 86-year-old male patient with medical history of cerebrovascular disease, HTN, DMII, dementia. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.

VAERS ID:	1261823 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-23
Onset:	2021-02-18
Days after vaccination:	26
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1283 / 1	LA / OT

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

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021442861

Write-up: had large bilateral PE; This is a spontaneous report from a contactable nurse. A 72-year-old female patient (not pregnant) received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), intramuscularly on 23Jan2021 (lot number EL1283) on Left arm at single dose for COVID-19 immunization. Facility type vaccine was at urgent care center. Medical history included hypertension. Concomitant medications were not reported. The patient had large bilateral PE (pulmonary embolism) several weeks after vaccine on 18Feb2021. The event resulted in emergency room visit, physician office visit and Hospitalization for 2 days. Serious criteria Life-threatening also reported for the event. The event was treatment with anticoagulation. The outcome of the event was resolved in 2021.; Sender''s Comments: A causal relationship between the event "had large bilateral PE" and suspect product BNT162B2 is possible based on the information provided and a temporal association in this 72-year-old female patient with hypertension. This case will be reassessed should additional information become available. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified.

VAERS ID:	1262349 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-05
Onset:	2021-04-27
Days after vaccination:	22
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Fibrin D dimer increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-27
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt came in with positive D-dimer, coded and passed

VAERS ID:	1262370 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-01
Onset:	2021-02-08
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Aggression, Aphasia, Cerebrovascular accident, Emotional disorder, Magnetic resonance imaging head abnormal, Memory impairment, Speech disorder
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Depression (excl suicide and self injury) (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Alprazolam, Lipitor, Gabapentin, Hydrocodone, Lisinopril, Metoprolol, Nitroglycerin, Oxycontin, Spiro lactone, Ventolin, Pantorprazole.
Current Illness: none
Preexisting Conditions: Anxiety, hypertension, cardiomyopathy, cerebral vascular incident, cardiac disease, depression, eczema, GERD, hyperlipidemia, Lymes disease, insomnia, systolic heart failure.
Allergies: Gentamycin, Lyrica, Methadone.
Diagnostic Lab Data: MRI of brain
CDC Split Type:

Write-up: Within a few weeks after receiving first COVID injection patient became experiencing memory issues. Workup has led to showing a temporal lobe stroke. Her symptoms include difficulty with memory. Impaired speech, knowing what she wants to say but words coming out wrong. Mild emotional issues. Mild aggression. Physically intact.

VAERS ID:	1262585 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-23
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient was admitted to the hospital within 6 weeks of receiving COVID vaccination.

VAERS ID:	1263083 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-10
Onset:	2021-04-18
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	038B21A / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Chest X-ray abnormal, Cough, Dyspnoea, Intensive care, Lung infiltration, Lung opacity, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received both doses of the Moderna COVID-19 vaccine, on 3/13/2021 and 4/10/2021. She was admitted to an outside hospital for COVID-19 related symptoms of SOB and cough on 4/18/2021, then tested positive via PCR. On 4/23/2021, she was transferred to this hospital for ICU level care. She is still inpatient in our ICU

VAERS ID:	1263742 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-03
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808978 / UNK	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Anticoagulant therapy, Computerised tomogram thorax abnormal, Deep vein thrombosis, Pulmonary embolism, Pulmonary infarction, Ultrasound Doppler abnormal
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin, atorvastatin, lisinopril
Current Illness: none
Preexisting Conditions: HTN, obstructive sleep apnea. Patient was found to have be heterozygous for Factor V Leiden after more testing after the event.
Allergies: wasp stings
Diagnostic Lab Data: Imaging on 4/3/21: Acute DVT of posterior tibial vein in the upper calf. 4/5/21 venous doppler CT appearance of mild to moderate pulmonary emboli bilaterally, most prominently of RIGHT lower lobe pulmonary arteries snd CT findings suggestive of mild pulmonary infarction of the posterior RIGHT lung base. 4/3/21 CT
CDC Split Type:

Write-up: AE = PE/DVT. Difficult to say if vaccine played an ancillary role (very short time course). Treatment = anticoagulation with apixaban. Outcome = patient discharged from hospital in good condition after 2 days.

VAERS ID:	1264316 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-15
Onset:	2021-04-18
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-04-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Guillain-Barre syndrome, Immunoglobulin therapy
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Write-up: guillain barre

VAERS ID:	1266411 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-16
Onset:	2021-03-23
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1266651 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-16
Onset:	2021-03-28
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1805031 / 1	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Acquired diaphragmatic eventration, Activated partial thromboplastin time, Acute respiratory failure, Anticoagulant therapy, Antiphospholipid antibodies, Atelectasis, Blood creatinine, Blood electrolytes, Blood gases, Blood lactic acid, Blood magnesium, Blood potassium, Blood sodium, COVID-19, Chest X-ray abnormal, Chest pain, Computerised tomogram abdomen abnormal, Computerised tomogram pelvis, Diarrhoea, Differential white blood cell count, Dyspnoea, Echocardiogram, Electrocardiogram, Fatigue, Feeling abnormal, Full blood count, Haemoglobin, Headache, Hernial eventration, Lipase, Metabolic function test, N-terminal prohormone brain natriuretic peptide, Platelet count, Pleural effusion, Pneumonia, Prothrombin time, Pulmonary embolism, Pulmonary hypertension, Rhinorrhoea, Right ventricular hypertrophy, SARS-CoV-2 test positive, Troponin, Troponin T, Urine analysis
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Pseudomembranous colitis (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient developed shortness of breath, chest pain ''fuzzy head,'' headache, rhinorrhea, diarrhea, and increased fatigue around 3/28/21 had clinic appointment 3/30/21, diagnosed with pneumonia. XR CHEST 2 VIEWS (PA AND LATERAL), TRANSTHORACIC ECHO (TTE) ADULT NON CONGENITAL, EKG 12-LEAD completed. given cefTRIAXone (ROCEPHIN-Equivalent) injection 1,000mg IM, and doxycycline monohydrate (MONODOX) 100 mg capsule PO. was evaluated in ED 4/5/21 CT Abdomen Pelvis with IV Contrast Final Result 1. Positive for extensive acute bilateral pulmonary emboli at the lung bases as detailed in the body of the report. DX Chest Portable 1 View Final Result Mild left ventricular prominence is noted. Small right pleural effusion is seen. Minimal discoid atelectatic changes in the left perihilar region and left lung base. Elevated right hemidiaphragm suggests eventration. Admitted to Hospital 4/5/21, per admission diagnosis: Acute pulmonary embolism (*) submassive likely secondary to covid 19 Per hospital course notes:Patient presented with acute hypoxic respiratory failure and was show to have submassive PE with severe pulmonary hypertension seen on TTE. He should be on lifelong therapy given 2nd VTE and severity. Iwould consider unprovoked (COVID in 11/20 wouldn''t count I wouldn''t think). He was started on eliquis 10 mg BID x 7 days than 5 mg bid. Given his severe pulm htn on TTE, left atrial pressure normal. We would have outpatient sleep study as well He will need VQ scan to assure no CTEPH. Will have outpatient follow up. We discontinued his aspirin on discharge as well.

VAERS ID:	1266653 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-10
Onset:	2021-03-03
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	031M20A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED on 3/3/2021 and was subsequently hospitalized. After 4 days he was transferred to Clinic on 3/7/2021 for another 10 days.

VAERS ID:	1267198 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-22
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized on 3/22/21 and 4/6/21. These visits are within 6 weeks of receiving COVID vaccination.

VAERS ID:	1267803 (history)
Form:	Version 2.0
Age:	95.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-07
Onset:	2021-02-06
Days after vaccination:	30
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025L20A / 1	- / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	042L20A / 2	- / IM

Administered by: Senior Living Purchased by: ?
Symptoms: C-reactive protein increased, COVID-19, Chest X-ray abnormal, Cough, Death, Full blood count normal, General physical health deterioration, Lung opacity, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient developed COVID-19 with complaints of increased cough on 4/6. Was found to be COVID positive on 4/12. Recieved combo Bamlanivimab/etesevimab treatment for infusion on 4/14. Patient had initial recovery to baseline period on 4/22. Rapidly declined shortly after and died 4/25.

VAERS ID:	1267828 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-16
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Acute respiratory failure, Dyspnoea, Hypoxia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad)

Write-up: Patient presented to the ED and was subsequently hospitalized for shortness of breath within a week of receiving COVID vaccination. She was diagnosed with acute on chronic respiratory failure with hypoxia.

VAERS ID:	1267914 (history)
Form:	Version 2.0
Age:	45.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-18
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Bulbar palsy, Guillain-Barre syndrome, Hypoaesthesia
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Write-up: Guillain Barre syndrome- symptoms of BLE numbness with ascending bulbar weakness developed 4/18 and diagnosed on 4/27

VAERS ID:	1268127 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-09
Onset:	2021-04-16
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram abnormal, Anticoagulant therapy, Cardiac telemetry normal, Echocardiogram abnormal, Ejection fraction decreased, Electrocardiogram normal, Hypokinesia, Pain in extremity, Peripheral artery occlusion, Peripheral artery thrombosis
SMQs:, Cardiac failure (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (narrow), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad)

Write-up: The patient got the second Moderna COVID vaccine on 4/9/2021. Then 1 week later on 4/16/2021, she developed pain in left calf that got progressively worse. Then came to ER on 4/18/2021 and was diagnosed with thrombosis/occlusion in left popliteal artery. She was admitted and put on IV heparin. This was thrombolyzed by interventional radiology on 4/19/2021. She was discharged on 4/23/2021. She has had resolution of pain in the left leg. She has never had this before. She does have some apical hypokinesis on echocardiogram but that is not really new. EF 45%. Now is on warfarin.

VAERS ID:	1268276 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-12
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED several times within 6 weeks of receiving COVID vaccination. ED visits on 3/12/21, 3/16/21, 3/7/21, 3/20/21, 3/28/21, and 3/30/21. He also presented to the ED on 3/30/21 and was hospitalized at that time. These visits were within 6 weeks of receiving COVID vaccination.

VAERS ID:	1268424 (history)
Form:	Version 2.0
Age:	47.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-24
Onset:	2021-04-26
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Cough, Death, Dyspnoea, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-26
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: History of blood clots
Allergies:
Diagnostic Lab Data: Swabbed for COVID by medical examiner, no results available.
CDC Split Type:

Write-up: The decedent was found in her bedroom by her daughter. Medical history only includes previous blood clots. Decedent has been complaining of coughing and shortness of breath the past few days. There is no history of drug use. The decedent had a foam cone when found.

VAERS ID:	1268440 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-04-26
Days after vaccination:	26
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027B21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Blood creatine phosphokinase MB increased, Blood creatine phosphokinase increased, Blood glucose normal, Blood pH decreased, Cardiac arrest, Death, Fibrin D dimer increased, International normalised ratio normal, Platelet count normal, SARS-CoV-2 test negative, Troponin increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-26
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: Diabetic
Preexisting Conditions: Cardiac cath with angioplasty in 2001
Allergies: unknown
Diagnostic Lab Data: ABG-pH 6.97 PTT 13.8 sec INR 1.0 Troponin 26/CK 423/CK-MB 4.4 Platelets 198 D dimer 1.49 COVID negative Glucose 177
CDC Split Type:

Write-up: Death due to cardiac arrest on 4/26/2021

VAERS ID:	1269277 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-04
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-04-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Gout, Meningitis viral, Psychotic disorder
SMQs:, Systemic lupus erythematosus (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Arthritis (narrow)

Write-up: Diagnosed with viral meningitis; gout (legs hurts when touched); He was "gone", "what the heck is wrong with dad", wierd things happen when he''s sleeping; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of MENINGITIS VIRAL (Diagnosed with viral meningitis), GOUT (gout (legs hurts when touched)) and PSYCHOTIC DISORDER (He was "gone", "what the heck is wrong with dad", wierd things happen when he''s sleeping) in a 69-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 013A21A and 001B21A) for COVID-19 vaccination. No medical history was provided by the reporter. Concomitant products included HYDROCHLOROTHIAZIDE, LISINOPRIL (LISINOPRIL HCTZ) for an unknown indication. On 02-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 29-Mar-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 04-Mar-2021, the patient experienced PSYCHOTIC DISORDER (He was "gone", "what the heck is wrong with dad", wierd things happen when he''s sleeping) (seriousness criterion hospitalization). On 04-Apr-2021, the patient experienced MENINGITIS VIRAL (Diagnosed with viral meningitis) (seriousness criteria hospitalization and medically significant) and GOUT (gout (legs hurts when touched)) (seriousness criterion hospitalization). The patient was hospitalized on 04-Apr-2021 due to GOUT, MENINGITIS VIRAL and PSYCHOTIC DISORDER. At the time of the report, MENINGITIS VIRAL (Diagnosed with viral meningitis), GOUT (gout (legs hurts when touched)) and PSYCHOTIC DISORDER (He was "gone", "what the heck is wrong with dad", wierd things happen when he''s sleeping) had not resolved. On 4th April 2021 the patient looked like he was dying, replies but not very coherent, After 2nd shot 7-8 days later he was "gone", "Little weird things" that would happen when he''s sleeping. No concomitant medication included. Very limited information regarding these events has been provided at this time. Further information has been requested Antibiotics are added as treatment medications. This case was linked to MOD-2021-072700 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 20-Apr-2021: Seriousness criteria upgraded.Events updated; Sender''s Comments: Very limited information regarding these events has been provided at this time. Further information has been requested.

VAERS ID:	1269669 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-05
Onset:	2021-04-18
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	- / -

Administered by: Private Purchased by: ?
Symptoms: CSF test abnormal, Condition aggravated, Electromyogram abnormal, Full blood count abnormal, Generalised oedema, Guillain-Barre syndrome, Hypertension, Lumbar puncture abnormal, Motor dysfunction, Musculoskeletal disorder, Respiratory distress
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Angioedema (broad), Haematopoietic leukopenia (broad), Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypertension (narrow), Demyelination (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Guillain Barre syndrome. Severe progressive motor impairment upper and lower extremities. Respiratory distress severe widespread edema, hypertension increase,

VAERS ID:	1269766 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Unknown
Location:	Wisconsin

Vaccinated:	2021-03-23
Onset:	2021-03-23
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	LA / -

Administered by: Private Purchased by: ?
Symptoms: Appendicitis, SARS-CoV-2 test
SMQs:, COVID-19 (broad)

Write-up: Appendicitis; This is a spontaneous report from a contactable consumer (patient). A 38-year-old patient of an unspecified gender received bnt162b2 (BNT162B2), dose 1 via an unspecified route of administration (at the age of 38-years-old), administered in Arm Left on 23Mar2021 08:00 (Batch/Lot number was not reported) as single dose for COVID-19 immunization. Medical history included eosinophilic oesophagitis (Eoe), multiple allergies, Latex, bees, pollen, animals, eggs, corn, and wheat. No history of COVID prior vaccination. Concomitant medications included chlorthalidone, lisinopril, pantoprazole, bupropion hydrochloride (WELLBUTRIN), all taken for unspecified indications, start and stop dates were not reported. The patient experienced appendicitis on 23Mar2021 08:15. The patient was hospitalized for appendicitis for 1 day. The patient underwent lab tests and procedures which included SARS-CoV-2 test: negative on 24Mar2021 (Nasal Swab, Negative). Therapeutic measures were taken as a result of appendicitis which included Emergency Appendectomy. The outcome of the event was recovering. Event resulted in Emergency room/department or urgent care, Hospitalization, Life threatening illness (immediate risk of death from the event). Facility type vaccine was Hospital. No other vaccines in four weeks. Information about the Lot/batch number has been requested.

VAERS ID:	1270103 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-04-22
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Anaphylactic reaction, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)

Write-up: Anaphylaxis- patient unconscious briefly prior to receiving Epinephrine. After injection, patient slightly arousable- transferred to ED via EMS.

VAERS ID:	1270567 (history)
Form:	Version 2.0
Age:	36.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-27
Onset:	2021-04-27
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0158 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Fatigue, Laboratory test normal, Muscular weakness, Pregnancy test urine negative, Pruritus, Rash, Rash erythematous
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: 15 minutes after dose, complained of itching. Sent to Emergency Department. Found to have lacy erythematous rash on thighs and back. No breathing difficulty and no swelling. Received diphenhydramine IV, famotidine IV, and methylprednisolone IV. Discharged with prescriptions for oral diphenhydramine, famotidine, and prednisone. Returned to ED 15 hours after dose complaining of fatigue and extremity weakness. No rash, no breathing difficulty, and no swelling noted. Admitted for observation and to rule out neurologic syndrome. Workup negative. However patient reported transient neurologic symptoms at various times in the past. Discharged with instructions to follow up with neurologist in the future.

VAERS ID:	1270609 (history)
Form:	Version 2.0
Age:	25.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-04-29
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 1	LA / IM

Administered by: School Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Anticoagulant therapy, Computerised tomogram thorax abnormal, Dyspnoea, Fibrin D dimer increased, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Write-up: Patient vaccinated with Moderna COVID vaccine 3/25/21 and 4/22/21. Patient presented to Hospital 4/29 with SOB. The patient actually stated the SOB started 4/21 and he received his second Moderna vaccination 4/22. SOB progressively worsened from 4/21 until ED visit. Patient thought it was asthma flare. 4/29 04:00 CTA chest showing extensive bilateral pulmonary emboli, left greater than right. Started on heparin protocol for PE in the ER. 4/29 afternoon, patient is currently an inpatient at GSH on a heparin drip for anticoagulation.

VAERS ID:	1270726 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-27
Onset:	2021-04-03
Days after vaccination:	35
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Anticoagulant therapy, Atelectasis, Computerised tomogram abnormal, Computerised tomogram thorax, Cough, Lymphadenopathy, Musculoskeletal chest pain, Pleural effusion, Pulmonary embolism, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, venous (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Write-up: Patient rec''d Moderna COVID vaccines 1/30/21 and 2/27/21. On 4/3 she presented to the emergency department following a syncopal episode. Prior to syncopal episode she had a 2 week history of dry, nonproductive cough, left side rib pain (Pain rating 8/10). She was admitted and treated for PE and possible pneumonia. She was discharged 4/5 on warfarin anticoagulation. She had follow up appointments with PCP and hematology and will likely be on anticoagulation for unprovoked PE x 6 months.

VAERS ID:	1271454 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-18
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / UNK	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1271472 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-23
Onset:	2021-04-21
Days after vaccination:	29
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 1	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Alcohol withdrawal syndrome, Angiogram abnormal, Cerebral infarction, Cerebrovascular accident, Echocardiogram normal, Hemiparesis, Heparin-induced thrombocytopenia test, Magnetic resonance imaging, Magnetic resonance imaging head abnormal, Platelet count decreased, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient admitted with left sided weakness on 4/21/21. First covid-19 vaccine (Moderna) received on 3/23/21. MRI/MRA shows acute infarcts of the right caudate body and striatum. H/o HTN, hep C with cirrhosis, COPD, tobacco abuse, alcohol use disorder, GTC seizure disorder. ECHO on 4/21/21 which was normal. Patient thought to be actively overusing alcohol at home. Patient was treated for stroke and discharged on medications to help with alcohol withdrawal symptoms (clonidine, gabapentin) as well as aspirin, plavix, and atorvastatin for new stroke. Thrombocytopenia noted (platelets 50K), however patient?s platelets have historically been low likely related to alcohol use. Per hospitalist discharge summary, low suspicion for vaccine induced thrombocytopenia. HIT Ab test ordered on 4/21/21, resulted negative. It seems to be coincidental that stroke occurred about a month after patient?s first covid-19 vaccine but reported to VAERS for completeness. Did not add covid-19 vaccine to patient?s allergy list. Patient received second covid-19 vaccine (Moderna) on 4/28/21.

VAERS ID:	1271495 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-02
Onset:	2021-04-28
Days after vaccination:	85
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	AR / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Hypotension, Pyrexia, SARS-CoV-2 test positive, Urinary tract infection
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: The patient was admitted for hospitalization on 4/28/2021 from a Unit with an ongoing COVID outbreak. Patient presented with a fever and hypotensive. Patient also reports a UTI. Tested for COVID has a part of hospital admission guidelines. The test returned positive.

VAERS ID:	1271643 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-04-27
Days after vaccination:	34
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Flank pain, Headache, Klebsiella infection, Pain, Pyrexia, Urine analysis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Write-up: Client had first Pfizer injection on 3/24/2021. The client presented to the emergency department on 4/27 with a fever, generalized weakness, body aches, headache and right flank pain. She had lithotripsy and a right ureteral stent replacement the day before, 4/26. She is on ciprofloxacin. Urine Analysis was consistent with a UTI. Most recent positive urine culture grew out multidrug-resistant Klebsiella. The patient will be admitted to the hospital service for further evaluation and treatment.

VAERS ID:	1271756 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-04-26
Days after vaccination:	54
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Deep vein thrombosis, Intestinal obstruction, SARS-CoV-2 test positive
SMQs:, Embolic and thrombotic events, venous (narrow), Gastrointestinal obstruction (narrow), Thrombophlebitis (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client COVID PCR positive on 12/04/2021. Vaccinated with Moderna on 02/03/2021 and 03/03/2021. COVID PCR Presumptive on 4/26/2021 and listed as suspect reinfection. Client hospitalized on 4/26/2021 with signs of bowel obstruction, but also noted to be diagnosed with DVT. Notes indicate client was bedbound. Submitter does not have access to further vaccination or medical records for additional information.

VAERS ID:	1271786 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-04-25
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045B21A / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-25
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient came to pharmacy for 1st Moderna Covid-19 vaccination on 4/21/21. Spouse reported she died on 4/25/21. Our pharmacy does not have information about her medications or health conditions as she wasn''t a regular customer of ours.

VAERS ID:	1271806 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-08
Onset:	2021-04-08
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0158 / 1	RA / SYR

Administered by: Unknown Purchased by: ?
Symptoms: Abdominal discomfort, Dyspnoea, Eye irritation, Feeling abnormal, Headache, Insomnia, Oropharyngeal pain, Pain, Paraesthesia, Sinus pain, Vision blurred
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Dementia (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Cardiomyopathy (broad), Lens disorders (broad), Corneal disorders (broad), Retinal disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Multivitamin
Current Illness: Lyme disease, Babesia, EBV, Hashimoto?s, mold toxicity
Preexisting Conditions: Chronic fatigue, brain fog, nasal congestion.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Severe insomnia, severe brain fog, sinus pain, sore throat, shortness of breath, body aches and tingling, eye irritation, blurred vision, headaches, stomach discomfort.

VAERS ID:	1271844 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-23
Onset:	2021-04-23
Days after vaccination:	59
Submitted:	0000-00-00
Entered:	2021-04-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Unknown Purchased by: ?
Symptoms: SARS-CoV-2 test positive, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Admitted to hospital 4/23/2021 with syncopal episode. Discharged to home 4/25/2021. Covid vaccination history: Pfizer 2/1/2021 and 2/23/2021. Covid PCR positive on 4/23/2021. Submitter does not have access to further vaccine or hospital medical records.

VAERS ID:	1273385 (history)
Form:	Version 2.0
Age:	32.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-04-13
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-04-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	0385321A / 1	- / -

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient hospitalized within 60 days of receiving a COVID vaccine

VAERS ID:	1273703 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-29
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-04-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Arthralgia, Capillary nail refill test abnormal, Hypoaesthesia, Muscle spasms, Neck pain, Pain, Pain in extremity, Peripheral artery thrombosis, Peripheral coldness, Peripheral swelling, Pulse abnormal, Sleep disorder, Ultrasound scan abnormal
SMQs:, Cardiac failure (broad), Angioedema (broad), Peripheral neuropathy (broad), Embolic and thrombotic events, arterial (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Dehydration (broad)

Write-up: She presented for pain to her right arm. She notes Monday night (3/29/21) she couldn''t sleep well, so she decided to lay on her right side, with her arm up and tucked beneath the pillow. She woke up about 1-1.5 hours later with a "Charlie horse" in her bicep area, pain was so intense that she was crying/in tears. Notes that her right hand has been colder than her left and with numbness since Monday. Use of the right arm causes pain, such as brushing her hair. She does have DDD, and notes some pain/issues with her right shoulder - so she''s wondering if she has a pinched nerve. At this time she is having some numbing pain near the right side of her neck. She received COVID vaccine on 3/15/21 according to immunization registry.

VAERS ID:	1273771 (history)
Form:	Version 2.0
Age:	49.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-14
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-04-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / SYR

Administered by: Public Purchased by: ?
Symptoms: Abdominal pain, Computerised tomogram, Ovarian cyst, Ultrasound abdomen abnormal
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Write-up: Abdominal pain. Ovarian cyst. Emergency surgery on 04/18/2021

VAERS ID:	1276490 (history)
Form:	Version 2.0
Age:
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-04-16
Submitted:	0000-00-00
Entered:	2021-05-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	206AZ14 / UNK	- / -

Administered by: Other Purchased by: ?
Symptoms: Joint swelling, Lymphadenopathy, Myalgia, Pleural effusion, Tendon pain, Urticaria
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Angioedema (narrow), Systemic lupus erythematosus (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Arthritis (broad), Tendinopathies and ligament disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Write-up: SWOLLEN LYMPH NODES (FOUND IT HARD TO SWALLOW); SORE TENDONS; JOINT SWELLING IN KNEES, ANKLES, AND KNUCKLES IN HANDS; PLEURAL EFFUSION (HAD A HARD TIME BREATHING AND TAKING SHALLOW BREATHS); HIVES; SORE MUSCLES; This spontaneous report received from a health care professional (parent) concerned a 34 year old female. The patient''s height, and weight were not reported. The patient''s pre-existing medical conditions included patient had no history of allergies or autoimmune disease. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: 206AZ14, expiry: UNKNOWN) frequency 1 total, dose was not reported, administered on 10-APR-2021 to Left arm for prophylactic vaccination. No concomitant medications were reported. Patient started experiencing significant side effects about 6 days after receiving the vaccine. On 16-APR-2021 patient developed hives, swollen lymph nodes (found it hard to swallow), sore muscles, sore tendons, and joint swelling in her knees, ankles, and knuckles in her hands. All of these symptoms appeared within 1 day of each other.She went to the Emergency Department, and was subsequently hospitalized (date unspecified) for 3 days.There, she was diagnosed with pleural effusion, where she had fluid on the outside of her lungs, had a hard time breathing and was taking shallow breaths.Patient was treated with prednisone for hives in the hospital, which improved her hives. All other symptoms were still ongoing at the time of reporting. Caller also reported that the patient had an appointment with the allergist on 29-APR-2021 (this Thursday). The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient was recovering from hives, had not recovered from swollen lymph nodes (found it hard to swallow), sore muscles, sore tendons, and joint swelling in knees, ankles, and knuckles in hands, and the outcome of pleural effusion (had a hard time breathing and taking shallow breaths) was not reported. This report was serious (Hospitalization Caused / Prolonged).; Sender''s Comments: 20210451762-covid-19 vaccine ad26.cov2.s- pleural effusion. This event(s) is considered not related. The event(s) is deemed to be scientifically implausible, i.e., there is scientific evidence against a drug/event relationship; AND there is no known class effect.

VAERS ID:	1278540 (history)
Form:	Version 2.0
Age:	18.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-12
Onset:	2021-04-12
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	LA / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Loss of consciousness, Seizure, Somnolence, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Write-up: Loss of consciousness; Seizure; Drowsiness, couldn''t stay awake; Vomiting; This is a spontaneous report from a contactable consumer (patient). An 18-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number and expiration date were not reported) on the left arm on 12Apr2021 (11:30) as a single dose, with route of administration unspecified, for COVID-19 immunization at the pharmacy/drug store. Medical history included peanut and penicillin allergy. The patient''s concomitant medications were not reported. On12Apr2021 (11:45), the patient had loss of consciousness; seizure; drowsiness/could not stay awake; and vomiting. The events had resulted in an emergency room/department for urgent care, and were assessed as serious (medically significant). The patient was hospitalized in Apr2021 due to loss of consciousness. The patient had received epinephrine (EPIPEN) as treatment for the reported events. The outcome of the events was recovered in Apr2021. The patient did no have COVID-19 prior to the vaccination, and had not been tested post-vaccination. Information on the lot/batch number has been requested.

VAERS ID:	1279405 (history)
Form:	Version 2.0
Age:	30.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-03-01
Submitted:	0000-00-00
Entered:	2021-05-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8730 / 1	LA / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Abortion spontaneous, SARS-CoV-2 test
SMQs:, Termination of pregnancy and risk of abortion (narrow), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: None
Allergies:
Diagnostic Lab Data: Test Date: 20210422; Test Name: COVID-19 test; Test Result: Negative ; Comments: nasal swab
CDC Split Type: USPFIZER INC2021456214

Write-up: miscarriage of the 16-17 week fetus; This is a spontaneous report from a contactable consumer (patient). A 30-year-old female patient received the first dose of BNT162B2 (Pfizer-BioNTech COVID-19 vaccine, lot number : ER8730), via an unspecified route of administration, administered in the left arm on 26Mar2021 at 16:30 as a single dose for COVID-19 immunization. The patient had no medical history and no known allergies. The patient''s concomitant medications included unspecified prenatal vitamins. The patient did not have other vaccines in four weeks prior to the COVID vaccine. On an unspecified date in Mar2021, the patient had a miscarriage of the 16-17 week fetus. The patient had surgery to remove the fetus and tissue. The mother was due to deliver on 09Sep2021. The outcome of the event was recovering. The patient had a nasal swab COVID-19 test on 22Apr2021 with a result of negative. The event was reported as life-threatening.

VAERS ID:	1281523 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-08
Onset:	2021-04-06
Days after vaccination:	57
Submitted:	0000-00-00
Entered:	2021-05-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient was admitted to the hospital within 6 weeks of receiving COVID vaccination.

VAERS ID:	1281972 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-30
Onset:	2021-04-30
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	017C21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Chest discomfort, Electrocardiogram, Hypoaesthesia oral, Nausea, Pruritus, Throat irritation
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Pt was given the Moderna COVID vaccine at 1141. At 1150, she reported that she was nauseous and itchy. Pt received Benadryl 50 mg IM and one dose of Epipen. She continued to c/o itchiness and began to have numb lips, throat irritation and chest tightness. She was transported to the ER and was subsequently admitted to our inpatient floor for observation overnight and discharged on 5/1. On 5/2, she was readmitted for observation after her symptoms returned and was discharged later that day. During her stay, she received Benadryl, Zyrtec, epinephrine, solumedrol, albuterol and pulmicort nebs, famotidine, hydroxyzine, prevacid, and prednisone.

VAERS ID:	1282375 (history)
Form:	Version 2.0
Age:	87.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-13
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient was hospitalized within 6 weeks of receiving the covid vaccine. 3-13-21 for 6 days, 3-22-21 for 3 days and again on 3-25 for 4 days.

VAERS ID:	1282431 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-03-27
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-05-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient hospitalized within 6 weeks after receiving covid vaccine. Once on 3-17 for 2 days and once on 4-21 for 7 hours.

VAERS ID:	1282617 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-30
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-05-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1283410 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-15
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-05-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 1	- / UN

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Levothyroxine Alprozalan Combivent Serevent Incruse Montelucart Qvar
Current Illness: Asthma - emphagsema
Preexisting Conditions: Anxiety
Allergies: Aspirin Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had a stroke on March 15, 2021 as described as a blood clot in her brain. Medical personnel were unable to correct it surgically and she passed away that evening in the hospital. Death was the final result.

VAERS ID:	1284033 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-21
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-05-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Areflexia, Blood test, Diplopia, Lumbar puncture, Magnetic resonance imaging, Myelitis transverse, Paraesthesia, Spinal cord injury, Urinary retention, X-ray
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Demyelination (narrow), Ocular motility disorders (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: transverse myelitis - potentially related to immunosuppression from Humira, the herpes simplex virus or the vaccine (or combination of all 3). Sx included areflexia, bilateral paresthesia (legs and feet), double vision, cord damage from cervical region to conus of the cord. Also developed urinary retention.

VAERS ID:	1285200 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-22
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	- / -

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: ED-Hospitalization within 6 weeks of receiving first COVID vaccine.

VAERS ID:	1285292 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-03-20
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	UN / SYR

Administered by: Other Purchased by: ?
Symptoms: Blood glucose decreased, Blood magnesium decreased, Chest pain, Dysstasia, Lethargy, Lymphopenia, Pain in extremity, Troponin increased, Vomiting
SMQs:, Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow)

Write-up: 7 day post shot 2: sore feet - could not stand up 9 days post shot 2: vomiting, lethargy, severe chest pains, lymphopenia, low magnesium, low glucose, mildly elevated troponin

VAERS ID:	1285303 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-23
Onset:	2021-04-18
Days after vaccination:	26
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Bilevel positive airway pressure, COVID-19, Chest X-ray abnormal, Chills, Cough, Death, Hypophagia, Lung consolidation, Respiratory disorder, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-03
Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: aspirin 81mg, atorvastatin 40mg, calcium citrate 200mg, cholecalciferol 1000 units, Tylenol PM, Ferrous Sulfate 325mg, Finasteride 5mg, Loratadine 10mg, Metoprolol succinate 25mg, Multivitamin, Potassium 99mg, Tamsulosin 0.4mg, Varenicline
Current Illness: Arthritis, Bladder Cancer, BPH, Coronary artery disease, Chronic Lymphocytic leukemia, hypertension, idiopathic thrombocytopenic purpura, hyperlipidemia
Preexisting Conditions: same as item 11
Allergies: Rituxan, Levaquin, Oxycodone-APAP, Pregabalin
Diagnostic Lab Data: Covid-19 PCR, chest x-ray 4/16/2021
CDC Split Type:

Write-up: Patient admitted to Hospital on 4/16/2021 with 2 weeks of generalized weakness, chills, poor oral intake and nonproductive cough. Chest x-ray shows consolidation. Patient tested for covid-19 which returned positive on 4/18/21. Patient remained hospitalized and started on steroids and vitamin c/e after covid testing returned positive. Patient respiratory status worsened requiring high flow nasal cannula and BiPAP as needed. Patient did not want to be intubated and decided to go to comfort care. Patient passed away on 5/3/21 in the hospital.

VAERS ID:	1285327 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-05-03
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	03B21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood culture, Blood lactic acid, Body temperature increased, Chills, Full blood count, Heart rate increased, Metabolic function test, Nausea, Pyrexia, Sepsis, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad)

Write-up: Patient presented to the ED via ambulance with fever, nausea, vomiting. Patient noted to have 103 degree temperature at home. Patients heart rate was elevated in the 110s. Patient has rigors. Fever increased while at hospital. Patient admitted to the hospital for sepsis. Started on numerous antibiotics, fluid boluses.

VAERS ID:	1285923 (history)
Form:	Version 2.0
Age:	31.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-05-01
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Amylase increased, Lipase increased, Pancreatitis
SMQs:, Acute pancreatitis (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Pancreatitis

VAERS ID:	1285946 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-04-01
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / UNK	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Seizure
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Write-up: Suffered several seizures in the weeks following the administration of first dose.

VAERS ID:	1286022 (history)
Form:	Version 2.0
Age:	44.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-05
Onset:	2021-02-08
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	041L20A / 2	RA / -

Administered by: Private Purchased by: ?
Symptoms: Blood creatinine normal, Computerised tomogram thorax, Haemoglobin normal, Liver function test normal, Platelet disorder, Pulmonary embolism, White blood cell count increased
SMQs:, Haematopoietic thrombocytopenia (broad), Neuroleptic malignant syndrome (broad), Embolic and thrombotic events, venous (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Pulmonary embolism of the distal right main pulmonary artery and right middle lobe pulmonary artery

VAERS ID:	1286651 (history)
Form:	Version 2.0
Age:	49.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-10
Onset:	2021-04-21
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiotensin converting enzyme, Anti-ganglioside antibody, Anti-muscle specific kinase antibody, Aspiration, Bladder catheterisation, Borrelia test negative, Borrelia test positive, CSF glucose increased, CSF lymphocyte count increased, CSF protein increased, CSF white blood cell count increased, Condition aggravated, Facial paralysis, Facial paresis, Lumbar puncture abnormal, Lyme disease, Magnetic resonance imaging head abnormal, Magnetic resonance imaging thoracic abnormal, Multiple sclerosis, Muscular weakness, Urinary retention, Viral test negative
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Optic nerve disorders (broad), Cardiomyopathy (broad), Demyelination (narrow), Hearing impairment (broad), Malignant lymphomas (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: The patient is a 49 year old male who has a past medical history significant for bipolar disorder with manic episodes, OSA on CPAP, morbid obesity, HLD, and relapsing remitting MS. Per chart review, patient''s MS was initially diagnosed in 2012 on MRI and LP and was on Copaxone for several years but stopped taking in 2017. Symptoms and imaging remained stable through 2019 then patient was lost to follow up until he was seen by Dr. on 4/12/21 who ordered an outpt MRI. Patient had COVID vaccine with Jansen vaccine on 4/10/21. He developed bilateral upper and lower exremity weakness and urinary retention on 4/21/21 which prompted presentation. He came into ED 4/21/21 and had foley placed but removed foley and decided to leave AMA. Returned on 4/22/21 with worsening symptoms and was subsequently admitted. Patient was seen by neurology and started on high dose steroid x5d for MS exacerbation. Initial MRI of the brain obtained on 4/22/21 was notably stable without change in previously described white matter disease. No new lesions to suggest active demyelination. New plaques were noted on MRI C and T spine (4/22/21). It is noted that patient received COVID19 vaccination with J&J vaccine on 4/10/21 and temporal relationship between his acute presentation and recent vaccination was questioned. On 4/30/21, patient developed severe bilateral facial weakness and he additionally was reported to have had an episode of aspiration. Repeat MRI brain on 4/30/21 showed new bilateral facial nerve enhancement. Etiologies could include: GBS, Lyme disease, botulism, neurosarcoidosis, less likely myasthenia gravis. LP was pursued on 5/1/21 which was significant for tube 4 with 136 WBC, 88% lymphocytes, glucose 89, protein 632. Meningitis/encephalitis panel was negative. Lyme CSF was negative, Lyme antibody panel was positive. MuSK antibody negative. ACE blood level normal. Ganglioside antibody panel and myasthenia graivs adult panel pending. He is being treated for Lyme disease with Ceftriaxone 2g IV daily since 5/1/21 with plan for 2-4 week course to cover for Lyme disease. He is still admitted and is still having symptoms of facial palsy as of today (5/4/21)

VAERS ID:	1286758 (history)
Form:	Version 2.0
Age:	92.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-03-23
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-05-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1289022 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-04-29
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-05-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0169 / 2	RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 1	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Jan 2020: Ativan, Ambien, Tulicity, Kenalog, Glucophage, Lisinopril
Current Illness: Unknown
Preexisting Conditions: Past Medical History: Rosacea, HTN, Hyperlipidemia, Diabetes Type 2, degenerative disease
Allergies: PCN - GI intolerance
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient passed away on 4/29/2021. A member of our staff noticed his name on the obituary section of our local news. We do not know of any other details.

VAERS ID:	1290042 (history)
Form:	Version 2.0
Age:	36.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-03
Onset:	2021-02-08
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-05-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / 2	RA / SYR

Administered by: Public Purchased by: ?
Symptoms: Acoustic stimulation tests normal, Anxiety, Blood thyroid stimulating hormone normal, Panic attack, Tinnitus, White blood cell count normal
SMQs:, Hearing impairment (narrow), Hypoglycaemia (broad)

Write-up: Tinnitus. Primary doctor care, antibiotics. Anxiety, panic attack. Emergency room care. Mental health inpatient/outpatient. Daily anti anxiety medication. ENT doctor visit. Hearing test. Audiologist visit, hearing test. Chiropractic care. No change in symptoms.

VAERS ID:	1290064 (history)
Form:	Version 2.0
Age:	24.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-13
Onset:	2021-04-15
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0162 / 1	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Back pain, Balance disorder, Blood creatine phosphokinase normal, Blood creatinine increased, Blood folate normal, C-reactive protein normal, CSF protein increased, Cough, Echocardiogram normal, Hyperhidrosis, Hypoaesthesia, Immunoglobulin therapy, Influenza like illness, Limb discomfort, Lumbar puncture, Magnetic resonance imaging head normal, Mobility decreased, Pain in extremity, Paraesthesia, SARS-CoV-2 test positive, Syncope, Vitamin B12 normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: He states he had the first Pfizer COVID-19 vaccine in the series on 4/13/2021. He states that two days later on 4/15/2021 he felt like his feet were heavy. He continues to experience that sensation in his feet, and even feeling like his feet are asleep at nighttime and when he first gets up in the morning. The asleep feeling in the feet gets better when he gets up and moves around but the heavy sensation in the legs does not get better. He states that his mobility is affected though that his legs feel heavy and he is not as easily mobile as he used to be. He feels his balance is off. Patient later reported that he did have and episode of syncope about 5 minutes after he got the vaccine but otherwise was doing okay until 4/15/2021. He presented to the ED with these symptoms on 5/3/2021 at approximately 7:14pm and was admitted to the hospital for evaluation. Patient states that he normally exercises regularly and has been having a great deal of difficulty especially with squatting and now has difficulty walking up stairs, feels very weak and his legs feel heavy. He reports that the numbness and tingling sensation of his feet when sleeping is new and he has never had it in the past. Symptoms get worse with exertion and prolonged activity. Neurologist was consulted and several tests were ordered. Neurology consult noted that patient had a prior COVID 19 infection in November 2020. Per neurologist notes: His symptoms first started about two days after he received Pfizer COVID vaccine on April 13, 2021. He recalled feeling his feet heaviness and it was hard to pick them up. He also had some calf pain. He also had difficulty with doing his stretches and yoga positioning. A week ago, he began to have difficulty with picking up a ball or anything from the ground. He also developed pins and needles at the fingertips at the same time he developed tingling sensation of his feet. He also has lower back pain. He tested positive for SARS-COV-2 antigen on November 12, 2020. He recalled having symptoms lasting for a few days consisting of diaphoresis, cough, and flu-like symptoms. Per neurologist, symptoms seem to resemble acute inflammatory demyelinating polyneuropathy (AIDP). Patient was treated with IVIG for 5 days.

VAERS ID:	1290257 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-18
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Public Purchased by: ?
Symptoms: Death, Malaise, Peripheral coldness
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Emphysema
Preexisting Conditions: Emphysema
Allergies: Unknown
Diagnostic Lab Data: unknown contact daughter for more info Found dead in his room about 5 pm on April 22 by the manager.
CDC Split Type:

Write-up: Pt. called his daughter on Sunday April 18 and told her was not feeling well and said it was from the effects of the (one shot) COVID-19 vaccine. You would have to contact her directly for more information. He was found dead in his room by the manager around 5 pm on April 22nd. Manager told me his body was cold to the touch so she thought he may have passed the previus day on April 21st. Daughter todl me earlier today that a doctor is running some tests to try to determine the cause of death. You would need to contact her for the doctors name. My own inpression is that the emphysema was not severe enough to have d=caused his death as he could walk up to half a mile.

VAERS ID:	1291288 (history)
Form:	Version 2.0
Age:	43.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-12
Onset:	2021-04-12
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8731 / 1	LA / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Abdominal discomfort, Abdominal pain, Appendicitis, Breast pain, Computerised tomogram, Decreased appetite, SARS-CoV-2 test, Vomiting
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Lipodystrophy (broad), COVID-19 (broad)

Write-up: abdominal pain; vomited; acute appendicitis; appetite decreased steadily; increasing discomfort in my abdomen; my left breast was experiencing significant stabbing pain around nipple area; This is a spontaneous report from a contactable consumer (reporting for herself). A 43-year-old female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), dose 1 via an unspecified route of administration, administered in Arm Left on 12Apr2021 at 10:30 (Batch/Lot Number: ER8731) as single dose for COVID-19 immunization. Medical history was reported as none. The patient''s concomitant medications were not reported. On 12Apr2021, immediately within 15 min. of injection, the patient''s left breast had significant stabbing pain around nipple area. This lasted all day, until she went to bed at 9:30 PM. On 17Apr2021 throughout the week, her appetite decreased steadily and she had increasing discomfort in her abdomen. Saturday morning, she woke up at 5 AM in severe abdominal pain, she vomited, and was still horribly uncomfortable for hours. Finally, she went to the emergency room at 11 AM, where they performed a computerized tomography (CT) scan and told me she had acute appendicitis and required surgery to remove my appendix. The events resulted in emergency room / department or urgent care and hospitalization. The patient was hospitalized for 1 day and had emergency appendectomy. The patient underwent lab test and procedure which included nasal swab negative on 17Apr2021. The outcome of the event breast pain was recovered on 12Apr2021 at 21:30 while the outcome of the other events were recovering. The patient had no COVID prior to vaccination.

VAERS ID:	1291994 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-19
Onset:	2021-03-15
Days after vaccination:	24
Submitted:	0000-00-00
Entered:	2021-05-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	023M20A / 2	UN / IM

Administered by: Other Purchased by: ?
Symptoms: Acute myocardial infarction, Chest discomfort
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Write-up: Patient presented to the ED on 3/15/21 and was subsequently hospitalized with NSTEMI. She also presented to the ED on 4/14/21 with chest heaviness.

VAERS ID:	1292047 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-26
Days after vaccination:	24
Submitted:	0000-00-00
Entered:	2021-05-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient was admitted to the hospital within 6 weeks of receiving COVID vaccination.

VAERS ID:	1292574 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-23
Onset:	2021-05-01
Days after vaccination:	39
Submitted:	0000-00-00
Entered:	2021-05-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 1	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Balance disorder, Chills, Cough, Dizziness, Pain, Pyrexia, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Write-up: Client was feeling generally weak, off balance and chilled starting on 5/1. Subsequently, he developed body aches and a non productive cough. He has no sore throat, chest pain, or shortness of breath. On 5/4 the client presented to the emergency department with generalized weakness, lightheadedness, chills, cough, and fever. He received Tylenol and IV fluids while in the ER. Covid test was negative. Client admitted to hospital for further evaluation.

VAERS ID:	1292715 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-20
Onset:	2021-05-05
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-05-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 1	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19 pneumonia, Dyspnoea, Lung disorder, Pneumonia, Pyrexia, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client has a history of former tobacco abuse, CAD, DVT on apixaban, PAD s/p stenting, COPD, end-stage interstitial lung disease, chronic hypoxic respiratory failure (4L), sepsis complicated by aorto-embolic lower extremity thrombosis ultimately requiring L BKA, aorto-embolic RUE embolism treated with thrombectomy, RLE stent thrombosis while on anticoagul ation, GERD, steroid-induced diabetes, C difficile colitis, stress-induced cardiomyopathy. Client presented to the Emergency Room with shortness of breath, fever, and respiratory failure in the setting of COVID-19 and severe underlying pulmonary illness. Admitted with: Severe COVID-19 bronchopneumonitis

VAERS ID:	1292869 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-05-05
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-05-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 1	UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Hypoaesthesia, Muscular weakness, Neurological examination
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad)

Write-up: Sudden onset of left arm numbness and weakness on 5/5/21, admitted for CVA evaluation

VAERS ID:	1295648 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-04-10
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-19
Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: antibiotic
Current Illness: pneumonia
Preexisting Conditions: lymphoma
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient DIED 10 days after 2nd dose of Covid vaccine.

VAERS ID:	1295756 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-05-05
Days after vaccination:	34
Submitted:	0000-00-00
Entered:	2021-05-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time, Angiogram pulmonary abnormal, Echocardiogram, Full blood count, Metabolic function test, Oxygen saturation decreased, Prothrombin time, Pulmonary embolism, Ultrasound Doppler
SMQs:, Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Respiratory failure (broad), Infective pneumonia (broad)

Write-up: Pulmonary Embolism - desaturating to the 70''s on admission, requiring 4L NC oxygen supplementation and heparin gtt

VAERS ID:	1296099 (history)
Form:	Version 2.0
Age:	41.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-10
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-05-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood cholesterol normal, Cardiac imaging procedure abnormal, Cardiomegaly, Catheterisation cardiac abnormal, Echocardiogram abnormal, Myocardial infarction, Troponin
SMQs:, Cardiac failure (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad)

Write-up: 8 days after receiving the shot I was out for a run and had a heart attack. The septal region of my heart was enlarged but nothing else was showing... all arteries wide open, heart functioning at 55, cholesterol 171. My troponin levels were 76...

VAERS ID:	1296384 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-13
Onset:	2021-04-26
Days after vaccination:	13
Submitted:	0000-00-00
Entered:	2021-05-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Cardiac arrest, Chest pain, Death, Dyspnoea, Hypovolaemic shock, Pain, SARS-CoV-2 test positive, Upper gastrointestinal haemorrhage
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (narrow), Dehydration (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client admitted to the hospital on 4/26/2021 with Covid symptoms, body aches, SOB and chest pain. Diagnosed with Covid -19 pneumonia. Antigen test positive for Covid-19 on 4/26/2021. Subsequent admission on 5/4/2021 with cardiac arrest secondary to hypovolemic shock from UGI bleed, likely variceal. Client died 5/5/2021.

VAERS ID:	1299785 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-19
Onset:	2021-04-21
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8731 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Hypertension
SMQs:, Neuroleptic malignant syndrome (broad), Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Insulin, NP Thyroid, Krill oil, Vitamin d3
Current Illness: none
Preexisting Conditions: diabetes, hypo thyroid
Allergies: penicillin
Diagnostic Lab Data: Blood pressure checks
CDC Split Type:

Write-up: After a life time and family history of normal to low blood pressure, my blood pressure skyrocketed and has remained high. I discovered this two days after the shot at a normal visit to my medical doctor.

VAERS ID:	1300103 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-20
Onset:	2021-04-22
Days after vaccination:	33
Submitted:	0000-00-00
Entered:	2021-05-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / IM

Administered by: Private Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Feeling abnormal, Pericarditis
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: On 04/22/2021, a patient was determined to have pericarditis, possibly secondary to COVID-19 vaccination. The patient received his first COVID-19 vaccination (Pfizer) on 2/27/2021. The patient reported feeling poorly and presented to ER on 03/02/2021 with chest pain and dyspnea. He states the chest pain he is experienced this week is similar to the 2 episodes of chest pain he had after each of the two-step Pfizer COVID vaccination that he received in February 02/27/2021 and March 03/15/2021. He underwent a stress test on 03/11/2021 which did not show any reversible perfusion defects. Of note, the patient had COVID-19 back in October 2020 which manifested with night sweats, malaise for a few days and then cleared completely without any "long hauler" symptoms. The patient was treated with ibuprofen and colchicine. I did not find any evidence suggesting a relationship between pericarditis and covid-19 vaccination. In clinical trials, pericarditis was not statistically significantly different between treatment arms. Other potential causes of pericarditis include atrial fibrillation.

VAERS ID:	1300411 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-05-02
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-05-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0171 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Alanine aminotransferase normal, Analgesic drug level, Anion gap normal, Antiphospholipid antibodies negative, Aspartate aminotransferase normal, Balance disorder, Basophil count normal, Beta 2 microglobulin, Bilirubin conjugated normal, Blindness, Blood albumin, Blood alkaline phosphatase normal, Blood bicarbonate, Blood calcium normal, Blood chloride normal, Blood cholesterol normal, Blood creatinine increased, Blood electrolytes, Blood glucose normal, Blood immunoglobulin M, Blood magnesium normal, Blood potassium normal, Blood sodium normal, Blood triglycerides normal, Blood urea normal, Brain death, Cardiolipin antibody, Cerebrovascular accident, Computerised tomogram head, Eosinophil count decreased, Full blood count, Glomerular filtration rate normal, Haematocrit decreased, Haemoglobin normal, Heart rate decreased, Hypotension, Lymphocyte count normal, Mean cell volume, Metabolic function test, Monocyte count decreased, Nausea, Neutrophil count normal, Platelet count normal, Protein total normal, Red blood cell count increased, Red blood cell sedimentation rate normal, SARS-CoV-2 test negative, Troponin I increased, Vomiting, White blood cell count
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad), Vestibular disorders (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Famotidine tums tumeric garlic C50 Vitamin B multivitamin
Current Illness: none
Preexisting Conditions: none
Allergies: laytex, narcotic pain meds, gabapentin,
Diagnostic Lab Data: Metabolic/Electrolyte Panel May 6, 2021 CT HEAD WITHOUT IV CONTRAST May 5, 2021 Complete Blood Count May 5, 2021 CARDIOLIPIN ANTIBODY May 4, 2021 BETA 2 GP1 AB, IGM/IGG, S May 4, 202 Metabolic/Electrolyte Panel May 6, 2021 Potassium, P 4.0 mmol/L 3.6 - 5.2 mmol/L Sodium, P 137 mmol/L 135 - 145 mmol/L Chloride, P 104 mmol/L 98 - 107 mmol/L Bicarbonate, P 24 mmol/L 22 - 29 mmol/L Anion Gap, P 9 7 - 15 BUN, P 14 mg/dL 8 - 24 mg/dL Creatinine, P 1.25 mg/dL 0.74 - 1.35 mg/dL Calcium, Total, P 9.2 mg/dL 8.6 - 10.0 mg/dL Glucose, P 129 mg/dL 70 - 140 mg/dL CT HEAD WITHOUT IV CONTRAST May 5, 2021 FINDINGS: Large region of encephalomalacia involving the central and inferior right cerebellar hemisphere appears similar when compared with 05/04/2021 consistent with an evolving large right cerebellar hemisphere. No new infarcts. No intracranial hemorrhage, mass, mass effect, shift of the midline structures, ventriculomegaly, or new infarcts. Osseous structures are negative. Soft tissues within normal limits. No change. Complete Blood Count May 5, 2021 Hemoglobin 13.9 g/dL 13.2 - 16.6 g/dL Hematocrit 40.5 % 38.3 - 48.6 % Erythrocytes 4.48 x10(12)/L 4.35 - 5.65 x10(12)/L MCV 90.4 fL 78.2 - 97.9 fL RBC Distrib Width 11.9 % 11.8 - 14.5 % Platelet Count 224 x10(9)/L 135 - 317 x10(9)/L Leukocytes 8.7 x10(9)/L 3.4 - 9.6 x10(9)/L Neutrophils 5.78 x10(9)/L 1.56 - 6.45 x10(9)/L Lymphocytes 2.02 x10(9)/L 0.95 - 3.07 x10(9)/L Monocytes 0.74 x10(9)/L 0.26 - 0.81 x10(9)/L Eosinophils 0.09 x10(9)/L 0.03 - 0.48 x10(9)/L Basophils 0.05 x10(9)/L 0.01 - 0.08 x10(9)/L CARDIOLIPIN ANTIBODY May 4, 2021 Phospholipid Ab IgM, S <9.4 MPL <15.0 (Negative) MPL Phospholipid Ab IgG, S <9.4 GPL <15.0 (Negative) GPL General Information BETA 2 GP1 AB, IGM/IGG, S May 4, 2021 Beta 2 GP1 Ab IgG, S <9.4 U/mL <15.0 (Negative) U/mL Beta 2 GP1 Ab IgM, S <9.4 U/mL <15.0 (Negative) U/mL CT HEAD WITHOUT IV CONTRAST May 4, 2021 Routine CT of the head without contrast. No acute intracranial hemorrhage. No midline shift or mass effect. Mild central volume loss. Ventricles are mildly prominent, but are not significantly changed in the interval. Basilar cisterns are patent. No significant change in appearance of the fourth ventricle. Poorly defined area of decreased attenuation is identified throughout the right cerebellum, representing an area of evolving infarct. This has progressed compared to the CT from 5/2/2021. There is associated vasogenic edema and some mass effect. However, there is not significant change in morphology of the fourth ventricle. Some mass effect extends across the midline. No definite extra-axial fluid collection. Mild mucosal thickening along the paranasal sinuses. Complete Blood Count May 4, 2021 Hemoglobin 13.9 g/dL 13.2 - 16.6 g/dL Hematocrit 40.7 % 38.3 - 48.6 % Erythrocytes 4.44 x10(12)/L 4.35 - 5.65 x10(12)/L MCV 91.7 fL 78.2 - 97.9 fL RBC Distrib Width 12.0 % 11.8 - 14.5 % Platelet Count 225 x10(9)/L 135 - 317 x10(9)/L Leukocytes 8.0 x10(9)/L 3.4 - 9.6 x10(9)/L Neutrophils 4.81 x10(9)/L 1.56 - 6.45 x10(9)/L Lymphocytes 2.37 x10(9)/L 0.95 - 3.07 x10(9)/L Monocytes 0.71 x10(9)/L 0.26 - 0.81 x10(9)/L Eosinophils 0.09 x10(9)/L 0.03 - 0.48 x10(9)/L Basophils 0.04 x10(9)/L 0.01 - 0.08 x10(9)/L Metabolic/Electrolyte Panel May 4, 2021 Potassium, P 3.7 mmol/L 3.6 - 5.2 mmol/L Sodium, P 140 mmol/L 135 - 145 mmol/L Chloride, P 107 mmol/L 98 - 107 mmol/L Bicarbonate, P 23 mmol/L 22 - 29 mmol/L Anion Gap, P 10 7 - 15 BUN, P 14 mg/dL 8 - 24 mg/dL Creatinine, P 1.24 mg/dL 0.74 - 1.35 mg/dL eGFR Black 73 mL/min/BSA $g=60 mL/min/BSA ----ADDITIONAL INFORMATION---- Estimated GFR calculated using the 2009 CKD_EPI creatinine equation. eGFR Non-Black 63 mL/min/BSA $g=60 mL/min/BSA ----ADDITIONAL INFORMATION---- Estimated GFR calculated using the 2009 CKD_EPI creatinine equation. Calcium, Total, P 8.9 mg/dL 8.6 - 10.0 mg/dL Glucose, P 114 mg/dL 70 - 140 mg/dL MR BRAIN WITHOUT IV CONTRAST May 3, 2021 FINDINGS: Noncontrast brain MRI shows a large region of diffusion restriction, dark ADC signal involving the inferior right cerebellar hemisphere extending to the superior lateral right cerebellar hemisphere consistent with acute ischemia. There is some increased FLAIR, T2 signal noted. There is no evidence for petechial hemorrhage by MRI at this time. There is no structural abnormality Scattered areas of white matter signal in the cerebral hemispheres consistent with mild leukoaraiosis No supratentorial ischemia. There is no midline shift. Intervals are normal in size. The extracranial structures are unremarkable in appearance. IMPRESSION: 1. Moderate size region of acute ischemia right cerebellar hemisphere with associated mild increased FLAIR, T2 signal, no MRI changes for petechial hemorrhage at this time. 2. Minimal white matter signal changes consistent with leukoaraiosis. Noncontrast brain MRI otherwise negative ECHO TRANSTHORACIC (TTE)May 3, 2021 Fasting Lipid (Cholesterol) Screening May 3, 2021 Cholesterol, Total, P 162 mg/dL mg/dL ----REFERENCE VALUE---- Desirable: < 200 Borderline high: 200 - 239 High: $g or = 240 Triglycerides, Fasting, P 137 mg/dL mg/dL ----REFERENCE VALUE---- Normal: <150 Borderline high: 150-199 High: 200-499 Very high: $g or =500 Cholesterol, HDL, P 33 mg/dL $g=40 mg/dL L Calculated LDL 102 mg/dL mg/dL ----REFERENCE VALUE---- Desirable: <100 Above Desirable: 100-129 Borderline high: 130-159 High: 160-189 Very high: $g or =190 Non HDL Cholesterol 129 mg/dL mg/dL ----REFERENCE VALUE---- Desirable: <130 Above Desirable: 130-159 Borderline high: 160-189 High: 190-219 Very high: $g or =220 Complete Blood Count May 3, 2021 Hemoglobin 13.8 g/dL 13.2 - 16.6 g/dL Hematocrit 40.1 % 38.3 - 48.6 % Erythrocytes 4.42 x10(12)/L 4.35 - 5.65 x10(12)/L MCV 90.7 fL 78.2 - 97.9 fL RBC Distrib Width 12.0 % 11.8 - 14.5 % Platelet Count 220 x10(9)/L 135 - 317 x10(9)/L Leukocytes 9.9 x10(9)/L 3.4 - 9.6 x10(9)/L H Neutrophils 6.74 x10(9)/L 1.56 - 6.45 x10(9)/L H Lymphocytes 2.21 x10(9)/L 0.95 - 3.07 x10(9)/L Monocytes 0.82 x10(9)/L 0.26 - 0.81 x10(9)/L H Eosinophils 0.09 x10(9)/L 0.03 - 0.48 x10(9)/L Basophils 0.05 x10(9)/L 0.01 - 0.08 x10(9)/L Hemoglobin A1C (Average Blood Sugar)May 3, 2021 Hemoglobin A1c, B 5.8 % SARS Coronavirus 2, PCR Rapid, V May 2, 2021 undetected SARS Coronavirus 2, PCR, V May 2, 2021 undetected CT HEAD NECK ANGIOGRAM WITH IV CONTRAST May 2, 2021 EXAM: CT HEAD NECK ANGIOGRAM WITH IV CONTRAST Including 3-D image postprocessing. COMPARISON: CT May 2, 2021. FINDINGS: Right carotid system: Normal. Left carotid system: Normal. Vertebral arteries: Normal. Left dominant. Aortic arch: Unremarkable. Intracranial: Anterior, middle and posterior cerebral arteries are well opacified with contrast. No evidence of a stenosis or aneurysm. Nonvascular findings: Focal loss of gray-white matter differentiation in the right cerebellar hemisphere as well as a chronic right cerebellar lacunar infarct. Measurement of a carotid stenosis, if present, is based on length parameters that compare the residual internal carotid luminal diameter with that of the normal distal ICA in accordance with North American Symptomatic Carotid Endarterectomy Trial (NASCET). IMPRESSION: 1. There is now evidence of focal loss of gray-white matter differentiation in the right cerebellar hemisphere, likely related to acute infarct. 2. Negative CT angiogram of the head and neck. TROPONIN T, 2H/6H, P May 2, 2021 Troponin T, 2 hr, 5th gen 7 ng/L <=15 ng/L Biotin has been identified by the manufacturer as a potential interfering substance. Higher concentrations of biotin may be found in multivitamins, hair/nail supplements, and workout supplements. If the result does not match clinical observations, repeat testing after patient refrains from the use of supplements for at least 12 hours. 2H Delta 0 ng/L ng/L 2H Delta Interp Not Changing Troponin T, 6 hr, 5th gen CANCELED ng/L ng/L CT HEAD WITHOUT IV CONTRAST May 2, 2021 FINDINGS: There is no evidence of acute intracranial hemorrhage. There is no intracranial mass. There is no midline shift. Ventricles and sulci appear within normal limits. There is no evidence of acute infarction. IMPRESSION: No acute findings or evidence of an intracranial mass. Complete Blood Count May 2, 2021 Hemoglobin 14.8 g/dL 13.2 - 16.6 g/dL Hematocrit 43.2 % 38.3 - 48.6 % Erythrocytes 4.88 x10(12)/L 4.35 - 5.65 x10(12)/L MCV 88.5 fL 78.2 - 97.9 fL RBC Distrib Width 11.9 % 11.8 - 14.5 % Platelet Count 240 x10(9)/L 135 - 317 x10(9)/L Leukocytes 11.3 x10(9)/L 3.4 - 9.6 x10(9)/L H Neutrophils 9.70 x10(9)/L 1.56 - 6.45 x10(9)/L H Lymphocytes 0.96 x10(9)/L 0.95 - 3.07 x10(9)/L Monocytes 0.55 x10(9)/L 0.26 - 0.81 x10(9)/L Eosinophils <0.03 x10(9)/L 0.03 - 0.48 x10(9)/L Basophils 0.05 x10(9)/L 0.01 - 0.08 x10(9)/L Extended Metabolic/Electrolyte panel May 2, 2021 Potassium, P 3.9 mmol/L 3.6 - 5.2 mmol/L Sodium, P 141 mmol/L 135 - 145 mmol/L Chloride, P 105 mmol/L 98 - 107 mmol/L Bicarbonate, P 25 mmol/L 22 - 29 mmol/L Anion Gap, P 11 7 - 15 BUN, P 15 mg/dL 8 - 24 mg/dL Creatinine, P 1.26 mg/dL 0.74 - 1.35 mg/dL eGFR Black 72 mL/min/BSA $g=60 mL/min/BSA ----ADDITIONAL INFORMATION---- Estimated GFR calculated using the 2009 CKD_EPI creatinine equation. eGFR Non-Black 62 mL/min/BSA $g=60 mL/min/BSA ----ADDITIONAL INFORMATION---- Estimated GFR calculated using the 2009 CKD_EPI creatinine equation. Calcium, Total, P 9.8 mg/dL 8.6 - 10.0 mg/dL Glucose, P 170 mg/dL 70 - 140 mg/dL H Protein, Total, P 6.9 g/dL 6.3 - 7.9 g/dL Albumin, P 4.2 g/dL 3.5 - 5.0 g/dL Aspartate Aminotransferase (AST), P 28 U/L 8 - 48 U/L Alkaline Phosphatase, P 79 U/L 40 - 129 U/L Alanine Aminotransferase (ALT), P 27 U/L 7 - 55 U/L Bilirubin, Total, P 1.0 mg/dL <=1.2 mg/dL TROPONIN T, BASELINE, 5TH GEN, P May 2, 2021 Troponin T, Baseline, 5th gen 7 ng/L <=15 ng/L Magnesium Level May 2, 2021 Magnesium, P 2.0 mg/dL 1.7 - 2.3 mg/dL SALICYLATE LEVEL May 2, 2021 Salicylate, P <0.3 mg/dL <30.0 mg/dL ECG May 2, 2021 Ventricular Rate ECG/Min 66 BPM BPM PR Interval 198 ms ms QRSD Interval 86 ms ms QT Interval 418 ms ms QTC Interval 438 ms ms P Axis 35 degrees degrees R Axis 45 degrees degrees T Wave Axis 29 degrees degrees
CDC Split Type:

Write-up: stroke on 5/2 8:45 am hospitalized 5 days no physiologiical explanation. 3/4 of right cerebellum is dead. at onset nausea vomiting vision loss, loss of balance and coordination BP bottomed out low heartrate while sleepiing

VAERS ID:	1300903 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-03-31
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-05-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8733 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Epistaxis, Platelet count normal
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Write-up: Developed severe nosebleed 23 hours and 30 minutes after receiving vaccine. Bleeding time OK but platelet count on the low side (165,000)

VAERS ID:	1302016 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-04-13
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-05-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	038B21A / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Hyponatraemia, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad)

Write-up: Patient presented the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination. Diagnosis was hyponatremia and intractable vomiting.

VAERS ID:	1302404 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-20
Onset:	2021-04-20
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0169 / 1	RA / SYR

Administered by: Unknown Purchased by: ?
Symptoms: Burning sensation, Headache, Limb discomfort, Limb injury, Neck pain, Pain in jaw, Painful respiration, Toothache
SMQs:, Peripheral neuropathy (broad), Accidents and injuries (narrow), Osteonecrosis (broad), Arthritis (broad)

Write-up: Day of shot within 1 hour Felt like my arm was dislocated for several days. Still feeling discomfort. Day 3 Extreme burning in lower jaw with pain also similar to toothache and all teeth and lower jaw. Eventually extended throughout my neck and lower part of my head. Inhaling felt like stabbing in lower neck and a three and four.

VAERS ID:	1302438 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-04-30
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-05-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	FW0172 / 1	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-30
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lorazepam, furosemide, isosorbide mononitrate, carvedilol, buspirone, potassium chloride
Current Illness: Patient had been sick and in the hospital for a period of time prior to her vaccination. She had ''internal bleeding'' from an unknown source according to her husband. On May 3 patient''s husband called the pharmacy to report that patient had passed away on April 30. He did not give any reasons for her death or any symptoms prior to her passing. Patient was well known and like by our pharmacy staff.
Preexisting Conditions: Patient had anxiety, high blood pressure, heart conditions, and p/h of internal bleeding.
Allergies: no known allergies
Diagnostic Lab Data: not known to the staff
CDC Split Type:

Write-up: Patient received the first Pfizer immunization on 4-22-2021. She passed away on 4-30-2021. Her husband notified the pharmacy. Patient had been hospitalized for a period of time before the vaccination for ''bleeding internally'' due to an unknown cause.

VAERS ID:	1302442 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-19
Onset:	2021-04-07
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-05-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED within 6 weeks of receiving COVID vaccination. She was subsequently admitted.

VAERS ID:	1303476 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-29
Onset:	2021-04-12
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-05-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / IM

Administered by: Other Purchased by: ?
Symptoms: Retinal haemorrhage, Retinal vein thrombosis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Retinal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Computer is the source for the following medication list: INSULIN NPH HUMAN 100 UNIT/ML NOVOLIN N Sig: INJECT 23 UNITS UNDER THE SKIN TWICE A DAY FOR DIABETES FINASTERIDE 5MG TAB Sig: TAKE ONE TABLET BY MOUTH EVERY DAY FOR PROSTATE ME
Current Illness:
Preexisting Conditions: 2. Fall 3. Cough at night 2nd to phlegm 4. Lymphedema 5. Benign prostatic hyperplasia Prostate Cancer 2007 6. Gastroparesis due to diabetes mellitus 7. Gout 8. History of adenomatous polyp of colon, Onset 05/15/20 Tubular adenoma. Repeat Colonoscoy 2022 9. Constipation (SCT 14760008) 10. Insomnia 11. Atrial fibrillation On Anticoagulation - Warfarin 12. CKD stage 4 13. Proteinuria 14. Hyperuricemia 15. Secondary hyperparathyroidism 16. Diabetes mellitus 17. Benign hypertensive heart disease and chronic renal disease stage 3 18. Obesity
Allergies: Sulfamethoxazol/trimethoprim Tuberculin
Diagnostic Lab Data: Exam by ophthalmology
CDC Split Type:

Write-up: Central retinal vein thrombosis with associated retinal hemorrhage. Started the week after vaccination. Identified by opthalmology on 4/12/21

VAERS ID:	1303640 (history)
Form:	Version 2.0
Age:	19.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-05
Onset:	2021-05-07
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Catheterisation cardiac normal, Chest pain, Electrocardiogram normal, Troponin, Ultrasound scan normal
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: Patient started having chest pain on Friday night. The pain increased throughout the night. The next morning we took him to the emergency room. He was admitted to the hospital and remained there until Monday afternoon.

VAERS ID:	1305990 (history)
Form:	Version 2.0
Age:
Sex:	Unknown
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-05-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Kidney infection, Nephrolithiasis
SMQs:

Write-up: Kidney infection; Kidney stones; This is a spontaneous report from a Pfizer-sponsored program . A contactable consumer reported for patient. A patient of unspecified age and gender received second dose of BNT162b2 (PFIZER-BIONTECH COVID-19 VACCINE; Solution for injection; Lot number and expiration date unknown), via unspecified route of administration on 14Mar2021 at a single dose for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. On an unspecified date, the patient developed kidney infection and kidney stones and hospitalized after receiving 2nd dose. The outcome of the events were unknown. No follow-up attempts are needed; information about lot/batch number cannot be obtained.

VAERS ID:	1305999 (history)
Form:	Version 2.0
Age:
Sex:	Unknown
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-05-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Kidney infection, Nephrolithiasis
SMQs:

Write-up: Kidney infection; Kidney stones; This is a spontaneous report from a contactable consumer. This contactable consumer reported for a patient that stating that received second dose of bnt162b2 (BNT162B2; formulation: solution for injection; Lot number and expiration date were not reported) via an unspecified route of administration, on an unknown as single dose for COVID-19 immunization. The patient medical history and concomitant medications were not reported. Consumer reported that two of my relatives developed kidney infection and kidney stones and hospitalization after receiving second dose. Information about lot/batch number has been requested.

VAERS ID:	1306335 (history)
Form:	Version 2.0
Age:	21.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-08
Onset:	2021-05-11
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Echocardiogram abnormal, Ejection fraction decreased, Electrocardiogram, Myocarditis, Troponin increased
SMQs:, Cardiac failure (narrow), Myocardial infarction (narrow), Cardiomyopathy (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Myopericarditis requiring hospital admission. Elevated trop and decreased EF on ECHO.

VAERS ID:	1307182 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-24
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-05-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	038B21A / 1	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Back pain, Biopsy bone marrow, Biopsy spinal cord, CSF protein increased, Chemotherapy, Diffuse large B-cell lymphoma, Guillain-Barre syndrome, Immunoglobulin therapy, Lumbar puncture abnormal, Muscular weakness, Paraplegia, Spinal compression fracture, Spinal stenosis
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Guillain-Barre syndrome (narrow), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Demyelination (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Osteoporosis/osteopenia (broad), Malignant lymphomas (narrow), Haematological malignant tumours (narrow), Immune-mediated/autoimmune disorders (narrow)

Write-up: Patient presented to the outside hospital on 4/27/21 with lower extremity weakness which progressed to paralysis and back pain (which had been intermittent since Dec. 2020), but had started to become persistent and rapidly worsen starting around 4/24/21. Patient subsequently transferred to HCF on 4/28/21 for concerns of Guillain-Barr? syndrome with recent COVID-19 vaccination (Moderna: first dose on 4/14/21) with lower extremity paraplegia lack of deep tendon reflexes. Unable to perform MRI due to type of pacemaker that patient has. Lumbar puncture done 5/1/21 was consistent with Guillain-Barr? with elevated protein. However, patient had minimal improvement in symptoms despite full 5-day course of IVIG. During her hospitalization, concern emerged for central compression and after further imaging patient was subsequently found to have a T8 compression fracture, spinal mass, and severe spinal canal stenosis at the level of the compression fracture. Spinal biopsy completed suggestive of DLBCL. Hematology/Oncology were consulted, and chemotherapy initiated. Bone marrow biopsy done on 5/7/21 with results pending as of 5/11/21.

VAERS ID:	1307341 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-05
Onset:	2021-05-06
Days after vaccination:	121
Submitted:	0000-00-00
Entered:	2021-05-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011L20A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Cough, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: 5/6/2021-symptomatic with Covid symptoms of fever, cough. 5/10/2021-admitted to Hospital for Covid 19 issues.

VAERS ID:	1307670 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-26
Onset:	2021-05-04
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-05-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram cerebral normal, Aortic valve incompetence, Aortic valve sclerosis, Arteriogram carotid normal, Atrial enlargement, Cerebral small vessel ischaemic disease, Cerebrovascular accident, Computerised tomogram head normal, Diastolic dysfunction, Echocardiogram abnormal, Lacunar infarction, Left ventricular hypertrophy, Mitral valve incompetence, Mitral valve prolapse, Speech disorder, Tricuspid valve incompetence
SMQs:, Cardiac failure (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Pulmonary hypertension (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad)

Write-up: Patient admitted on 5/5/21 for suspected acute ischemic CVA after presenting with altered speech for a day (last known well on 5/4/21 PM). No CT evidence of an acute intracranial process. Her pacemaker precluded MRI evaluation. Pacer interrogated on 5/6/21 with AT/AF burden <0.1%. She was seen in consultation by neurology. Evaluation and clinical deficits were suggestive of acute ischemic CVA. Risk factors for CVA include age, HTN, Afib. Patient recently received her first COVID-19 vaccine (Pfizer) on 4/26/21. Patient?s symptoms improving with antiplatelet and statin therapies along with blood pressure management. Per Neurology consult, possible etiologies include cardioembolic versus atheroembolic versus thrombotic versus inflammatory related to recent COVID-19 vaccine. The neurologist specifically stated that ?The COVID vaccine was temporally close to this event. I have seen transient CNS inflammation from the vaccine--probability low but still possibility.?

VAERS ID:	1308069 (history)
Form:	Version 2.0
Age:	37.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-09
Onset:	2021-04-27
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-05-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	LA / SYR

Administered by: Public Purchased by: ?
Symptoms: Guillain-Barre syndrome, Lumbar puncture
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Write-up: Developed Guillian Barre

VAERS ID:	1309546 (history)
Form:	Version 2.0
Age:
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-05-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	LA / -

Administered by: Unknown Purchased by: ?
Symptoms: Headache, Hypoaesthesia, Malaise, Pain in extremity, Peripheral swelling, Swelling of eyelid, Urticaria
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (narrow), Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Periorbital and eyelid disorders (narrow), Hypersensitivity (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: none
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021469625

Write-up: Extreme swelling and pain in both hands; Extreme swelling and pain in both hands; numbness; Left eyelid swelling; Hives on head and stomach; not feeling well; headache; This is spontaneous report received from a contactable consumer (patient). A 29-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Batch/Lot Number: EW0150), via an unspecified route of administration, administered in Arm Left on an unspecified date in 2021 (pending clarification) as 2ND DOSE, SINGLE for Covid-19 immunization. The patient was not pregnant at the time of vaccination. The patient has no medical history. Concomitant medication included birth control (unspecified). The patient was not diagnosed with COVID-19 prior to vaccination. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. The patient experienced extreme swelling and pain in both hands, and numbness. The patient also experienced left eyelid swelling, hives on head and stomach, generally not feeling well, and non-stop headache. The event onset date was not reported (pending clarification). There was no treatment received for the adverse event. The adverse events resulted in disability or permanent damage. The patient has not been tested for COVID-19 since the vaccination. The outcome of events was not recovered. Information on lot/batch number was available. Additional information has been requested.

VAERS ID:	1310012 (history)
Form:	Version 2.0
Age:	27.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-04-25
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Acute myocardial infarction, Chest pain, Echocardiogram abnormal, Ejection fraction decreased, Electrocardiogram abnormal, Headache, Pain in jaw, Pericarditis, Vomiting
SMQs:, Cardiac failure (narrow), Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (narrow), Osteonecrosis (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Patient reported chest pain for 2 days and intermittent jaw pain after receiving his second Pfizer COVID vaccine on 4/22, and presented to the ER on 4/25 with a headache and emesis. An ECHO was performed and LVEF was 45%, and an EKG showed possible ST elevation. Per the Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine study there were no reports of STEMI being an adverse effect. Given the patient''s ejection fraction of 45%, there was likely a prior medical condition the patient was unaware of and may have precipitated the STEMI rather than the vaccine . Hospitalized for 2 days and diagnosed with pericarditis.

VAERS ID:	1310183 (history)
Form:	Version 2.0
Age:	37.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-09
Onset:	2021-04-13
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-05-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0518 / 1	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Abdominal pain, Angiogram pulmonary abnormal, Anticoagulant therapy, Chest X-ray, Computerised tomogram abdomen, Cough, Dyspnoea, Pneumonia, Pulmonary embolism, Scan with contrast
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: Chest x-ray 04/14/2021, CT ABDOMEN PELVIS WITH IV CONTRAST 04/15/2021, CT Chest Angiogram and Pulmonary Arteries with IV Contrast 05/04/2021
CDC Split Type:

Write-up: Cough, abdominal pain, pneumonia, shortness of breath, multiple subsegmental pulmonary embolism, Lovenox shots, warfarin, antibiotics, nebulizer treatments, albuterol.

VAERS ID:	1310469 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-26
Onset:	2021-05-06
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-05-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 1	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Hemiparesis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Write-up: Client went to Emergency Room with right sided weakness on 5/6/2021. He was admitted for full evaluation and follow up.

VAERS ID:	1310910 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-11
Onset:	2021-05-11
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001BZ1A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Gait disturbance, Guillain-Barre syndrome, Hypoaesthesia, Muscular weakness, Paraesthesia, Plasmapheresis
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (narrow), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalopathy/delirium (broad), Demyelination (narrow), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: On 4/27, patient began to experience tingling/numbness in feet and hands. This progressed to weakness of the extremities, affecting patient''s ability to walk. He presented to the hospital on 4/30 and was admitted with a diagnosis of Guillain Barre syndrome. He was treated with plasmapheresis, and has been clinically improving with this. Patient was discharged to inpatient rehabilitation on 5/5, and remains there as of this report. Certainly unclear if the vaccine had any role in the onset of GBS, but given the concern with other vaccines, am reporting this in case other similar reports can create a measurable trend.

VAERS ID:	1311739 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-04-09
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-05-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	LA / SYR

Administered by: Other Purchased by: ?
Symptoms: Acoustic stimulation tests, Audiogram, Deafness unilateral
SMQs:, Hearing impairment (narrow)

Write-up: Nine days after 2nd shot, sudden, nearly complete hearing loss occurred in right ear, which previously was within normal hearing ranges.

VAERS ID:	1314042 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-02-28
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 2	AR / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Amnesia, Anaemia, Arthralgia, Asthenia, Dehydration, Fall, Fatigue, Gait disturbance, Haematocrit decreased, Haemoglobin decreased, Leukocytosis, Mobility decreased, Monocyte count abnormal, Pain in extremity, Platelet count normal, Rhabdomyolysis, Thermal burn, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (narrow), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (broad), Peripheral neuropathy (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (narrow)

Write-up: Patient was in his usual state of health and independent with his ADLs until 2-3 days after his 2nd COVID vaccination on Feb 26th when he began to have bilateral knee and LE pain. He then was having difficulty walking for a couple of weeks. The leg pain was not constant, but he did fatigue easily with walking. On 3/11 he had his lower dentures placed and that evening/early morning of 3/12 he apparently fell. Patient does not remember anything about the fall - he cannot recall when he fell, how he fell, or any of his symptoms leading up to the fall. Patient remembers being on the floor and attempting to get up but was too weak. He has rug burns on his forearms from attempting to get up. He was hospitalized on 3/13 for dehydration, traumatic rhabdomyolysis, and w/u following fall. Despite very stable labs prior to 1st dose of vaccination on 2/5/21, following vaccination he has had significant and substained leukocytosis as well as transfusion dependent anemia that has not resolved at the time of the reporting (5/13/21). He remains at a skilled nursing facility due to debility.

VAERS ID:	1314113 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-19
Onset:	2021-05-09
Days after vaccination:	79
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 1	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Dizziness, Dyspnoea, Pulmonary function test, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (broad), COVID-19 (broad)

Write-up: Patient presented to Hospital emergency room on 5/10/2021 with shortness of breath and dizziness. He had tested for Covid on 5/9/2021 for a pre procedure for a pulmonary function test. It is stated that he feels slightly short of breath chronically at baseline. Patient also notes occasional dizziness. No other symptoms.

VAERS ID:	1314215 (history)
Form:	Version 2.0
Age:	81.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-14
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1314403 (history)
Form:	Version 2.0
Age:	35.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-29
Onset:	2021-04-29
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	044B21A / 1	RA / SYR

Administered by: Other Purchased by: ?
Symptoms: Chills, Fatigue, Headache, Hyperhidrosis, Injected limb mobility decreased, Pain, Pain in extremity, Pyrexia, Skin tightness
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Irregular menstrual cycle.
Preexisting Conditions: Depression, Anxiety, PTSD, OCD, Delayed Gastric Emptying.
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: For 1.5 days: had headache, body aches especially legs, fever, severe chills, sweats, fatigue, and severe right arm pain throbbing and unable to use or move it. For 3 days: severe right arm pain and unable to move or use. Ongoing: still having right arm pain and tightness as well as restricted movement.

VAERS ID:	1314511 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-15
Onset:	2021-03-08
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	042L20A / 2	AR / IM

Administered by: Private Purchased by: ?
Symptoms: Cerebral ischaemia, Computerised tomogram head abnormal, Death, Generalised tonic-clonic seizure, Headache, Laboratory test normal, Lactic acidosis, Unresponsive to stimuli
SMQs:, Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Ischaemic central nervous system vascular conditions (narrow), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-12
Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol, eliquis, buspirone, atorvastatin, duloxetine, tylenol, ibuprofen.
Current Illness: None.
Preexisting Conditions: CVA, A-fib, HTN, DM 2, dyslipidemia.
Allergies: NKDA, no other allergies.
Diagnostic Lab Data: In the ER on 3/8/21, head CT was done and labs were drawn. DX: lactic acidosis, tonic clonic seizures, acute ischemia left parioto-occipital lobe.
CDC Split Type:

Write-up: had severe headaches that started a week after his 2nd covid shot., he was seen by NP on 2/25/21, was instructed to take ibuprofen short term, labs were drawn and were normal. On 3/8/21 suffered tonic clonic seizures, was unresponsive and taken to ER by EMS. remained unresponsive following the seizures and was placed on hospice care and died on 3/12/21.

VAERS ID:	1314691 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-27
Onset:	2021-05-08
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	206A21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Asthenia, Blood bilirubin increased, Chronic sinusitis, Contusion, Decreased appetite, Deep vein thrombosis, Dyspnoea exertional, Epistaxis, Fatigue, Haemoglobin normal, Headache, International normalised ratio increased, Lacunar infarction, Lymphocyte percentage decreased, Muscular weakness, Neutrophil percentage increased, Pain in extremity, Paranasal sinus inflammation, Platelet count decreased, Rhinorrhoea, Skin discolouration, Thrombocytopenia, Visual impairment, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Acute pancreatitis (broad), Haematopoietic leukopenia (broad), Haematopoietic thrombocytopenia (narrow), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Biliary system related investigations, signs and symptoms (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: History of Present Illness: Patient has a history of sinus problems. He was schedule for sinuplasty and had preoperative evaluation on 04/21/2021 with WBC 5.8, Hb 15.5, PLT 193,000. He had J&J covid vaccination on 04/27/2021. He underwent sinuplasty on 05/05/2021. Subsequent to his surgery he was having headache. He had some nasal discharge with blood. He took tramadol but had persistent pain. His symptoms were worsening up with some weakness of his right upper extremity. Was having generalized fatigue and weakness. He states he was getting short of breath with a flight of stairs. He had decreased appetite. He was given Vicodin for his headache with some improvement. He noted discoloration and bruising with pain pain in his left internal thigh area. Was noticing some changes in his vision but no loss of vision. He presented to the ED on 05/11/2021 and laboratory showed WBC 8.7 Hb15.2, PLT 6,000, segs 77%, lymphs 9%. He had no dark colored urine. INR 1.4 PTT 33, immature platelets 30.2. His bili was 2.1. He was treated with dexamethasone 40 mg. There is tiny focus of restricted diffusion in the both cerebellar hemispheres measuring up to 0.4 cm white matter left cerebellar hemisphere of left parietal junction measuring 0.5 cm compatible small lacunar infarcts. Chronic paranasal sinusitis. Patient described minimal blood with flushing his sinuses. Patient was ultimately transferred to Hospital after 3 days (on 5/11) for further acute care management given the multiple clots and bleeds associated with severe thrombocytopenia.

VAERS ID:	1315645 (history)
Form:	Version 2.0
Age:	16.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-24
Onset:	2021-04-25
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 1	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Abdominal pain upper, Appendicectomy, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Write-up: Constant stomach pain , and vomiting - symptoms occurred 24 hours after injection of 1st vaccine shot.

VAERS ID:	1315776 (history)
Form:	Version 2.0
Age:
Sex:	Male
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-05-12
Submitted:	0000-00-00
Entered:	2021-05-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / UNK	- / -

Administered by: Other Purchased by: ?
Symptoms: Pulmonary thrombosis
SMQs:, Embolic and thrombotic events, venous (narrow)

Write-up: CLOT IN LUNGS; This spontaneous report received from a pharmacist concerned a 58 year old male. The patient''s height, and weight were not reported. The patient''s pre-existing medical conditions included unknown. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported and batch number: 043A21A expiry: UNKNOWN) dose was not reported, administered on 06-APR-2021 for prophylactic vaccination. No concomitant medications were reported. On 12-MAY-2021, the patient experienced clot in lungs, and was hospitalized (date unspecified). The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient had not recovered from clot in lungs. This report was serious (Hospitalization Caused / Prolonged).; Sender''s Comments: V0 : 20210522762 - Covid-19 vaccine ad26.cov2.s - CLOT IN LUNGS . This event(s) is considered unassessable. The event(s) has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event(s).

VAERS ID:	1316063 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-15
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / -

Administered by: Unknown Purchased by: ?
Symptoms: Dysphagia, Dysphonia, Heart rate, Hypersensitivity, Investigation, Throat irritation, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: My throat was itchy/my throat felt worse; My throat was itchy in between that half hour my voice started to change; my throat felt worse; I have wheezing in my lungs; I am allergic to them/ Severe reactions and had to be hospitalized overnight; had problem swallowing a little bit and voice changes after talking; This is a spontaneous report from a contactable consumer. A 60-years-old female patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, lot number and expiration date were not reported), via an unspecified route of administration, administered in Arm Left on 15Mar2021 (Age at Vaccination 60 year), as single dose for covid-19 immunisation. Medical history of the patient included anxiety, depression, nerve pain, ongoing blood pressure (hypertension), change in personality and cardiac disorder. Concomitant medication of the patient included levothyroxine, atorvastatin calcium (cholestat [atorvastatin calcium]), pantoprazole, 1300mg fluconazole (Fluxizol), 81mg aspirin, lubiprostone (Amitiza), alpha lipoic acid, baclofen, linezolid (Zenix [linezolid]), centrum silver, 10mg rosuvastatin calcium (Crestor), 100mg docusate sodium (stool softener), amlodipine and magnesium oxide for blood pressure. Patient was on Benazepril HCTZ for heart, Pristiq for anxiety or depression, citalopram for pain (something to do with pain I can''t remember), Effexor for Anxiety, Lexapro, Levaquin, and Sulfa for rashes. Patient got it from her bladder infection. Cyclobenzaprine (I can''t remember), Gabapentin, change in personality and nerve pain. Metoprolol for heart. Patient was not taking any of these medications now she got several allergies from them. Patient had a lot of allergies. She was on lot of medications. But it was not what she was taking any these medications on the same, so she was like what was going on. Patient not taking the medication (Unspecified Medication), she was allergic to them, but she was taking other medication. Patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, lot number, PF12ER6200), via an unspecified route of administration, administered in Arm Left on 22Feb2021 (Age at Vaccination 60 year), as single dose for covid-19 immunisation. On 15Mar2021, the patient had severe reactions and had to be hospitalized overnight. Within mild reaction for 15 minutes and within 40 minutes severe. Patient went to have it done at the hospital they walked her down to the ER they get to give her an epi Pen injection into IV." When again probed for the concern, Patient stated, she had it done at the hospital, they after 15 minutes her throat was itchy they may say another half hour in between that half hour her voice started to change and her throat felt worse they walk her down to the ER her throat was hurting then slowly they gave her Epi Pen and they injected in an IV with steroids. Patient had wheezing in her lungs and she spent the night in hospital for observation. Patient stated that she still had problem swallowing a little bit and voice changes after talking. Patient wanted to know it was like how she supposed to find out what she was allergic. Patient further stated, "Because she want to you know she need an update how was it bad so she want to had to go all this what she was allergic. Event outcome for the events swallowing difficult and for voice alteration it was not recovered and for other events it was unknown. Information about lot/batch number has been requested.

VAERS ID:	1316875 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-04
Onset:	2021-05-04
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0173 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Angiogram cerebral normal, Aphasia, Arteriogram carotid normal, Cerebral infarction, Cerebral small vessel ischaemic disease, Cerebrovascular accident, Chest pain, Computerised tomogram head normal, Echocardiogram normal, Headache, Hemiparesis, Hypoaesthesia, Magnetic resonance imaging head abnormal, Muscular weakness, Musculoskeletal discomfort, Paraesthesia, Vitamin D deficiency
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Write-up: ED Note: "presents to the ED via RRT from pre-op after having a left SI injection with complaints of a stroke alert. at 1132 this morning. Per NP from pre-op, the pt received the injection without issue. After the injection she was developed groin numbness, which progressed into a headache, and chest pain. She then became aphasic, with left sided weakness and numbness. BS was 154 at that time. Per husband at bedside, the pt had numbness and tingling after injection but was otherwise at baseline. While the pt was getting dressed, the husband went to get the car. He notes the pt is on Xarelto secondary to PE and has taken it as prescribed. He denies any missed doses but states he is unsure of what time the last dose was. He states that the pt has no lasting deficits from her prior stroke. Of note, the pt is able to respond by nodding yes or no but is unable to speak. Pt able to write on a white board. She states she was taken off the Xarelto 3 months ago. The pt states she is unable to talk. She endorses left arm and leg weakness. The pt states she has a prior stoke years ago with weakness but has no lasting deficits. " Admitted to the hospital Diagnoses: -Dysphasia -Small vessel cerebrovascular disease -Bereavement -Vitamin-D deficiency

VAERS ID:	1317704 (history)
Form:	Version 2.0
Age:	19.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-17
Onset:	2021-04-20
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0164 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Biopsy, Chest discomfort, Computerised tomogram abnormal, Echocardiogram abnormal, Ejection fraction, Fibrin D dimer increased, Hypokinesia, Left ventricular dysfunction, Magnetic resonance imaging, Troponin I increased, Ventricular hypokinesia
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Myocardial infarction (narrow), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Focalin XR 10 mg PO daily
Current Illness: none
Preexisting Conditions: ADHD
Allergies: Allergen Reactions ? Other Anaphylaxis Bee sting ? Venom-Honey Bee Shortness Of Breath ? Sulfa (Sulfonamide Antibiotics) Hives ? Bactrim [Sulfamethoxazole-Trimethoprim] Hives ? Omnicef [Cefdinir] Other (See Comments) Swelling of lips, hands and feet and a rash ? Penicillins Swelling Swelling of lips and face and rash ? Cephalosporins Rash
Diagnostic Lab Data: see above, elevated d-dimer and troponin.
CDC Split Type:

Write-up: developed chest pressure, taken to ED via ambulance. D-dimer and tropinin elevated. CT PE Angio = 5.0 x 3.4 cm soft tissue lesion in the anterior mediastinum which could represent residual thymic tissue although size and convex margins appear greater than expected for age. ECHO = There is mild left ventricular systolic dysfunction. There is mild global hypokinesis. The visually estimated LVEF is 46-51%. The quantitative LVEF based on modified Simpson''s method is 51%. CT consulted, sent for bx of mass, on repeat imaging with MRI had decreased in size so bx canceled. Bx of L axillary node = benign.

VAERS ID:	1317744 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-13
Onset:	2021-05-13
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0186 / 2	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-14
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: ALS
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death

VAERS ID:	1317886 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-03-14
Onset:	2021-03-27
Days after vaccination:	378
Submitted:	0000-00-00
Entered:	2021-05-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Anticoagulant therapy, Asthenia, Cerebrovascular accident, Dysphagia, Dyspnoea, Facial paralysis, Fatigue, Injection site pain, Magnetic resonance imaging, Speech disorder
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hearing impairment (broad)

Write-up: Client during TC, expressed through the telephone Spanish Interpreter, received the J & J COVID 19 vaccine, in left arm, on 3/14/2021. After receiving vaccine had slight soreness at site, and on 3/27/2021 started having left sided facial droopiness, difficulty swallowing, talking, fatigue, SOB and weakness, around 10:00 am. Per Client, children called 911, and was transported to Hospital. Per Client, was treated at hospital and informed by medical personal, that she probably experienced a stroke. Client was not admitted to hospital, sent home the same day, and instructed to follow up with PCP. Per Client, on 3/29/2021 followed up with PCP, and on 5/12/2021 had a MRI procedure and due to fo

VAERS ID:	1317920 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-04-09
Days after vaccination:	23
Submitted:	0000-00-00
Entered:	2021-05-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Acute coronary syndrome, Acute myocardial infarction, Cardiac arrest, Cardiac assistance device user, Coronary arterial stent insertion, Percutaneous coronary intervention, Resuscitation, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Respiratory failure (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: tobacco abuse
Allergies: codeine
Diagnostic Lab Data: He was administered CPR and received shock times 1 with return to sinus rhythm. The patient''s ROSC was achieved in 2 to 3 minutes. Patient went to cath lab for PCI, DES to right coronary artery.
CDC Split Type:

Write-up: Patient developed acute coronary syndrome, ST-elevation myocardial infarction, and ventricular fibrillation cardiac arrest on April 9, 2021. He had no prior history of coronary artery disease.

VAERS ID:	1320381 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-29
Onset:	2021-05-03
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-05-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0179 / 1	LA / OT

Administered by: Pharmacy Purchased by: ?
Symptoms: Atrial fibrillation
SMQs:, Supraventricular tachyarrhythmias (narrow)

Write-up: Patient was hospitalized for an episode of A-fib; This is a spontaneous report from a contactable Pharmacist. This Pharmacist reported for a 55-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTEC COVID-19 mRNA VACCINE, Solution for injection, lot number: EW0179 and expiry date was not reported), via intramuscularly, in Arm Left, on 29Apr2021, as a single dose for COVID-19 immunization. The patient was not pregnant at the time of vaccination. The patient medical history included that she was diagnosed with COVID-19 prior to the vaccination. The patient did not receive any other vaccines within four weeks prior to the COVID vaccine. Concomitant medications included lurasidone hydrochloride (LATUDA), Metoprolol, Lorazepam, rivaroxaban (XARELTO), Quetiapine, Bupropion, Oxybutynin, Atorvastatin, Diltiazem, Losartan, Gabapentin and Furosemide. Since the vaccination, the patient was not tested for COVID-19. It was reported that on 03May2021, the patient was hospitalized for an episode of A-fib which resulted in emergency room/department or urgent care. The patient was hospitalized due to the event from an unspecified date in May2021 to an unspecified date in May2021. Device date was reported as 11May2021. Outcome of the event was recovered with sequel. Information on Lot/Batch number was available. Additional information has been requested.; Sender''s Comments: Based on known drug safety profile, there is reasonable possibility of causal association between the event atrial fibrillation and the suspect drug. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.

VAERS ID:	1320460 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-15
Onset:	2021-05-15
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Arthralgia, Blood test abnormal, Condition aggravated, Neck pain, Pain in extremity, Rheumatoid arthritis
SMQs:, Arthritis (narrow), Tendinopathies and ligament disorders (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: rovastation, metformin, equivan,
Current Illness: none
Preexisting Conditions: diabetes, lymes disease 15 years ago
Allergies: sulfas,, pennacillian
Diagnostic Lab Data: diagnosed with rhematoid arthritis, from blood work.
CDC Split Type:

Write-up: extreme joint pain, shoulders, neck, hands, brought on rheumatoid arthritis, 2n shot excellarated it more.

VAERS ID:	1320975 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-12
Onset:	2021-05-14
Days after vaccination:	32
Submitted:	0000-00-00
Entered:	2021-05-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / 1	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Amnesia, Angiogram, Aphasia, Computerised tomogram head normal, Computerised tomogram neck, Diplopia, Dysarthria, Facial paralysis, Hemiparesis, Magnetic resonance imaging head abnormal
SMQs:, Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad), Ocular motility disorders (broad), Hypoglycaemia (broad)

Write-up: Patient had been working all day in her flower gardens. At 4:30 p.m. she felt like she had double vision and difficulty talking. She does not remember much of what happened after that, but her husband said she had sudden onset of right arm weakness, leg weakness and drooping of the right side of her face. Denies having numbness. He immediately called 911 and EMS took her the Hospital. She had a CT scan of the head that was negative. When she arrived at the emergency room her symptoms had resolved, but she had recurrent episode of her symptoms in the emergency room with an NIH score of 5 scoring a point for level of consciousness, best language, and dysarthria and 2 points for facial droop. She was given tPA and her symptoms resolved. A CT angio of her head and neck did not show any large thrombus. She was transferred for ongoing care and neurology evaluation. Neuro deficits resolved. Patient was discharged the second day after the event on Aspirin, Plavix and Lipitor. Hospitalist (Dr) asked me to file VAERS report given recent Janssen vaccine administration.

VAERS ID:	1322255 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-14
Onset:	2021-05-15
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-05-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	009C21B / 2	LA / IM

Administered by: Military Purchased by: ?
Symptoms: Death, Hyperventilation, Loss of consciousness, Muscle twitching, Posture abnormal, Respiratory arrest, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dyskinesia (broad), Dystonia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-15
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Influenza vaccine- Required hospitalization, Actual reaction unknown by report filer
Other Medications: Please contact PCP for current medication list
Current Illness: None
Preexisting Conditions: History of heart attack, stroke, high cholesterol, diabetes,
Allergies: None that we are aware of
Diagnostic Lab Data: None needed per medical examiner
CDC Split Type:

Write-up: At approximately 8 pm pt. sucked in a deep breath, head began to roll and he began twitching on the right side of his body. Pt. only has muscle function in the right side of his body due to his stroke damage. His wife immediately approached him in his chair and asked him what was wrong and all he was able to state was "I don''t know" before loosing consciousness and stopping breathing. 911 was immediately called and due to his wife being frail herself she was not able to remove him from his wheelchair to perform any CPR. EMS arrived and begin performing CPR until the DNR papers for pt. were located. Medical examiner came to the home and stated she did not feel that an autopsy was needed even though family had told her NUMEROUS times that pt. had received his second Covid vaccine the day prior. He was pronounced dead by the medical examiner and taken directly to the funeral home due to the DNR papers being present.

VAERS ID:	1323157 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-27
Onset:	2021-05-09
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-05-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Hypotension
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Dehydration (broad), Hypokalaemia (broad)

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

Write-up: ERRATIC HYPOTENSIVE EPISODES IN A PATIENT WITH HYPERTENSION WHILE NOT ON ANTIHYPERTENSIVE MEDICATIONS.

VAERS ID:	1323535 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-08
Onset:	2021-05-15
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-05-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0183 / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first Pfizer COVID 19 vaccine on 5/8/2021. Pt became ill with COVID and was admitted to the hospital for treatment on 5/15/2021.

VAERS ID:	1323734 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-12
Onset:	2021-05-09
Days after vaccination:	27
Submitted:	0000-00-00
Entered:	2021-05-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / 1	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Anaemia, Blood smear test normal, Chromaturia, Computerised tomogram abdomen abnormal, Cough, Epistaxis, Flank pain, Haematocrit decreased, Haemoglobin decreased, Headache, Heavy menstrual bleeding, Hepatomegaly, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume normal, Menstruation irregular, Oropharyngeal pain, Ovarian cyst, Platelet count decreased, Red blood cell count decreased, Red cell distribution width increased, Splenic infarction, Splenomegaly, Thrombocytopenia, Urinary tract infection, Vomiting, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Fertility disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient admitted for left flank pain. Was treated for urinary tract infection, although never had symptoms of a UTI. No dysuria, frequency or urgency. Urine is dark. Irregular menses. Has had cough, sore throat, vomiting, headache over past week. Mild epistaxis and heavy menses last month. CBC shows anemia and thrombocytopenia. Imaging showed splenomegaly with small acute splenic infarct. Hematology/oncology consulted and TTP ruled out.

VAERS ID:	1323981 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-16
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-05-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Lacunar stroke
SMQs:, Ischaemic central nervous system vascular conditions (narrow)

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination. Diagnosis was thalamic stroke,

VAERS ID:	1324077 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-04-18
Days after vaccination:	32
Submitted:	0000-00-00
Entered:	2021-05-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1326685 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-11
Onset:	2021-04-12
Days after vaccination:	32
Submitted:	0000-00-00
Entered:	2021-05-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination. Patient was diagnosed with pneumonia.

VAERS ID:	1326791 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-30
Onset:	2021-05-07
Days after vaccination:	97
Submitted:	0000-00-00
Entered:	2021-05-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Bell's palsy, Herpes zoster, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Hearing impairment (broad), Opportunistic infections (broad)

Write-up: Son states that on February 7th his mother developed shingles. On February 12th developed Bell''s Palsy. On May 15th at 9:00 PM his mother had a heart attack. Is recovering at healthcare facility.

VAERS ID:	1327027 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-12
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-05-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient hospitalized on 4/12/21 for 8 days. Patient presented to the ED and was subsequently hospitalized on 4/23/21. These visits were within 6 weeks of receiving COVID vaccination.

VAERS ID:	1327434 (history)
Form:	Version 2.0
Age:	44.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-04-04
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-05-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Abdominal pain, Artery dissection, Computerised tomogram abdomen abnormal, Hypertension, Laboratory test, Ultrasound abdomen abnormal
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow)

Write-up: Event: 10 days after 1st dose, I suffered a celiac artery dissection and common hepatic artery dissection. Symptoms: Horrific abdominal pain!!!! Extremely high blood pressure. Treatment: Lisinopril

VAERS ID:	1327617 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-11
Onset:	2021-04-29
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-05-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0161 / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Hypertension, Pulmonary embolism
SMQs:, Neuroleptic malignant syndrome (broad), Embolic and thrombotic events, venous (narrow), Hypertension (narrow)

Write-up: Bilateral pulmonary emboli, hypertension requiring hospitalization

VAERS ID:	1330070 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-29
Onset:	2021-05-15
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-05-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	203A21A / 1	LA / IM

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

Write-up: Pt received COVID-19 J&J vaccination on 4/29/2021. Pt began having symptoms of COVID around 5/8/2021, worsening to the point of needing hospitalization on 5/15/2021. Diagnosed with COVID pneumonia. Hospitalized for 3 days, symptoms improved enough to discharge.

VAERS ID:	1330277 (history)
Form:	Version 2.0
Age:	101.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-04-04
Days after vaccination:	23
Submitted:	0000-00-00
Entered:	2021-05-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Acute myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Write-up: Patient presented to the ED on 4/4/21 and 4/7/21. Patient presented to the ED on 4/10/21 with NSTEMI and was subsequently hospitalized. These visits are within 6 weeks of receiving COVID vaccination.

VAERS ID:	1330410 (history)
Form:	Version 2.0
Age:	72.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-20
Onset:	2021-04-24
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-05-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	UN / UN

Administered by: Private Purchased by: ?
Symptoms: Balance disorder, Dizziness, General physical health deterioration, Hemiparesis, Hypoaesthesia, Hyporesponsive to stimuli, Intensive care, Lethargy, Pyrexia, Rash, Respiratory distress
SMQs:, Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-13
Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen AmLODIPine Amoxicillin Ascorbic Acid (Vitamin C?) Aspirin Cetirizine Cholecalciferol (Vitamin D3) Clopidogrel (Plavix?) Cyanocobalamin (Vitamin B-12?) Cyclobenzaprine EPINEPHrine (EpiPen 2-Pak?) Injection Famotidine Glucosamin
Current Illness: Prostate CA - taking Lupron Urgent care visit for popular rash to arms, chest, back, and abd 4/28/20 Admission to hospital 5/8/21 with L weakness and numbness, loss of balance, dizziness. Alteplase given.
Preexisting Conditions: Prostate CA TIA - no date Insertion mesh - 4/2/2019 Repair hernia - 4/2/19 Bunionectomy - 12/8/2017
Allergies: Drug Allergies/Adverse Reactions: ?Aspirin: stomach ulcers ?Celecoxib (Celebrex?): Joint swelling ?Salicylates: Gastrointestinal upset Non-Drug Allergies/Adverse Reactions: ?Latex: Rash; Swelling ?''rubber chemical'': Contact dermatitis
Diagnostic Lab Data:
CDC Split Type:

Write-up: Rash presented several days after 2nd dose of vaccine. Seen in urgent care on 4/28 for this. On 5/8/21, patient had left weakness and numbness, dizziness, and loss of balance. Alteplase given,. Transferred to Medical Center, medical intensive care unit. Transferred to medical/surgical unit 5/9/21. Intermittently Febrile - T-max 39.5. CT for mild lethargy 5/9/21. 5/11 - mild respiratory distress and minimally responsive. Continued decline. TOD 1644 5/13

VAERS ID:	1330631 (history)
Form:	Version 2.0
Age:	20.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-13
Onset:	2021-04-20
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-05-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 1	UN / UN

Administered by: Unknown Purchased by: ?
Symptoms: Laboratory test, Ophthalmological examination abnormal, Optic neuritis, Vision blurred, Visual impairment
SMQs:, Anticholinergic syndrome (broad), Glaucoma (broad), Optic nerve disorders (narrow), Demyelination (narrow), Lens disorders (broad), Corneal disorders (broad), Retinal disorders (broad), Ocular infections (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Pt is an otherwise healthy 20 year old male who presents with 2 weeks of blurred vision in R eye. The blurry vision developed suddenly 1 week after getting 1st dose of covid vaccine (moderna). He was seen in ophthalmology clinic on 04/29 and diagnosed with R optic neuritis; The patient reports that his blurred vision has not improved or worsened since onset. It affects both his near and far vision in the right eye only. He denies double vision, eye pain, headaches, nausea, vomiting, numbness, tingling, or weakness. This has never happened before. No recent illness including fever, chills, runny nose, cough, or sore throat. Pt admitted to hospital. Etiology of his optic neuritis is unclear, but possibility include demyelinating etiology (like clinically isolated syndrome). Infectious etiology was thought to be unlikely given no signs/symptoms of infection and reassuring lab workup. No family history of similar symptoms reported, making hereditary optic neuritis less likely. Other considerations included other primary ophthalmological disease, although otherwise reassuring ophthalmological exam makes that less likely. Unclear association with COVID vaccination.

VAERS ID:	1330643 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-04-28
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-05-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Catheterisation cardiac normal, Headache, Troponin increased, Vomiting
SMQs:, Acute pancreatitis (broad), Myocardial infarction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: various herbal supplements and nutritional supplements Docusate, miralax, bupropion, levothyroxine
Current Illness: NA
Preexisting Conditions: chronic constipation, hypothyroidism
Allergies: sulfa, amoxicillin, erythromycin, ciprofloxacin, metronidazole, vilazodone
Diagnostic Lab Data: troponin elevation 4/28/2021
CDC Split Type:

Write-up: Headache, vomiting so severe it was associated with a troponin elevation despite coronary arteries having no significant coronary artery disease on cardiac catheterization.

VAERS ID:	1330699 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-05-14
Days after vaccination:	28
Submitted:	0000-00-00
Entered:	2021-05-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Arthralgia, COVID-19, COVID-19 pneumonia, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Arthritis (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Vaccinated for COVID-19 with Pfizer on 3/11/2021 and 4/16/2021, tested positive for Covid-19 by PCR on 5/12/2021. Entered emergency department with complaints of knee pain on 5/14/2021 (knee aspiration done 5/12/2021). Also noted to have Covid-19 pneumonia and hypoxemic respiratory failure and was admitted to hospital.

VAERS ID:	1330852 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-20
Onset:	2021-03-15
Days after vaccination:	54
Submitted:	0000-00-00
Entered:	2021-05-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL0142 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood test, Cardiac monitoring, Cerebrovascular accident, Computerised tomogram, Echocardiogram, Intensive care, Magnetic resonance imaging, Pain in extremity, Vomiting
SMQs:, Acute pancreatitis (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Tendinopathies and ligament disorders (broad)

Write-up: I experienced left sore arm after my Pfizer vaccine. I had two episodes and I do not know if they are related to the Pfizer vaccines. Feb 28,2021 @ 10pm, severe onset vomiting. March 15, 2021 @9:45am had a mild stroke. I was in ICU, CT scans, MRI, echocardiogram, extensive blood work done. They also put in a heart monitor.

VAERS ID:	1332449 (history)
Form:	Version 2.0
Age:	21.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-19
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: CSF pressure increased, Diplopia, Intracranial pressure increased, Lumbar puncture, Magnetic resonance imaging abnormal, Papilloedema, Venogram abnormal, Vision blurred
SMQs:, Anticholinergic syndrome (broad), Embolic and thrombotic events, venous (narrow), Guillain-Barre syndrome (broad), Glaucoma (broad), Optic nerve disorders (narrow), Lens disorders (broad), Retinal disorders (broad), Ocular motility disorders (broad), Hypoglycaemia (broad)

Write-up: Patient developed visual symptoms the week following administration of the COVID vaccine. Symptoms included blurry vision and double vision. Patient did not seek care. Patient received 2nd dose of Moderna vaccine on 5/12 and had escalation in symptoms after that dose. Patient finally saw her PCP on 5/18 who immediately sent her to optometry where she was noted to have papilledema. She was sent to the ED where an MRI/MRV confirmed increased intercranial pressure without space occupying lesion. LP showed elevated opening pressure of 45/ Patient started on Diamox for presumed IIH.

VAERS ID:	1332981 (history)
Form:	Version 2.0
Age:
Sex:	Male
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Hospitalisation, Incomplete course of vaccination
SMQs:, Medication errors (narrow)

Write-up: Was in and out of the hospital; His second shot is now more than 42 days after the first shot; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of HOSPITALISATION (Was in and out of the hospital) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced HOSPITALISATION (Was in and out of the hospital) (seriousness criterion hospitalization) and INCOMPLETE COURSE OF VACCINATION (His second shot is now more than 42 days after the first shot). At the time of the report, HOSPITALISATION (Was in and out of the hospital) outcome was unknown and INCOMPLETE COURSE OF VACCINATION (His second shot is now more than 42 days after the first shot) had resolved. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. No concomitant medications provided. The patient was in the hospital and his second shot was now more than 42 days after the first shot. He was in and out of the hospital and this put his schedule off caller. No treatment information provided. Company Comment: Very limited information regarding this event of hospitalization has been provided at this time. Further information has been requested. Based on the current information available, temporal association between the use of the product and the start date of the event of hospitalization, a causal relationship cannot be excluded.; Sender''s Comments: Very limited information regarding this event of hospitalization has been provided at this time. Further information has been requested. Based on the current information available, temporal association between the use of the product and the start date of the event of hospitalization, a causal relationship cannot be excluded.

VAERS ID:	1333262 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-05-19
Days after vaccination:	49
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 1	- / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 2	- / SYR

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Chills, Nausea, Pyrexia, SARS-CoV-2 test positive
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client admitted to Medical Center on 5/19/2021 due to fever, chills, and nausea. Covid plus admitted for further assessment.

VAERS ID:	1334004 (history)
Form:	Version 2.0
Age:	34.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-05-11
Days after vaccination:	35
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808978 / UNK	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Acute kidney injury, COVID-19, Drug screen positive, Liver function test increased, Mental status changes, SARS-CoV-2 test positive, Seizure, Toxic encephalopathy, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Convulsions (narrow), Drug abuse and dependence (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Experienced seizure event on 5/11/2021 ER reports non- verbal upon admission, altered mental status, urine screen positive marijuana & benzodiazepines. Tested positive for Covid-19 5/11/2021 Hospitalized 5/11/2021- 5/18/2021. D/C diagnosis: Acute metabolic encephalopathy Active issues: hypolalemia, Seizure (HCC) , Covide infection, AKI (Acute kidney injury), elevated troponin, elevated LFTs. Hospital Attending Hospitalist MD Consults: Doctor of teleneurology

VAERS ID:	1334277 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-04-05
Days after vaccination:	32
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027A21A / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Culture stool positive, Occult blood positive
SMQs:, Haemorrhage laboratory terms (narrow), Gastrointestinal haemorrhage (narrow)

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination. Diagnosis was guaiac positive stools.

VAERS ID:	1334331 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-14
Onset:	2021-05-14
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	021C21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Balance disorder, Chills, Computerised tomogram, Disturbance in attention, Dizziness, Feeling abnormal, Feeling drunk, Headache, Influenza like illness, Laboratory test, Lethargy, Limb discomfort, Magnetic resonance imaging head, Magnetic resonance imaging spinal, Mobility decreased, Neurological examination abnormal, Pain in extremity, Pyrexia, Speech disorder, Vertigo
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Vestibular disorders (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: Moderna COVID-19 Vaccine EUA. Friday, Sat and Sun flu-like symptoms sore left arm pain extending into hand fever, chills, headache lethargy. Mon May 17 above symptoms with dizziness, spinning in head, hard to think and talk, affects speech everything is fuzzy, felt like I was very drunk. Both legs became heavy feeling and unable to move. Went to hospital. Transferred to hospital for neurological evaluation. Same symptoms on Tues May 18 with some resolution later in the day. Early in the day, a test where I was to follow a finger with my eyes only, and hold my head still, brought on the symptoms. Wed May 19, symptoms resolved and I was discharged. Today, Thurs, May 20, 9:00 am, I had a 20 min episode of dizziness, spinning in head, hard to think and talk, speech was affected and I felt like I was drunk, balance was affected, but no lower leg mobility issues. I had another episode at 11:00 am of longer duration (45 mins) but the same symptoms.

VAERS ID:	1334600 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-13
Onset:	2021-04-30
Days after vaccination:	48
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001B21A / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Computerised tomogram head, Concussion, Death, Fall, Resuscitation, Somnolence, Syncope, Thrombosis, Traumatic haemorrhage
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-30
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient has passed away. Wife reports patient was on Plavix and medications for high cholesterol, high blood pressure, and Type II Diabetes. He also took immunotherapy every 6 months (an injection) for prostate cancer.
Current Illness: history of prostate cancer, high blood pressure, high cholesterol, Type II Diabetes, heart failure, past heart attack with stents
Preexisting Conditions: see item 11
Allergies: Bumex
Diagnostic Lab Data: Wife reports a head CT was performed on 4/29/21 in the emergency room. She is unsure if labs were drawn as she was not allowed to be in the room the entire time.
CDC Split Type:

Write-up: Patient passed away on 4/30/21. Wife reports that on 4/29/21, she found him in the garage in a "pool of blood, face down" after a fall. Upon finding him on 4/29/21, she took him to the emergency room where he had a CT scan. Patient was diagnosed with a "concussion" and sent back home, and was instructed to follow-up with his primary care provider on 4/30/21. On 4/30/21, patient was "sleepy all day." On his way out of the house around 3:30, he suddenly put his hand on his wife and proceeded to collapse. The wife also fell, and by the time she gathered herself and went to check on her husband, he had passed away. An ambulance came to the house; CPR was performed for 40 minutes but "they could not get him back." He was not transported to a medical center. An autopsy was not done, but the coroner informed patient''s wife that he likely died from a "clot, maybe a PE." Wife wonders how this could be, since he was on Plavix for 5 years. Wife does not feel that the COVID vaccine is to blame, but thought she should report the issue just in case. This writer is assisting wife of patient to fill out electronic report.

VAERS ID:	1336040 (history)
Form:	Version 2.0
Age:	17.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-13
Onset:	2021-05-14
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-05-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0183 / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: C-reactive protein increased, Chest pain, Echocardiogram normal, Electrocardiogram ST segment depression, Electrocardiogram ST segment elevation, Myocarditis, Troponin increased
SMQs:, Myocardial infarction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Other ischaemic heart disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: Troponin up to 15 ng/ml Initial EKG -- Mild ST segment elevation in lead I, aVL, and V3-V6, mild ST segment depression in lead III and V1 Echocardiogram essentially normal CRP 6 mg/dl
CDC Split Type:

Write-up: About 18 hours after the vaccine was given, the patient developed chest pain. The chest pain progress over about 24 hours to 9/10. He presented to the ER where he was found to have elevated troponin (up to 15) and ST changes on EKG. Echo was normal x2. He was treated for myopericarditis with NSAIDs and colchicine. He quickly improved. No clear etiology of his myopericarditis was identified, raising suspicion that it may have been an adverse reaction to the vaccine.

VAERS ID:	1336588 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-15
Onset:	2021-05-08
Days after vaccination:	23
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Bacterial test negative, Computerised tomogram abdomen normal, Computerised tomogram pelvis, Haemoglobin decreased, Hepatitis viral test negative, Infection, Procalcitonin increased, Pyrexia, Respiratory viral panel, Sepsis, Streptococcus test negative, White blood cell count normal
SMQs:, Liver related investigations, signs and symptoms (narrow), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad)

Write-up: Patient admitted to hospital a few weeks after his second Moderna vaccine with an acute febrile illness of unclear etiology. Patient was felt to be septic due an atypical infection with an elevated procalcitonin level. All tests for infectious etiology were negative. He responded to ceftriaxone and doxycycline and was feeling better at transitional care management follow-up on 5/21/21.

VAERS ID:	1336695 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-04-11
Days after vaccination:	17
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 1	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Atrial fibrillation, Death, Hyponatraemia, Pneumonia
SMQs:, Supraventricular tachyarrhythmias (narrow), Hyponatraemia/SIADH (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-21
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination. Diagnoses were pneumonia, A-fib and hyponatremia. Patient died on 4/21/2021

VAERS ID:	1336832 (history)
Form:	Version 2.0
Age:	26.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-13
Onset:	2021-03-16
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1805025 / 1	LA / SYR

Administered by: Public Purchased by: ?
Symptoms: Asthma, Blood culture negative, Chest X-ray normal, Chest pain, Chills, Computerised tomogram normal, Culture urine negative, Differential white blood cell count abnormal, Dyspnoea, Electrocardiogram normal, Fatigue, Heart rate increased, Malaise, Myalgia, Pyrexia, SARS-CoV-2 test negative, Systemic inflammatory response syndrome, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (broad)

Write-up: Experienced 2 days of worsening fever, chills, myalgias, mild chest pain, fatigue and malaise. Went to the ER after having a low grade fever, chills, shortness of breath, mild chest pain, and an elevated resting heart rate. Was diagnosed with SIRS as a response to the covid vaccine and hospitalized for observation. Was discharged the next day. Diagnosed with SIRS, possibly due to the COVID vaccine with a secondary diagnosis of asthma.

VAERS ID:	1336845 (history)
Form:	Version 2.0
Age:	32.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-27
Onset:	2021-05-01
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN/INFO NO / 1	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Acute myocardial infarction, Angiogram pulmonary normal, Chest pain, Dyspnoea, Electrocardiogram ST-T change, Myalgia, Oropharyngeal pain, Pyrexia, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: no notable previous history who presented 5/1/2021 ~0130 with chest pain and shortness of breath. History notable for Moderna COVID-19 vaccination 4 days prior (that would be 4/27/21) with subsequent development of fever, myalgias, sore throat. Then on 4/30/21 developed acute onset of shortness of breath and chest pain. Seen at ED. Exam and work-up revealed elevated troponin, unremarkable CTA of chest, EKG with diffuse slight ST changes. Patient was subsequently admitted to hospital for possible myocarditis. Per consult - Differential diagnosis includes pericarditis, myocarditis, acute coronary syndrome. Later in the day (~1530), had worsening chest pain and ST elevated noted on EKG. Pt did disclose at that time that he used cocaine about 8 days earlier. Pt transferred to Hospital for treatment of STEMI. Note: covid-19 vaccine info is pt reported, unable to access any Immunization records for this patient. Place where pt received vaccine is also unknown.

VAERS ID:	1337267 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-08
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6205 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized on 3/8/21. She presented to the ED on 3/13/21. Patient presented to the ED and was subsequently hospitalized on 4/6/21.

VAERS ID:	1337614 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-19
Onset:	2021-05-20
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0186 / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Dysstasia, Mobility decreased, Muscular weakness, Musculoskeletal stiffness, SARS-CoV-2 test negative, Walking aid user, Wheelchair user
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), COVID-19 (broad)

Write-up: Patient with hx of multiple sclerosis presented to ED on 5/20/21 with bilateral lower extremity weakness. Patient got her 2nd COVID vaccine on 5/19/21 (Pfizer), and since that time she developed bilateral lower extremity weakness. She generally uses a wheelchair and a walker but at baseline can ambulate with a walker and currently she cannot stand at all. She reports her last MS flare was about 6 months ago and when she has MS flares, she always has symptoms with her legs. She gets ocrelizumab injections every 6 months (last dose was 5/18/21). She denies any vision changes or difficulty with speech, no upper extremity weakness, numbness/tingling. Denies any bowel or bladder incontinence. She denies any chest or abdominal pain, nausea, emesis, diarrhea, urinary issues, cough, fevers, chills. SARSCOV2PCR test on 5/20/21 = not detected. She does report some mild stiffness in her right upper arm but states that also happened with the first dose of the vaccine. Case was discussed with neurologist who recommended admission and observation but deferring on steroids at this time. As of 5/21/21, patient is still hospitalized. Her lower extremity weakness is improving, but the medical team anticipates she will need short term inpatient rehab or possibly home PT/OT before being able to safely return home.

VAERS ID:	1337723 (history)
Form:	Version 2.0
Age:	36.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-13
Onset:	2021-05-18
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0179 / 2	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-18
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: 05/13-DISCUSSED WITH PHARMACIST A TOPICAL ALLERGIC REACTION HE HAD BEEN HAVING FROM A NEW BODY SOAP. PHARMACIST RECOMMENDED TOPICAL HYDROCORTISONE CREAM AND ORAL BENADRYL TO HELP MANAGE SYMPTOMS.
Allergies: UNKNOWN
Diagnostic Lab Data: UNKNOWN
CDC Split Type:

Write-up: PATIENT WAS IMMUNIZED 5/13. PATIENT WAS FOUND DECEASED IN THEIR APARTMENT ON 5/18. FAMILY LAST SAW HIM ON 5/16 WHEN THEY DROPPED HIM OFF AT HIS APARTMENT. MEDICAL EXAMINER HAS NOT YET DETERMINED CAUSE OF DEATH OR EXACT DATE OF DEATH.

VAERS ID:	1337768 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-04-11
Days after vaccination:	40
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1337849 (history)
Form:	Version 2.0
Age:	31.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-13
Onset:	2021-04-15
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	038B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Caesarean section, Delivery, Exposure during pregnancy, Pregnancy
SMQs:, Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow), Normal pregnancy conditions and outcomes (narrow)

Write-up: Patient hospitalized for cesarean section within 6 weeks of receiving COVID vaccination. Per doctor''s notes she delivered a 7 pound 10 oz baby, who was doing well at time of discharge. Pregnancy and delivery was uncomplicated.

VAERS ID:	1337925 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-13
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-05-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043821A / 1	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Balance disorder, Blood test abnormal, Carotid artery occlusion, Carotid artery thrombosis, Cerebrovascular accident, Computerised tomogram head abnormal, Condition aggravated, Dizziness, Factor V Leiden mutation, Headache, Impaired work ability, Intensive care, Magnetic resonance imaging head abnormal
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Congenital, familial and genetic disorders (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Vestibular disorders (broad)

Write-up: Client was seen by his doctor on April 13th related to severe headaches . He stated that he had headaches prevaccine and was given Tropromax for it which he only took for 2 days as it caused him dizziness. He had CT scan of Head and MRIs on April 13 and 14th and then again on April 27th. The scan on April 27th showd a blood clot with 80% blockage in carotid artery and was dxd with a blood clot via CT scan. . He was told to get to Hospital where he was admitted to ICU for 4 days Client was also dxd with Factor5 Leiden at that time. Per client he ha a stroke and is recovering. Per client still unable to work r/t poor balance and dizziness

VAERS ID:	1340716 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-05-14
Days after vaccination:	22
Submitted:	0000-00-00
Entered:	2021-05-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 1	LA / IM

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Adderall, asa, atorvastatin, remeron, nicotine patch, oxycodone
Current Illness: None
Preexisting Conditions:
Allergies: PCN, nickel
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented in the ED on 5/14/20 at Hospital with a left sided stroke. Was treated with alteplase. Pt was then transferred to another Hospital

VAERS ID:	1341479 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-15
Onset:	2021-05-18
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016C21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood test, Catheterisation cardiac abnormal, Chest X-ray abnormal, Chest pain, Echocardiogram, Electrocardiogram abnormal, Lipids, Magnetic resonance imaging heart, Metabolic function test, Myocarditis, Troponin, Ultrasound scan abnormal
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Received second dose on Saturday, woke up on Tuesday at 5 AM with chest pains. Went to the emergency room around 4PM Tuesday, transferred to another hospital, diagnosed with myocarditis, and treated and monitored there for 2 days and then discharged. On medication for the next 3 months due to condition.

VAERS ID:	1341539 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-27
Onset:	2021-04-01
Days after vaccination:	33
Submitted:	0000-00-00
Entered:	2021-05-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Arthralgia, Bradycardia, Bundle branch block right, Chest X-ray normal, Cough, Coxsackie virus test, Electrocardiogram QRS complex prolonged, Electrocardiogram abnormal, Laboratory test normal, Pain, Painful respiration, Pericarditis, Troponin normal
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Arthritis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulosin for BPH, Naproxin on days I bike, about 1/2 the days
Current Illness: BPH, joint pains from prior injury
Preexisting Conditions: Hx of Several viral pneumonitides: persistent ''walking pneumonia'' in 1964, missed 3 weeks of school; Hosp''d with flu in 1969; Coxsackie B3 pleurodynia in Nov 2000, was air med-evac''d to ICU, discharged after 2 weeks no dx; viral test came back positive 1 month after discharge; 2012, again med evac''d to Medical center for 6 month productive cough & ?cardiomyopathy v. low grade respiratory infection with low PO2. Now have new RBBB. 3wks after acuter pericarditis ER visit 4/4/2021, I had a high Coxsackie B3 & B4 titer. Wonder if vaccination triggered heart inflammation.
Allergies: none
Diagnostic Lab Data: EKG Bradycardia, wide QRS, RBBB was not initially seen, neg for tropinins, normal chem, normal CXR, no pleural or pericardial effusions; 4/23/2021 high Coxsackie B3 & B4 titers 1:160 each. Symptoms this episode were quite different than the Devil''s Grip symptoms in 2000. Question: chronic viral infection for 20 years that the vaccination activated v. chronic inflammation & EKG changes
CDC Split Type:

Write-up: 4/1/2021 odd tickling cough, brief. Biked anyway, 60 min hard ride. But just in case started 81mg ASA qd. 4/2 odd tickling cough brief. Biked anyway, 60 min, good hard ride. not feeling ill, no fever, cough did not continue, not productive, no URI symptoms. Cough was different. 4/3 woke with pain upon taking a deep breath HR in high 40''s (normal 60 +-) Like the pain of breathing after aspirating a lot of pool water. This pain was only on deep breathing; a second ''radiating?'' pain was more of a constant ache in region of R scapula or supra scapular region, no tenderness to palpation. Had GB out Feb 2020.

VAERS ID:	1343223 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-18
Onset:	2021-05-22
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-05-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	022B21A / 1	- / IM

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

Write-up: Pt received one dose of the Moderna vaccine, then tested positive for COVID-19 on 5/22/2021 and was ill enough to be admitted for inpatient treatment. She is still currently in our inpatient Gen med unit.

VAERS ID:	1343415 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-04-26
Days after vaccination:	26
Submitted:	0000-00-00
Entered:	2021-05-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Deep vein thrombosis
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Write-up: Patient presented to the ED and was subsequently hospitalized for DVT within 6 weeks of receiving COVID vaccination.

VAERS ID:	1343555 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-08
Onset:	2021-02-16
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-05-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043LZOA / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Computerised tomogram abnormal, Intestinal perforation, Ultrasound scan abnormal
SMQs:, Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal perforation (narrow), Ischaemic colitis (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Sertraline, Black Cohosh
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CT Scan, Ultrasound 02/19/2021
CDC Split Type:

Write-up: perforated intestine

VAERS ID:	1344079 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-20
Onset:	2021-05-02
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-05-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Arthropod bite, Asthenia, Back pain, Blood immunoglobulin G normal, Blood immunoglobulin M normal, Blood sodium decreased, Borrelia test negative, CSF protein increased, CSF test abnormal, Computerised tomogram abdomen normal, Condition aggravated, Confusional state, Fluid intake restriction, Gait inability, Guillain-Barre syndrome, Hypertension, Hypertensive urgency, Hyponatraemia, Hypotension, Immunoglobulin therapy, Impaired driving ability, Inappropriate antidiuretic hormone secretion, Intensive care, Labile hypertension, Limb discomfort, Loss of personal independence in daily activities, Lumbar puncture abnormal, Magnetic resonance imaging head normal, Magnetic resonance imaging spinal normal, Magnetic resonance imaging thoracic normal, Movement disorder, Spinal X-ray normal
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Hypertension (narrow), Demyelination (narrow), Chronic kidney disease (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: Covid-19 vaccine administrations (Moderna) 3/23/21 lot# 013A21A 4/20/21 lot# 013A21A Admission to Hospital (5/2/21 ? 5/10/21) for hypertension and acute on chronic back pain requiring ICU admission, hyponatremia thought to be due to SIADH. CT of abdomen done at hospital noting no significant lumbar abnormalities and a plain film of her lumbar spine with no obvious compression fracture. Outside hospital notes do not further outline why she could no longer ambulate. Brain MRI done and negative during that admission. Discharged to a rehab facility for ongoing weakness. On 5/13/21, patient?s son requested admission to hospital for further evaluation. She states that she feels confused and her legs are very heavy and she can barely move them. Notably she lives alone in her own home, used to drive, did not use any assistive device to walk, and paid her own bills until 2 weeks ago. The symptoms did occur approximately a week after receiving her last Covid vaccine. Pt also notes around April 1, 2021 having taken an engorged deer tick off her head. 5/14/21 Lyme serology IgM & IgG = negative. Neurology was consulted. She had an MRI of her thoracic and lumbar spine, as well as an LP. She had had an MRI brain at a hospital. Her MRIs did not reveal a source of her weakness and pain. Her CSF revealed albuminocytologic dissociation. Given this finding and the constellation of symptoms and LP findings, it was thought she had Guillain Barre Syndrome, presumably due to her COVID vaccine. She was given IVIG for 5 days. She improved with this. As above, she had a recent admission for hyponatremia and hypertensive urgency. Here, her blood pressure was somewhat labile, but at times was low. She was started back on amlodipine and carvedilol, but at much lower doses with plan for ongoing monitoring. In terms of her hyponatremia, her salt tabs were stopped, and eventually her fluid restriction was able to be lifted. Her sodium was 136 at discharge.

VAERS ID:	1345843 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-05-09
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	044B21A / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Cardiac failure, Product dose omission issue
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad), Medication errors (broad)

Write-up: Heart failure; was scheduled for her second dose, but was unable to get it because she was hospitalized; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of CARDIAC FAILURE (Heart failure) in a 46-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 044B21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Heart disorder (heart condition) and Blood pressure high. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 09-May-2021, the patient experienced CARDIAC FAILURE (Heart failure) (seriousness criteria hospitalization and medically significant). On 11-May-2021, the patient experienced PRODUCT DOSE OMISSION ISSUE (was scheduled for her second dose, but was unable to get it because she was hospitalized). The patient was hospitalized from 09-May-2021 to 13-May-2021 due to CARDIAC FAILURE. On 11-May-2021, PRODUCT DOSE OMISSION ISSUE (was scheduled for her second dose, but was unable to get it because she was hospitalized) had resolved. On 13-May-2021, CARDIAC FAILURE (Heart failure) outcome was unknown. The patient''s concomitant medications included unspecified high blood pressure pills and heart pills. Treatment information was not provided. Very limited information regarding this event has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.

VAERS ID:	1346465 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-24
Onset:	2021-03-20
Days after vaccination:	24
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 2	UN / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Cerebral infarction, Dysphagia, Facial paralysis, Hemiplegia, Magnetic resonance imaging abnormal
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Sertraline Senna Omega 3 Mirtazapine Metoprolol Furosemide Famotidine Donepezil Calcium Atorvastatin ASA APAP
Current Illness: None
Preexisting Conditions: CKD Heart failure HTN BPH Cardiac arrhythmia GERD Hyperlipidemia Dementia
Allergies: No known allergies.
Diagnostic Lab Data: MRI during hospitalization revealed acute infarct in the superior right parietal centrum semi ovale.
CDC Split Type:

Write-up: On 3/20 this patient started exhibiting right sided facial droop and paralysis of right arm and leg, dysphagia. On 3/25 he was discharged from the hospital on hospice.

VAERS ID:	1346659 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-05-11
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Condition aggravated, Myasthenia gravis
SMQs:, Immune-mediated/autoimmune disorders (narrow)

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination. diagnosis was Myasthenia gravis with acute exacerbation.

VAERS ID:	1346680 (history)
Form:	Version 2.0
Age:	47.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-05-21
Days after vaccination:	35
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / 2	UN / UN

Administered by: Unknown Purchased by: ?
Symptoms: Anticoagulant therapy, SARS-CoV-2 test negative
SMQs:, COVID-19 (broad)

Write-up: Report indicates client was hospitalized on 5/21/2021 for "abnormal diagnostic test". No other details about client condition were noted. It did indicate he received heparin.

VAERS ID:	1346709 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-05-19
Days after vaccination:	63
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 1	- / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	NA / 2	- / SYR

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

Write-up: Client began having shortness of breath on 5/19. She was admitted to the ER on 5/21 at Hospital for further evaluation and requiring oxygen.

VAERS ID:	1346772 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-15
Onset:	2021-05-24
Days after vaccination:	39
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8733 / 1	UN / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0169 / 2	UN / SYR

Administered by: Private Purchased by: ?
Symptoms: Bronchoalveolar lavage abnormal, COVID-19, Computerised tomogram abnormal, Follicular lymphoma, Lung opacity, SARS-CoV-2 test positive
SMQs:, Interstitial lung disease (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Malignant lymphomas (narrow), Haematological malignant tumours (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Received Pfizer vaccines on 3/25/21 and 4/15/21. Tested positive for COVID-19 by PCR from Bronchoalveolar lavage on 5/20/21. Had been previously positive for COVID-19 by PCR in November 2020. Patient has underlying follicular lymphoma. Admitted to hospital for IV Remdesivir and convalescent plasma on 5/22/21. Had 3 month history of fever of unknown origin, persistent cough; hospital notes mention ground glass opacities on CT concerning for chronic COVID-19 pneumonia.

VAERS ID:	1347356 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-22
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient presented to the ED on 3/6/21. Patient hospitalized on 4/22/21. These visits are within 6 weeks of receiving COVID vaccination.

VAERS ID:	1347526 (history)
Form:	Version 2.0
Age:	84.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-03-17
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Atrial fibrillation, Electrocardiogram, Laboratory test
SMQs:, Supraventricular tachyarrhythmias (narrow)

Write-up: Atrial fib

VAERS ID:	1347704 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-30
Onset:	2021-05-20
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Cerebrovascular accident, Facial paralysis, Hemiparesis, Hemiplegia, Hypoaesthesia, Magnetic resonance imaging abnormal
SMQs:, Peripheral neuropathy (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Fluticasone Fexofenadine Proventil Baclofen Vit B12 Topiramate Vit D
Current Illness: None
Preexisting Conditions: Osteoarthritis GERD Hyperlipidemia RLS Multiple Sclerosis
Allergies: Penicillin Copaxone
Diagnostic Lab Data: MRI 5/20: acute infarct within the left frontal lobe
CDC Split Type:

Write-up: On 5/20 patient started experiencing right arm and leg weakness, accompanied by right sided facial numbness and facial droop. She was taken to the ER and admitted to the hospital for right sided hemiplegia and left sided frontal lobe stroke per MRI. No signs of atrial fibrillation. Hospital notes indicate that etiology of stroke is unclear.

VAERS ID:	1348042 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-03-26
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8727 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood sodium decreased, Chills, Dizziness, Joint range of motion decreased, Loss of consciousness, Pyrexia, Radius fracture, Splint application, Syncope, Tremor, Ulna fracture, Wrist fracture, X-ray limb abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: Early 3/26/21, I experienced low grade fever, chills, and shaking. About 9 hours later, I became light-headed and fainted. I broke my left wrist on a coffee table after losing consciousness on the way down. Wrist was in splint for 4 weeks. 8 weeks later I am still receiving occupational therapy to regain motility/strength.

VAERS ID:	1348328 (history)
Form:	Version 2.0
Age:	25.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-08
Onset:	2021-05-09
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-05-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Abdominal discomfort, Abdominal pain upper, Anxiety, Blood test, Chills, Crying, Depression, Fear, Feeding disorder, Head discomfort, Headache, Hyperhidrosis, Impaired work ability, Loss of personal independence in daily activities, Nausea, Pyrexia
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Depression (excl suicide and self injury) (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: One a day Mens Multivitamin
Current Illness: None
Preexisting Conditions: None
Allergies: Amoxicillin
Diagnostic Lab Data: Blood test 05/25/2021
CDC Split Type:

Write-up: First night after receiving 2nd dose of the Moderna Vaccine, I experienced a high fever and chills, sweating and a disturbing Ringing in my head. The second day after was roughly the same as the first night. I expected some of these symptoms and was willing to power through them. It is now past 2 weeks since I have had the Vaccine. I still have a maddening Ringing in my head. Different than a Ringing in my ears. It does not feel the same. I feel pressure in my head, resulting in constant headaches that never subside. I have felt nauseous at random times, stomach pain from not being able to eat, and I am for the first time in my life experiencing anxiety and depression. I feel like my pain will never go away and I am scared. This pressure/pain in my head accompanied with the constant ringing is driving me insane. I have lost time at work, lost time with friends and family trying to sleep off my pain and symptoms but it never helps. I have taken headache medication which helps a small amount for the head pain, but leaves me with an upset stomach. I can not take these pain pills any more. My Doctor, had me do a blood test and we are awaiting results as of today 5/25/21. I do not think they will find anything that will be able to help me with what I feel this Vaccine has done to me. I do not know what to do besides try not to cry myself to sleep anymore. I hate this and I do not want to feel this way anymore.

VAERS ID:	1350606 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-22
Onset:	2021-05-22
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-05-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0182 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Anaphylactic reaction, Blood pressure decreased, Chest discomfort, Dizziness, Dyspnoea, Lacrimation increased, Pharyngeal swelling, Vaccination complication
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Lacrimal disorders (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: VIT. D 3 50,000 IU Q WK. MESALAMINE 800 MG Q DAY.
Current Illness:
Preexisting Conditions: CHRONE''S DISEASE, ASTHMA
Allergies: ALLERGIC TO NITRO AND IVP DYE.
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: APPROXIMATELY 22 MIN. AFTER RECEIVING VACCINE, CLIENT BECAME LIGHT HEADED, DIZZY, SHORT OF BREATH, THROAT SWELLING, EYES WATERING, BLOOD PRESSURE DROPPED, TIGHTNESS IN CHEST. 911 CALLED. PARAMEDICS GAVE IV EPI. AND TRANSPORTED CLIENT TO HOSPITAL ER. MD DIAGNOSED ANAPHYLAXIS DUE TO COVID VACCINE. IN ER, CLIENT WAS GIVEN PREDNISOLONE AND ALBUTEROL TREATMENT. CLIENT RESTED IN ER WHILE BEING MONITORED. CLIENT THEN RELEASED TO GO HOME.

VAERS ID:	1351137 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-08
Onset:	2021-05-17
Days after vaccination:	39
Submitted:	0000-00-00
Entered:	2021-05-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 1	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0158 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Dyspnoea, Obstruction gastric, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client tested positive for COVID-19 on 11/07/2020. She received Pfizer COVID-19 vaccine on 03/18/2021 and 04/08/2021. She then tested positive for COVID-19 again on 05/17/2021. She was hospitalized from 05/17/2021-05/21/2021. She has a history of gastric bypass surgery. She was short of breath at the time of her positive COVID test on 05/17/2021. She was found to have an obstructed gastric outlet at the time of her hospitalization. When I spoke with her on the phone on 05/25/ 2021, she reported that her medical provider felt that her shortness of breath was related to her gastric issues. She is no longer short of breath and will be having further surgery in June 2021.

VAERS ID:	1351376 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-18
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-05-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	LA / SYR

Administered by: Other Purchased by: ?
Symptoms: Audiogram abnormal, Deafness, Deafness unilateral, Gait disturbance, Nausea, Tinnitus, Vertigo
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hearing impairment (narrow), Vestibular disorders (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: lactobacillus rhamnosus (GG) 10 billion cell capsule Men''s Health Multivitamin
Current Illness: none
Preexisting Conditions: Lupus Barrett''s esophagus
Allergies: none
Diagnostic Lab Data: Audiogram confirmed complete hearing loss in left ear and very good hearing in right ear the day after hearing loss.
CDC Split Type:

Write-up: Started with loud ringing in my left ear at 2pm, followed 2 hours later with complete hearing loss in left ear and then woke up the next morning at 6:30am with severe vertigo (nausea and inability to walk). Vertigo got better after lights turned on to the point that I had no nausea anymore, but needed to hold onto things while walking. Ringing Went to urgent care at 10am to get assessed and after speaking with an ENT they prescribed Prednisone and Meclizine. Meclizine didn''t help so only took for 2 days, was on Prednisone for 3 weeks .

VAERS ID:	1351609 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-12
Onset:	2021-04-22
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-05-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0164 OR EN016 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Acute myocardial infarction, Burning sensation, Chest pain, Electrocardiogram abnormal, Myocardial infarction, Stent placement, Troponin
SMQs:, Peripheral neuropathy (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Verapamil, Lisinopril, Rosuvastatin, Buspirone, Diazapam, Low Dose Aspirin 1 Megamen vitamin Quinol CBD Oil
Current Illness: nothing
Preexisting Conditions: Hypertension, cholestorol issues, coronary artery disease, obesity, allergies, PTSD
Allergies: Tegritol, Pennicilan
Diagnostic Lab Data: Triponin 3.77 peaked EKG abnormal showed STEMI in ER on date it happened
CDC Split Type:

Write-up: Heart Attack, burning from center of chest expanding to back like a dagger and outwards 1 stent placed to stop it 2 more stents the next day preventative Now attending cardiac rehab New meds prescribed

VAERS ID:	1354829 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-24
Onset:	2021-05-26
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-05-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Abnormal behaviour, Alcohol test, Ammonia, Amnesia, Analgesic drug level, Blood creatine phosphokinase, Blood glucose, Blood magnesium, Computerised tomogram head, Confusional state, Drug screen, Fatigue, Full blood count, Magnetic resonance imaging head, Metabolic function test, SARS-CoV-2 test, Urine analysis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Drug abuse and dependence (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hypoglycaemia (broad), COVID-19 (broad)

Write-up: Confusion, memory loss, fatigue, acting abnormally

VAERS ID:	1357247 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-05-01
Days after vaccination:	86
Submitted:	0000-00-00
Entered:	2021-05-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9269 / 2	LA / -

Administered by: Public Purchased by: ?
Symptoms: Cerebral thrombosis, Cerebrovascular accident, Headache, Musculoskeletal disorder, Speech disorder
SMQs:, Rhabdomyolysis/myopathy (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad)

Write-up: Stroke/in her head on her left side; Blockage in her head, there was a blood clot in her head; Arm doesn''t work; All she could say was I cant/still needs speech therapy; Really bad headaches; This is a spontaneous report from a Pfizer-sponsored program. A contactable consumer (patient) reported that a 68-year-old female patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot Number: EL9269; Expiration date was not reported) on the left arm on 04Feb2021 (13:21) as a 2nd dose, single dose, with route of administration unspecified, for COVID-19 immunization at the public health department (not a military facility). The patient had a family history of five heart bypass surgeries (father); stroke (father); and stents (mother). There were no concomitant medications. The patient had previously received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number: EL3249; Expiration date was not reported) on 14Jan2021 (when the patient was 68 years old) for COVID-19 immunization, and had hypersensitivity, rash and cerebrovascular accident. On 07May2021, the patient had a stroke (in her head on the left side). The patient was hospitalized from 07May2021 to 10May2021 due to the stroke. In May2021, the patient had a blockage in her head/there was a blood clot in her head; her arm did not work; all she could say was "I can''t", and still needed speech therapy; and had really bad headaches. The events had resulted into an emergency room visit. The patient had received clopidogrel (PLAVIX) as treatment for stroke and blockage in her head/there was a blood clot in her head; and duloxetine ACL as treatment for the really bad headaches. The outcome of the events was recovering for ''stroke'' and ''all she could say was "I can''t", and still needed speech therapy''; was not recovered for ''really bad headaches''; and was unknown for all the other events. Information on lot/batch number was available. Additional information has been requested.

VAERS ID:	1358447 (history)
Form:	Version 2.0
Age:	84.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-05-24
Days after vaccination:	109
Submitted:	0000-00-00
Entered:	2021-05-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Public Purchased by: ?
Symptoms: COVID-19 pneumonia, Cough, Fall, Fatigue, Left atrial appendage closure implant, Oropharyngeal pain
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Accidents and injuries (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client received his Pfizer vaccines on 1/14/2021 and 2/4/2021. On 5/13/21, client had a Watchman device placed in his heart, spending one night in the hospital. From 5/13 through 5/27, client complained of a sore throat, fatigue and had a cough. These symptoms escalated and became much worse on 5/25, according to his wife. On 5/26, client fell at home, was taken by fire rescue to the hospital, admitted early AM on 5/27, and diagnosed w/ COVID-19 pneumonia (and possibly a fractured back).

VAERS ID:	1360485 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-24
Onset:	2021-02-27
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-05-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN / UNK	- / -

Administered by: Other Purchased by: ?
Symptoms: Nausea, SARS-CoV-2 test, Tongue discomfort
SMQs:, Acute pancreatitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: TRAZODONE; HYDROXYZINE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19; Familial hypercholesterolemia; Hashimoto''s disease
Allergies:
Diagnostic Lab Data: Test Date: 20210507; Test Name: SARS-COV-2; Test Result: Negative ; Comments: Nasal Swab
CDC Split Type: USPFIZER INC2021547989

Write-up: Persistent nausea; tongue often feels different; This is a spontaneous report from a contactable health care professional (patient). A 42-year-old female patient received BNT162B2 (Pfizer-BioNTech COVID-19 vaccine, lot number and expiry date unknown), via an unspecified route of administration on 24Feb2021 as an unknown dose number, as a single dose for COVID-19 immunization. Medical history included familial hypercholesterolemia and hashimotos antibodies both from an unknown date and unknown if ongoing. Prior to vaccination, the patient was diagnosed with COVID-19. Concomitant medications included trazodone (manufacturer unknown) and hydroxyzine (manufacturer unknown), both taken for an unspecified indication, start and stop date were not reported. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. The patient experienced persistent nausea and tongue often feels different on 27Feb2021. The events resulted to a doctor or other healthcare professional office/clinic visit. As treatment for the events, the patient''s gall bladder was removed (as reported). The events were reported with a seriousness of disability. The outcome of the events was not recovered. The patient had a nasal swab SARS-COV-2 test on 07May2021 with a result of negative.; Sender''s Comments: Events represent intercurrent medical conditions and unrelated to BNT162B2 . The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.

VAERS ID:	1363989 (history)
Form:	Version 2.0
Age:	71.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-29
Onset:	2021-03-03
Days after vaccination:	33
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Hepatic cancer
SMQs:, Liver malignant tumours (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-17
Days after onset: 74
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: MODERNATX, INC.MOD2021154

Write-up: Liver cancer (It was in his ducts & everything)/ had the cancer, but this vaccine accelerated it; This spontaneous case was reported by a consumer and describes the occurrence of HEPATIC CANCER (Liver cancer (It was in his ducts & everything)/ had the cancer, but this vaccine accelerated it) in a 71-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 007M20A and 013A21A) for COVID-19 vaccination. No Medical History information was reported. On 29-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 26-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 03-Mar-2021, after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced HEPATIC CANCER (Liver cancer (It was in his ducts & everything)/ had the cancer, but this vaccine accelerated it) (seriousness criteria death and medically significant). The patient died on 17-May-2021. The reported cause of death was liver cancer. It is unknown if an autopsy was performed. No concomitant medications was reported. No treatment medications was provided. 03-Mar-2021: Husband was diagnosed with liver cancer. It was in his ducts and everything. He had cancer at the time we took both vaccines. He died 10 weeks after being diagnosed with liver cancer. Caller felt the vaccine escalated the process. Company comment: Very limited information regarding the event has been provided at this time. Further information has been requested. This case was linked to MODERNATX, INC.-MOD-2021-019697 (E2B Linked Report).; Sender''s Comments: Very limited information regarding the event has been provided at this time. Further information has been requested. MODERNATX, INC.-MOD-2021-019697:Wife''s case; Reported Cause(s) of Death: Liver cancer

VAERS ID:	1364296 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-03
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6206 / 1	LA / OT

Administered by: Other Purchased by: ?
Symptoms: Vaccination site pain
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: SENNA ACUTIFOLIA; ASPIRIN (E.C.); GLIMEPIRIDE; IBUPROFEN; LOSARTAN; AMLODIPINE; METOPROLOL SUCCINATE
Current Illness: Cerebrovascular disorder; Constipation; Dementia; Essential hypertension; Pain; Type II diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021562642

Write-up: moderate pain in left arm following first injection; This is a spontaneous report from the contactable nurses. An 86-year-old male patient received bnt162b2 (PFIZER BIONTECH COVID-19 VACCINE), intramuscular administered on arm left on 03Mar2021 11:00 (Batch/Lot Number: EN6206) as 1ST DOSE, SINGLE for COVID-19 immunization at the urgent care facility. Ongoing medical history included cerebrovascular disease, dementia, essential hypertension, type II diabetes mellitus (DM), constipation and pain. Concomitant medications included senna acutifolia (SENNA ACUTIFOLIA) taken for constipation from an unspecified start date and ongoing; acetylsalicylic acid [ASPIRIN (E.C.)] taken for cerebrovascular accident (also reported as decrease stroke risk) from an unspecified start date and ongoing; glimepiride (GLIMEPIRIDE) taken for type 2 diabetes mellitus from an unspecified start date and ongoing; ibuprofen (IBUPROFEN) taken for pain from an unspecified start date and ongoing; and losartan (LOSARTAN), amlodipine (AMLODIPINE), and metoprolol succinate (METOPROLOL SUCCINATE) all three taken for blood pressure/essential hypertension from unknown dates. On 03Mar2021 11:00, the patient had moderate pain in left arm following first injection. The event was considered as serious (life threatening and persistent/ significant disability/ incapacity). Outcome of the event was not recovered.; Sender''s Comments: Based on the compatible temporal association, there was a reasonable possibility that the vaccination with BNT162B2 played a contributory role in triggering the onset of the reported vaccination site pain. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Committees and Investigators, as appropriate.

VAERS ID:	1364556 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-19
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	044B21A / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Hepatic cirrhosis
SMQs:, Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow)

Write-up: Patient hospitalized within 6 weeks of receiving COVID vaccination. First hospitalization was 4/19/21, then 5/4/21. On 5/11/21 patient presented to the ED and was subsequently hospitalized for 16 days with decompensation of cirrhosis of liver.

VAERS ID:	1364583 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-20
Onset:	2021-04-28
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Chronic obstructive pulmonary disease
SMQs:

Write-up: Patient presented to the ED on 4/28/2021for COPD exacerbation. Patient presented to the ED on 5/11/2021 and was subsequently hospitalized for 3 days. These visits are within 6 weeks of receiving COVID vaccination.

VAERS ID:	1364615 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-09
Onset:	2021-03-09
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	AR / SYR

Administered by: Private Purchased by: ?
Symptoms: Anaphylactic reaction, Immediate post-injection reaction
SMQs:, Anaphylactic reaction (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (narrow)

Write-up: Anaphylactic reaction immediately after receiving the Moderna covid 19 vaccine

VAERS ID:	1364938 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-17
Onset:	2021-04-18
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Arthralgia
SMQs:, Arthritis (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Same day, a couple of hours after first dose I rode 30+ miles on bicycle with no adverse effects. Day after first dose on 4-18-21 I rode 125 miles on bicycle. Around mile 110 I started experiencing knee joint pain. Knee pain lasted for approximately 3 days after this first incident. Since then I have experience knee joint pain every time I ride a bicycle. I have tried adjusting bike fit on my own and with professional bike fit. I have tried rides on older bike whose fit never gave me any problems for years including many longer rides. I found an article detailing a woman who experienced ReA(Reactive Arthritis) after receiving Covid-19 vaccination and thought my symptoms might be similar.

VAERS ID:	1365047 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-30
Onset:	2021-04-24
Days after vaccination:	84
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	NA / 1	- / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	NA / 2	- / SYR

Administered by: Unknown Purchased by: ?
Symptoms: Aortic stenosis, Chest pain, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: Client admitted to St Luke''s for chest pain, SOB, and aortic stenosis requiring oxygen.

VAERS ID:	1365105 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-27
Onset:	2021-03-30
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 2	AR / IM

Administered by: Unknown Purchased by: ?
Symptoms: Accident at home, Atrioventricular block first degree, Autism spectrum disorder, Blood creatine phosphokinase increased, Blood culture negative, Blood lactic acid normal, Blood magnesium normal, Blood sodium decreased, Bundle branch block right, Computerised tomogram abdomen normal, Computerised tomogram pelvis, Computerised tomogram thorax normal, Contusion, Developmental delay, Echocardiogram normal, Ejection fraction normal, Electrocardiogram QT interval, Electrocardiogram abnormal, Epilepsy, Essential hypertension, Fall, Functional residual capacity abnormal, Hypomagnesaemia, Hyponatraemia, Illiteracy, Immobile, Investigation noncompliance, Joint dislocation, Joint dislocation reduction, N-terminal prohormone brain natriuretic peptide increased, Parent-child problem, Partial seizures, Procalcitonin, Procalcitonin normal, Pyrexia, Renal function test normal, Rhabdomyolysis, Sepsis, Shoulder deformity, Sinus tachycardia, Troponin I increased, Urine analysis normal, Ventilation/perfusion scan abnormal, White blood cell count increased, X-ray limb abnormal
SMQs:, Rhabdomyolysis/myopathy (narrow), Cardiac failure (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (narrow), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hyponatraemia/SIADH (narrow), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteonecrosis (broad), Generalised convulsive seizures following immunisation (narrow), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: fluoxetine (PROzac) 40 MG capsule Take 1 capsule by mouth daily. lamoTRIgine (LaMICtal) 25 MG tablet Take 1 tab PO qPM for 2 weeks, then take 1 tab BID for 2 weeks and then increase by 1 tab every two weeks up to 2 tabs BID lisinopril (ZEST
Current Illness:
Preexisting Conditions: Autism Essential (primary) hypertension
Allergies: None
Diagnostic Lab Data: Severe sepsis, unknown origin, without end organ failure o SIRS/Sepsis criteria met o No source of infection identified clinically or through diagnostic imaging o Temperature 97.3?F, heart rate 103 BPM, respiratory rate 22, and WBC equals 15.9 upon arrival o Lactic acid equals 2.2 upon arrival o Procalcitonin equals 0.76 upon arrival o Blood cultures ?2 drawn. o Urinalysis unremarkable o Septic shock perfusion assessment completed o Patient meets criteria for severe sepsis but not septic shock o Patient does not meet criteria for fluid resuscitation Rhabdomyolysis o Unwitnessed fall and immobile on floor for unknown number of hours on 03/30/2021 o CPK 4870 upon arrival Elevated NTproBNP o NTproBNP 2117 upon arrival o Absent peripheral edema o Absent signs of vascular congestion upon imaging Elevated troponin I level o Troponin 1.58 upon arrival, peaked at 1.88 o EKG demonstrates sinus tachycardia with 1st degree AV block and RBBB, rate 101, QTc 487 Closed anterior dislocation of right glenohumeral joint o Presented to ED with right should deformity o Dislocation apparently sustained during fall on 03/30/2021 o Treatment discussed with Orthopedic Surgery by ED provider o Closed reduction successfully reduced in the ED and verified by repeat shoulder xray o Upon admission right shoulder active and passive range of motion intact o Distal neurovascular status intact Hyponatremia o Serum sodium 129 upon arrival o Baseline sodium 140 on 12/10/2020 Hypomagnesemia o Magnesium 1.6 upon arrival o Magnesium sulfate 2 g IVPB ordered
CDC Split Type:

Write-up: Patient is a 50 year old female with history significant for autism, developmental disability, hypertension, seizures, frequent falls, Tourette syndrome, s/p CVA. She presented 3/31/2021, through the Emergency Department from home with following an unwitnessed fall. She was found by her mother this evening on the floor at the bottom of a flight of stairs. She was last seen by her mother sometime in the morning. Patient not capable of providing history as verbalizations are limited at baseline to occasional single word expressions of needs. Patient was noted in the ED to have multiple bruises to her head, arms and legs in various stages of healing. Patient lives with her mother who is also her legal guardian. Mother was poor historian in the ED and was unable to help determine how long patient was on the floor. Patient''s mother verbalized to ED provider that she is not able to supervise the patient at all times due to her own medical needs. ED provider noted that upon leaving the ED the patient''s mother stated to staff that they should put the patient out of her misery. County Crisis Center was contacted by ED staff and a referral was made to Adult Protective Services. Patient does not answer review of systems questions when asked. Admit date: 3/30/2021 Discharge date: 4/5/2021 Primary diagnoses: Principal Problem: Severe sepsis, unknown origin, without end organ failure o Resolving, no fever o Vancomycin stopped. o Wbc improving, fever resolved o Blood cultures still negative o After 4days of IV antibiotics she was transitioned to oral augmentin whenDcing flagyl. o PCP to follow fever curve, white count... CT chest abdomen and pelvis negative at admission Blood cultures have remained negative Active Problems: Benign essential HTN Developmental disability Residual autistic disorder Fall o Most recent fall 03/30/2021, unwitnessed, possibly down unknown number of stairs o Followed by Neurology, for frequent falls, EEG on 01/18/2021 abnormal with focal epileptic seizures suspected, she has been started on Lamictal taper o Continue Lamictal as prior to admission Rhabdomyolysis o Due to Unwitnessed fall and immobile on floor for unknown number of hours on 03/30/2021 o CPK trending down. Kidney function has remained normal with ongoing IV infusion Hyponatremia Elevated troponin I level Cardiology, Dr. consulted from the ED, elevated troponin suspected to be secondary to rhabdomyolysis o Troponin 1.58 upon arrival, peaked at 1.88 and declining is subsequently o EKG demonstrates sinus tachycardia with 1st degree AV block and RBBB, rate 101, QTc 487 Echo was normal at 60% ejection fraction Closed anterior dislocation of right glenohumeral joint was reduced in the emergency department which will explain the large bruise over her right shoulder right shoulder active and passive range of motion intact Hypomagnesemia

VAERS ID:	1365116 (history)
Form:	Version 2.0
Age:	30.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-20
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	044B21A / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Postpartum haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow)

Write-up: Patient hospitalized for delivery of a healthy baby girl. The baby weighed 7 pounds 2.5 ounces. Per doctor''s notes: Her postpartum course was complicated by delayed postpartum hemorrhage requiring Methergine, Cytotec, and Hemabate, which controlled bleeding.

VAERS ID:	1365456 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-04-04
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-06-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	LA / SYR

Administered by: School Purchased by: ?
Symptoms: Atrial fibrillation, Electrocardiogram abnormal, Laboratory test normal
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, Testosterone gel
Current Illness: None
Preexisting Conditions: None
Allergies: none
Diagnostic Lab Data: EKG''s. My full lab panel shows I''m incredibly healthy. Waiting to see another Cardiologist on the course of action to correct the A-fib.
CDC Split Type:

Write-up: Since covid vaccination I developed A-Fib. My family practice Dr as well as the cardiologist I recently saw both believe that there could be a link between the Johnson & Johnson vaccine and possible inflammation that could be causing me to be having A-Fib.

VAERS ID:	1367747 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-04-30
Days after vaccination:	29
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Catheterisation cardiac, Echocardiogram, Magnetic resonance imaging heart, Myocarditis
SMQs:, Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Myocarditis

VAERS ID:	1367760 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-05-26
Days after vaccination:	55
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808978 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Cardiac imaging procedure abnormal, Chest pain, Computerised tomogram thorax abnormal, Cough, Ejection fraction, Electrocardiogram ST segment elevation, Fatigue, Left ventricular failure, Liver function test increased, Lung consolidation, Myocarditis, Pleural effusion, Pneumonia, Pyrexia, Splenomegaly, Troponin increased
SMQs:, Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), Immune-mediated/autoimmune disorders (broad)

Write-up: Pt presented with 1 week of progressive fatigue, dry cough, chest pain, nocturnal fevers. Presented to ER on 5/30/2021, hs troponins were 71 twice. Discharged with advice for symptom management with antipyretics. Symptoms worsened and pt returned to ER, worsening CP and fevers up to 100+F. Repeat troponins 1100 to 1200+, elevated LFTs, diffuse 1mm J point elevation on EKG Cardiac MRI 6/1/2021: IMPRESSION: 1. Patchy subepicardial left ventricular delayed enhancement, greatest in the basal inferolateral wall, compatible with myocarditis. Normal left ventricular size and systolic function. LVEF = 52%. 2. Patchy consolidation in the right lower lobe consistent with pneumonia. Small right pleural effusion. 3. Mild splenomegaly. CT chest RLL consolidation, splenomegaly

VAERS ID:	1368362 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-20
Onset:	2021-05-21
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Cardiac stress test normal, Chest pain, Computerised tomogram thorax normal, Dizziness, Echocardiogram normal, Electrocardiogram normal, Fibrin D dimer increased, Myalgia, Myocarditis, Nausea, Sinus rhythm, Troponin
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Haemorrhage laboratory terms (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Patient experienced myalgias, dizziness and nausea. Single episode of mild chest pain 2 minutes day prior to presentation. Diagnosed with myocarditis in the Emergency Department (5/24/2021) and admitted for treatment. Discharged on 5/26/2020.

VAERS ID:	1368464 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-19
Onset:	2021-04-20
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	047B21A / 2	RA / -

Administered by: Unknown Purchased by: ?
Symptoms: Magnetic resonance imaging, Pulmonary embolism, Ultrasound scan, X-ray
SMQs:, Embolic and thrombotic events, venous (narrow)

Write-up: Pulmonary Embolism in both lungs

VAERS ID:	1368470 (history)
Form:	Version 2.0
Age:	13.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-26
Onset:	2021-05-30
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Blood alkaline phosphatase increased, Blood creatine phosphokinase increased, Blood lactic acid normal, Borrelia test negative, C-reactive protein normal, Computerised tomogram head normal, Dissociative disorder, Drooling, Fatigue, Full blood count normal, Headache, Metabolic function test normal, Muscular weakness, Musculoskeletal stiffness, Myalgia, Pain, Pregnancy test negative, SARS-CoV-2 test negative, Staring, Urine analysis normal, Weight bearing difficulty, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Liver related investigations, signs and symptoms (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Biliary system related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Write-up: Patient is a 13 year old female who presents to the clinic today with her mother for a follow up ER visit from 5/30/21. Patients mother reports that patient had received her first Pfizer COVID-19 vaccination on 5/26/21, and developed a headache on Thursday. On Friday, mother and patient report that she had a very active day at school, and in Phy-Ed she did a cardio work out, followed by a 10 minute run and then golf practice after school. Patient reports that she does not frequently go running. Saturday, mom reports that patient was fatigued and rested most of the day. Sunday, she was up at 5am and was working by 6am until noon at the family restaurant. Her mother reports that it was very busy at the restaurant. Later in the afternoon on Sunday, the family went to their lake house in New Auburn, MN. Mother reports that the patient ate a good supper and the patient was asked to take the dog for a walk around 8pm. Patient took the dog for a walk for about 5 minutes, and then came back and went to her room, and her older sister found her lying in her room with her arms flexed and legs extended. Mom reports that she was drooling, staring and her muscles were stiff, and she wouldn''t bear weight on her legs. This lasted approximately 10 minutes and she was transferred by ambulance to the Bloomer ER for evaluation. Initial ER workup in Bloomer showed leukocytosis at 11.4, a CK of 333, and an alk phos of 263. Her CBC, Comp, CRP, Lactate, pregnancy, lymes, COVID and UA were all within normal limits. A head CT was negative as well. Given her symptoms, she was transferred from Bloomer ER to St. Mary''s in Rochester to the general pediatric floor early Monday morning. Peds neurology consulted and diagnosed her with dissociative (non-epileptic) attack, and discharged her home around 5pm on Monday evening with family. Since discharge, she reports that she is still experiencing fatigue, a mild headache, and her quadricep muscles feel weak and ache. Mom reports that she has been monitored by family since discharge and she has not had another episode since. For pain, she is taking tylenol and ibuprofen with minimal relief. She has started her menses, her onset of menarche was January, 2021, and she did not have a menstrual cycle in February, March or April, and she began her menses on 5/24 through 5/30. Clinic recommends oupatient testing for an EEG, Echo, EKG and MRI and follow up with neurology.

VAERS ID:	1368515 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-20
Onset:	2021-05-29
Days after vaccination:	70
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 1	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0162 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Chills, Headache, Pyrexia, SARS-CoV-2 test positive, Scrotal cellulitis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Positive COVID-19: 5/29/2021 Admitted for scrotal cellulitis, fever, chills, headache Was positive for COVID-19 on 2/7/2021

VAERS ID:	1368533 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-21
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	044B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Chemotherapy, Pancytopenia
SMQs:, Agranulocytosis (narrow), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Myelodysplastic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patient presented to the ED and was subsequently hospitalized for Pancytopenia due to antineoplastic chemotherapy within 6 weeks of receiving COVID vaccination.

VAERS ID:	1368543 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-05-31
Days after vaccination:	74
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Cardiac arrest, SARS-CoV-2 test positive, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: He was admitted to Hospital unresponsive as Ventricular Fibrillation cardiac arrest. Found to be COVID-19 positive upon testing on 5/31/2021. No prior positive tests on record.

VAERS ID:	1368686 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-05-05
Days after vaccination:	29
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Diplopia, Dizziness, Vertebrobasilar insufficiency
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Vestibular disorders (broad), Ocular motility disorders (broad), Hypoglycaemia (broad)

Write-up: Patient presented to the ED on 5/5/2021 for dizziness and double vision. Patient was subsequently hospitalized with vertebrobasilar insufficiency. These visits are within 6 weeks of receiving COVID vaccination.

VAERS ID:	1368699 (history)
Form:	Version 2.0
Age:	62.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-05-30
Days after vaccination:	54
Submitted:	0000-00-00
Entered:	2021-06-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / UNK	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Asthenia, Pain in extremity, Peripheral artery thrombosis, Peripheral coldness, Skin discolouration, Supernumerary rib
SMQs:, Congenital, familial and genetic disorders (narrow), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad)

Write-up: patient has developed blood clot after getting the J&J shot on 4/6/2021. The patient has had a sore arm since the day he got his vaccine. According to his wife, he started to feel weak on Sunday 5/30/2021. She said his hands were cold that day too, then by Tuesday his fingers turned white, this is when she took him to the hospital and found out about the blood clot. His wife also mentioned that after examination, they found out that he has an extra rib that was pressing on the brachial artery and that might have caused the blood clot. It doesn''t seem to be sure that the blood clot was caused by the covid vaccine or not

VAERS ID:	1371416 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-06-02
Days after vaccination:	69
Submitted:	0000-00-00
Entered:	2021-06-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER 8727 / 2	- / -
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6205 / 1	- / -

Administered by: Public Purchased by: ?
Symptoms: COVID-19, Cough, Dyspnoea, Fatigue, Headache, Rhinorrhoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client is fully vaccinated using Pfizer vaccine. Last dose on 3/25/2021. Tested positive for COVID -19 on 6/2/2021. Symptoms included: cough, shortness of breath, fatigue, headache, and runny nose. Vaccine given at hospital

VAERS ID:	1371438 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-16
Onset:	2021-06-01
Days after vaccination:	105
Submitted:	0000-00-00
Entered:	2021-06-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-06-01
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Client tested positive for COVID-19 on 5/18/21 client died of COVID pneumonia on 6/1/21
CDC Split Type:

Write-up: Clinet was vaccinated on 2/16/21 and on 3/9/21

VAERS ID:	1371545 (history)
Form:	Version 2.0
Age:	42.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-07
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / 1	RA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Arthralgia, Blood test, Electromyogram, Fatigue, Gait disturbance, Headache, Joint swelling, Lumbar puncture, Lymph node pain, Magnetic resonance imaging, Muscular weakness, Pain in extremity
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Levothyroxin Estradiol
Current Illness: None
Preexisting Conditions: None
Allergies: Amoxicillin,codien, kenaject,levofloxacin, ondansetron, sulfamethoxazole w trimethoprim, Varencline, leuprolid Acetate
Diagnostic Lab Data: Blood work, 4 MRI?s, EMG, spinal tap
CDC Split Type:

Write-up: Both feet hurt the day shot. As days go by the pain was in lymph nodes on my shins. The pain started moving up my legs as days passed. Fatigue. Headaches. By may 18th the pain was up to my hips, arms, and hands. My joins felt swollen. Muscle weakness in legs and arms. Difficult to walk.Was admitted to the hospital on the 19th. For 5 days

VAERS ID:	1371625 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-24
Onset:	2021-05-25
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 1	RA / IM

Administered by: Public Purchased by: ?
Symptoms: Catheterisation cardiac, Chest pain, Chills, Electrocardiogram, Headache, Injection site pain, Laboratory test, Myocardial infarction, Myocarditis, Pain in extremity, Ultrasound scan
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Per Client received COVID 19 in right arm on 5/24/2021, soreness at injection site on same day of vaccine. On 5/25/2021 around 4 am, started having chills and headache. On 5/26-5/27/2021 headache worsened and by Friday on 5/28/2021, along with headache, left sided pain in chest and arm. Per patient was taken to ER by wife and admitted to hospital on 5/28/2021. Per Client, was told first by hospital that he was having a heart attack. Client reported having labs collected, EKG, Catheterization and Ultra Sound. Per Client, later diagnosed with "myocarditis" and is now taking multiple mediations. Per Client was discharged from hospital on 5/29/2021, that evening. Will be following up with PCP in one week.

VAERS ID:	1371756 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-05-04
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-06-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0169 / 2	LA / IM

Write-up: Patient presented to the ED and was subsequently hospitalized for cryptogenic stroke within 6 weeks of receiving COVID vaccination.

VAERS ID:	1371810 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-05-11
Days after vaccination:	34
Submitted:	0000-00-00
Entered:	2021-06-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Aortic valve replacement, Catheterisation cardiac
SMQs:

Write-up: Patient hospitalized for 6 hours after having a cardiac catheterization on 5/11/2021. He was also hospitalized on 5/12/2021 for TAVR. These visits are within 6 weeks of receiving COVID vaccination.

VAERS ID:	1371862 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-02
Onset:	2021-06-03
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Anxiety, Asthenia, Blood gases, Blood lactic acid, Brain natriuretic peptide, Chest X-ray, Dyspnoea, Full blood count, Metabolic function test, Oxygen therapy, Procalcitonin, SARS-CoV-2 test, Tremor, Troponin, Urine analysis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Respiratory failure (broad), Hypoglycaemia (broad), COVID-19 (broad)

Write-up: Pt is a resident in a SNF. He went for dose 2 of his Pfizer Covid series at 950am on 6/2. At 12:30am on 6/3 he became weak, anxious, SOB and required oxygen supplementation. He was shaking and weak and transferred to hospital via ambulance.

VAERS ID:	1374769 (history)
Form:	Version 2.0
Age:	34.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-19
Onset:	2021-01-22
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-06-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013LZUA / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Cardiac imaging procedure abnormal, Catheterisation cardiac normal, Echocardiogram normal, Ejection fraction, Myocarditis, Troponin increased
SMQs:, Myocardial infarction (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Myocarditis requiring hospitalization and medication treatment

VAERS ID:	1375050 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-14
Onset:	2021-04-28
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-06-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0169 / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-28
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: none known
CDC Split Type:

Write-up: Client was screened as per CDC guidelines and had no contraindications for receiving the vaccine on 4/14/2021. LCHD had no notice of any adverse issues. He did not present to the 2nd dose clinic and follow up phone calls revealed that he had died on 4/28/2021.

VAERS ID:	1375608 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-17
Onset:	2021-04-14
Days after vaccination:	28
Submitted:	0000-00-00
Entered:	2021-06-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER2613 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Patient hospitalized within 6 weeks of receiving COVID vaccination.

VAERS ID:	1375926 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-29
Onset:	2021-06-01
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-06-04

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	180898 / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-06-01
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: mometasone nasal spray, cetirizine , buspirone, sertraline, spiriva, ipratropium nasal spray, symbicort, proair, metoprolol, omeprazole, gabapentin, atorvastatin,
Current Illness: Ongoing abdominal issues
Preexisting Conditions: See meds
Allergies: No
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patients wife stated he was found dead on floor the morning of 6/1/21 and exact time of death was unknown. It sounded like cause was unknown.

VAERS ID:	1376548 (history)
Form:	Version 2.0
Age:	90.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-01
Onset:	2021-06-04
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-06-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	038C21A / 1	AR / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Abdominal discomfort, Asthenia, Chills, Death, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-06-04
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: bumetanide, pramipexole, lidocaine patch, asa, vitamin D, Multaq, calcium +D, potassium, benefiber, bystolic, alphagan, hydrocodone/apap, latanoprost, omeprazole, acetaminophen
Current Illness: Admitted 5/10-5/12/21 post syncopal episode. Found to be orthostatic. Potassium supplement added. Reportedly had a few short asympt runs of V tach in hospital.
Preexisting Conditions: a fib, CKD 3b, h/o AKI, fecal incontinence, unsteady gait, protein calorie malnutrition, hypokalemia, vertebral compression fracture
Allergies: HCTZ, furosemide, indapamide, metoprolol, PCN, propranolol. reactions not known.
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt developed GI upset and weakness on 6/2, followed by chills and emesis 6/3. Was found deceased on the toilet on the morning of 6/4/21.

VAERS ID:	1376731 (history)
Form:	Version 2.0
Age:	29.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-23
Onset:	2021-06-04
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-06-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Contusion, Petechiae, Platelet count decreased
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Accidents and injuries (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Non-traumatic bruising. Petechiae in random areas of body. Denies history of bleeding disorders in self or family. PLT <3.

VAERS ID:	1377273 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-08
Onset:	2021-05-26
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-06-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0183 / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, COVID-19, COVID-19 pneumonia, Hypoxia, SARS-CoV-2 test positive
SMQs:, Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received first dose of COVID-19 vaccine on 5/8/21, pt later became ill with COVID19, presenting to ED for testing on 5/22/2021 but was not admitted at this time because symptoms were more mild and manageable at home. Returned to ED on 5/26 and at this time was admitted for weakness and hypoxemia related to COVID pneumonia. Discharged 6/1/2021

VAERS ID:	1378005 (history)
Form:	Version 2.0
Age:	66.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-05-18
Days after vaccination:	48
Submitted:	0000-00-00
Entered:	2021-06-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, COVID-19 pneumonia, Condition aggravated, Cough, Diarrhoea, Myalgia, Pulmonary congestion
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Supraventricular tachyarrhythmias (narrow), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt had first dose of Pfizer COVID vaccine on 3/9/2021 and second dose on 3/31/2021. Pt tested positive for COVID-19 on 5/18/2021 and did have symptoms, such as diarrhea, myalgia, and cough/chest congestion. He presented to the ED on 6/2/2021 and was admitted for COVID-Pneumonia and afib with RVR. Pt still inpatient.

VAERS ID:	1381815 (history)
Form:	Version 2.0
Age:	14.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-28
Onset:	2021-05-30
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-06-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0191 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Diarrhoea, Gait disturbance, Gait inability, Pain, Peripheral swelling, Rheumatoid factor, Urticaria, White blood cell count
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (narrow), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: 2 days post vaccination patient developed hives--parent treated with Benadryl, 3 days post vaccination--patient''s finger began swelling, worsening symptoms over following 4 days included increased difficulty walking (started with a limp), diarrhea, extreme pain with inability to walk Patient went to ER--admitted and given IV Toradol

VAERS ID:	1382033 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-06-07
Days after vaccination:	96
Submitted:	0000-00-00
Entered:	2021-06-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043L20A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	014M20A / 2	RA / IM

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

Write-up: Pt is fully vaccinated with the Moderna COVID-19 vaccine, first dose being received on 2/3/21 and second on 3/3/21. Pt tested positive for COVID-19 on 6/7/2021, presented to the ED with symptoms, and was ill enough to be admitted to our hospital on 6/7/2021. Pt still inpatient

VAERS ID:	1382317 (history)
Form:	Version 2.0
Age:	49.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-28
Onset:	2021-01-06
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-06-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL0140 / 1	UN / IM

Administered by: Private Purchased by: ?
Symptoms: Audiogram abnormal, Deafness neurosensory, Deafness unilateral, Magnetic resonance imaging head abnormal, Sudden hearing loss, Tympanoplasty
SMQs:, Hearing impairment (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Spironolactone Norvasc Cozaar Diclofenac Glipizide
Current Illness: none
Preexisting Conditions: Hypertension, Diabetes Type 2
Allergies: Sulfa
Diagnostic Lab Data: 1/14/2021-Audiology test and ENT visit 1/19.2021- IAC MRI 1/27/2021- Audiology test and Intratympanic Steroid injection 2/3/2021-Audiology test and Intratympanic Steroid injection 2/10/2021- Audiology test and Intratympanic Steroid injection 3/10/2021- ENT office visit 4/2/2021 Tympanoplasty surgery 4/22/2021- ENT office visit 5/12/2021- ENT office visit
CDC Split Type:

Write-up: Sudden Idiopathic Sensio Neuro Hearing Loss in the my left ear, severe/profound loss

VAERS ID:	1382688 (history)
Form:	Version 2.0
Age:	36.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-19
Onset:	2021-05-20
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time, Acute myocardial infarction, Amblyopia, Astigmatism, Blood calcium normal, Blood chloride normal, Blood cholesterol normal, Blood creatinine normal, Blood potassium normal, Blood sodium normal, Blood triglycerides normal, Blood urea decreased, Carbon dioxide increased, Cardiac telemetry normal, Chest discomfort, Chest pain, Chills, Dysphagia, Echocardiogram normal, Ejection fraction normal, Electrocardiogram PR segment elevation, Electrocardiogram ST segment elevation, Electrocardiogram abnormal, Glomerular filtration rate, High density lipoprotein decreased, Influenza like illness, International normalised ratio, Low density lipoprotein normal, Musculoskeletal discomfort, Myocarditis, Non-high-density lipoprotein cholesterol, Pain, Pyrexia, Skin lesion, Troponin, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Dyslipidaemia (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Optic nerve disorders (broad), Cardiomyopathy (broad), Corneal disorders (narrow), Lipodystrophy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Cardiology Consult: Patient ID: (Name) Date of birth: (Date) Primary Care Provider: (Name), MD Admitting Provider: (Name), MD Admitted: 5/22/2021 Reason for Admission: Chest pain SUMMARIZED H&P: Patient is a 36 year old male with no significant past medical history, healthy gentleman, that presents post covid vaccine with chest pain. He got his second dose of Moderna vaccine on Wednesday and then later that evening developed fevers, chills, body aches and flu likely symptoms. They continued through Thursday evening. He was taking ibuprofen but was having a hard time swallowing it. He started developing neck and chest discomfort and initially thought it was due to difficulty with pills. Symptoms continued through Friday despite the flu like symptoms improving. They talked to a family member that recommended they present for presentation. On presentation EKG showed diffuse ST elevation with PR depression. PR elevation in V4. Troponin peaked at 16.57 and is now 6.59. Echo with normal EF and no effusion. He was started on colchicine yesterday. Tele without any arrhythmias. He reports that symptoms were worse when laying down or taking deep breaths. Has not had any symptoms today. No history of heart disease, exertional symptoms or family history of early CAD Patient Active Problem List: Skin lesion of left leg Anisometropic amblyopia of right eye Myopia of both eyes with astigmatism NSTEMI (non-ST elevated myocardial infarction) PMH: has no past medical history on file. PSH: has a past surgical history that includes pr create eardrum opening,gen anesth (11/06). FH: family history is not on file. SH: reports that he has never smoked. He has never used smokeless tobacco. Social History Occupational History ? Not on file Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used Substance and Sexual Activity ? Alcohol use: Not on file ? Drug use: Not on file ? Sexual activity: Not on file Allergies: has No Known Allergies. Medications: Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider fexofenadine (ALLEGRA) 180 MG tablet Take 180 mg by mouth once daily as needed Yes Provider, Historical, MD FIBER PO Take 1 tablet by mouth once daily Yes Provider, Historical, MD ibuprofen (MOTRIN) 200 MG tablet Take 200-600 mg by mouth every 6 hours as needed for Pain Yes Provider, Historical, MD Review of Systems: A 10 point ROS was obtained and was otherwise negative except for chest pressure Physical Exam: GENERAL: thin, well-appearing individual in no apparent distress. Vital Signs:*BP 98/70 Pulse 79 Temp 96.3 ?F (35.7 ?C) (Oral) Resp 18 Ht 5'' 11" (1.803 m) Wt 156 lb 6.4 oz (70.9 kg) SpO2 98% BMI 21.81 kg/m2Body mass index is 21.81 kg/m?. EYES: EOM intact bilaterally. EARS: hearing is grossly intact. NOSE: patent and moist. OROPHARYNX: moist and pink. NECK: supple, no masses, no adenopathy, no thyromegaly, no JVD, no carotid bruits. LUNGS: Clear to auscultation bilaterally. No rhonchi, rales or wheezes. HEART: Regular rate and rhythm, normal S1 and S2, no murmur(s). No rubs or gallops. ABDOMEN: Soft, nondistended. Nontender to deep palpation. No palpable masses, or organomegaly. Positive bowel sounds. EXTREMITIES: No clubbing,cyanosis. no pedal edema. CIRCULATION: 2+ pedal pulses bilaterally. SKIN: No rashes or open lesions. NEURO/PYSCH: No gross focal deficits. Alert and oriented x 3. Appropriate affect and mood. Most recent diagnostics and Labs: Recent Labs Component Name 05/23/21 0808 CHOLESTEROL 142 TRIGLYCERIDE 60 HDL 44 LDL 86 NONHDL 98 Recent Labs Component Name 05/23/21 0808 05/22/21 1415 WBC 6.0 9.1 Recent Labs Component Name 05/23/21 0808 05/22/21 1415 SODIUM 141 140 POTASSIUM 3.8 4.0 CHLORIDE 104 102 CO2 32* 27* BUN 11 8 CREATININE 0.90 0.9 CALCIUM 9.4 9.2 GFR $g90 $g90 No results for input(s): APT, INR in the last 87600 hours. Echo: ? Ejection fraction is 5560%. Question extremely mild area of inferoapical hypokinesis. ? There is no clinically significant regurgitation or stenosis. ? Pulmonary arterial systolic pressure is within the normal range. ? No significant pericardial effusion. IMPRESSION: Myopericarditis 2/2 covid vaccine - EKG changes and positive troponin - No evidence of effusion - troponin trending down and symptoms are improving PLAN: I reviewed findings with patient and his fianc?. We discussed pathophysiology and treatment. Since he had a difficult time with ibuprofen, we will treat with colchicine for 6 weeks at 0.6mg BID. Discussed side effect of diarrhea. I reviewed recommendations for avoiding strenuous activity and contact sports for 1 month due to cardiac inflammation. I reviewed risk of cardiac arrhythmias with myopericarditis and do recommend continuing with metoprolol on discharge. Recommend follow up with general cardiology in 4-6 weeks for follow up Thank you, (Name), DO Cardiac Electrophysiology

VAERS ID:	1384941 (history)
Form:	Version 2.0
Age:	20.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-03
Onset:	2021-06-05
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Brain natriuretic peptide normal, Chest pain, Echocardiogram normal, Ejection fraction normal, Fibrin D dimer normal, Myocarditis, Troponin increased
SMQs:, Myocardial infarction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Acute myocarditis, pluritic chest pain, elevated troponins. normal echo

VAERS ID:	1384998 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-26
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0169 / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: ED/Multiple hospitalizations within 6 weeks of receiving COVID vaccination.

VAERS ID:	1385049 (history)
Form:	Version 2.0
Age:	67.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-01
Onset:	2021-05-03
Days after vaccination:	122
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Cardiac tamponade, Computerised tomogram thorax abnormal, Echocardiogram abnormal, Laboratory test abnormal, Pericardial effusion, Pericarditis
SMQs:, Systemic lupus erythematosus (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Pericarditis with large bloody pericardial effusion and tamponade physiology. A life threatening event.

VAERS ID:	1385184 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-11
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6205 / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Acute kidney injury, Dehydration, Haematuria, Hypokalaemia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow), Hypokalaemia (narrow)

Write-up: Patient presented to the ED on 3/11/2021 for dehydration and acute kidney injury. Patient had second vaccination dose on 3/24/2021. Patient hospitalized on 5/3/2021 for hypokalemia. Patient presented to the ED on 5/6/2021 for gross hematuria. These visits are within 6 weeks of receiving covid vaccinations.

VAERS ID:	1385195 (history)
Form:	Version 2.0
Age:	98.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-05-07
Days after vaccination:	37
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Lumbar spinal stenosis, Spinal claudication
SMQs:

Write-up: Patient presented to the ED and was subsequently hospitalized within 6 weeks of receiving COVID vaccination. Diagnosis was Spinal stenosis of lumbar region with neurogenic claudication.

VAERS ID:	1385946 (history)
Form:	Version 2.0
Age:	84.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-24
Onset:	2021-04-13
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8733 / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Atrioventricular block, Bradycardia, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Write-up: Patient presented to the ED on 4/13/2021 for syncope. Patient presented to the ED and was subsequently hospitalized on 4/23/2021 for bradycardia, AV block. These visits are within 6 weeks of receiving COVID vaccination.

VAERS ID:	1385986 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-04-29
Days after vaccination:	42
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 2	- / -

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: ED/Hospitalization within 6 weeks of receiving COVID vaccination.

VAERS ID:	1386167 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-02
Onset:	2021-06-07
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-06-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	017C21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Anticoagulant therapy, Brain natriuretic peptide, C-reactive protein increased, Chest X-ray abnormal, Chest pain, Computerised tomogram thorax, Electrocardiogram ST-T change, Electrocardiogram abnormal, Fibrin D dimer, Laboratory test, Leukocytosis, Pericarditis, Pulmonary congestion, Troponin, White blood cell count increased
SMQs:, Cardiac failure (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Patient brought to ED 6/8 am with substernal chest pain onset 6/7 pm. Tests include EKG, chest xray, serial troponin, Chest CT, BNP, d dimer, labs. Patient admitted for further work up which ruled out PE, aortic dissection, pneumothorax. Initial EKG showed ST changes in inferior lead and repeat EKG consistent with pericarditis. CXR showed pulmonary vascular congestion and prominent interstitial markings. WBC showed leukocytosis. Elevated CRP. Patient started on aspirin and colchicine with improvement and discharged home.

VAERS ID:	1388335 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-03
Onset:	2021-03-26
Days after vaccination:	23
Submitted:	0000-00-00
Entered:	2021-06-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 1	UN / IM

Administered by: Other Purchased by: ?
Symptoms: Traumatic intracranial haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow)

Write-up: Patient presented to the ED and was subsequently hospitalized for Traumatic hemorrhage of cerebrum without loss of consciousness within 6 weeks of receiving COVID vaccination.

VAERS ID:	1390368 (history)
Form:	Version 2.0
Age:	31.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-27
Onset:	2021-04-26
Days after vaccination:	89
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	043L20A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Anxiety, Echocardiogram abnormal, Electrocardiogram abnormal, Full blood count, Heart rate abnormal, Heart rate irregular, Insomnia, Pericardial effusion, Stress, Troponin increased
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Write-up: I started feeling that my heart rate is not steady and it?s very irregular. I had trouble sleeping from my heart beata for 2 weeks and I thought it was stress or anxiety. I went to see a doctor, they drew blood and then called me after 2 days and said I had to go to the ER because Troponin level was so high. I went to the ER and they kelt me at the hospital for 30 hours to monitor my Troponin level and they did and ECG and Echocardiogram. They said it was Pericardial effusion and Pericarditis. They prescribed me Ibuprofen 400 tid and my doctor have me Propranolol 20mg qd.

VAERS ID:	1391510 (history)
Form:	Version 2.0
Age:	14.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-21
Onset:	2021-05-22
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0183 / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: C-reactive protein increased, COVID-19, Chest X-ray abnormal, Cough, Lung disorder, Pneumonia, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient reports cough and fever since 5/22. Was seen by pediatrician in clinic on 5/25, diagnosed with pneumonia and prescribed azithromycin. Parent reported compliance with medication but reported that patient started to have coughing fits and fever of 104 at home. This prompted ER evaluation and subsequently admitted to hospital for observation. During admission, patient was treated with IV Ceftriaxone x 3 days and PRN Mucinex for pneumonia. No oxygen requirements, so no further intervention was needed per MD.

VAERS ID:	1391609 (history)
Form:	Version 2.0
Age:	21.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-08
Onset:	2021-06-09
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	054C21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Electrocardiogram abnormal, Malaise, Myocardial infarction, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Patients mother called. Her some began having symptoms (I believe she said) the day after the vaccine. Fever, feeling under the weather. Began having chest pains and shortness of breath. He was admitted to the hospital 2 days after vaccine. An EKG was performed showing the patient was experiencing mini heart attacks.

VAERS ID:	1391706 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-29
Onset:	2021-05-04
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	017C21A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood culture positive, C-reactive protein increased, COVID-19, Chest X-ray, Chills, Computerised tomogram thorax normal, Cough, Diarrhoea, Dyspnoea, Hyperhidrosis, Hypotension, Pyrexia, SARS-CoV-2 test positive, Staphylococcal infection
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Presented to ER with fever, chills, cough, shortness of breath and diarrhea. Suddenly became hypotensive and diaphoretic in ER, which prompted hospital admission. Had 1/2 positive blood cultures during admission of coagulase negative staph, which was thought to be contaminant. Recieved 1 dose of IV vancomycin during stay. Required supplemental oxygen during admission and received 2 doses of dexamethasone while inpatient.

VAERS ID:	1391785 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-05-03
Days after vaccination:	32
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 1	RA / IM

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

Write-up: Patient presented to the ED and was subsequently hospitalized for Cerebrovascular accident (CVA) due to occlusion of left middle cerebral artery within 6 weeks of receiving COVID vaccination.

VAERS ID:	1391835 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-18
Onset:	2021-05-24
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025C21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, C-reactive protein increased, COVID-19, Chest X-ray abnormal, Confusional state, Exposure to SARS-CoV-2, Fall, Pneumonia bacterial, Procalcitonin increased, Pyrexia, SARS-CoV-2 test positive, Superinfection
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Tested positive for COVID on 5/24 after exposure to family member. Presented to ER with increased weakness, confusion, fevers and fall at home. Patient admitted to hospital for suspected superimposed bacterial pneumonia and treated with IV antibiotics then subsequently discharged on oral cefprozil to complete 7 days.

VAERS ID:	1391866 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-01
Onset:	2021-06-10
Days after vaccination:	129
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / IM

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

Write-up: Reporting as patient has completed Moderna vaccine series and was admitted to the hospital with diagnosis of "pneumonia due to COVID-19 virus"

VAERS ID:	1391968 (history)
Form:	Version 2.0
Age:	45.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-15
Onset:	2021-05-01
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-06-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Anticoagulant therapy, Blood test abnormal, Cartilage injury, Hormone level abnormal, Impaired work ability, Injury, Loss of employment, Magnetic resonance imaging abnormal, Meniscus injury, Mobility decreased, Pain, Pain in extremity, Thrombosis, Ultrasound Doppler abnormal, X-ray
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Thrombophlebitis (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad)

Write-up: Started getting pain in my right leg on May 1st, seen my Family Dr. on 4/29/21 clean bill of health. Pain wouldn?t go away was going to my chiropractor the whole month of May 2 times a week, for my right leg, I favored that leg never missing work, I?m a childcare provider. On 31May2021 the pain went down my leg and behind my knee just throbbing, I was walking up steps and a loud snap happens in my leg dropped me right there couldn?t move. Was taken to the ER, where they found a blood clot in my leg which caused pressure to build up on my knee which ruptured my meniscus, damaged joints, and cartilage in my knee. They put me on blood thinners, have to have surgery and can?t for 3 months I have to be off blood thinners. Can?t work and was forced to close my daycare business of 18 yrs and sell everything due to this injury. My Dr has linked it to the vaccine my blood wok showed high levels of hormones. Never ever had an issue until I got second shot. So now I?m trying to get disability, not looking good due to me being self employed. So who is gonna step up and help me financially, I was open threw the whole pandemic and this is how I go out of Business! Devastating to say the least?. My Community is shook up over this, so I took one for the team my family refuses to get the vaccine and others have decided NO after hearing my story.

VAERS ID:	1394864 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-02-22
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-06-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN5318 / 2	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Atrial fibrillation, Cardiac operation, Endocarditis bacterial, Heart valve replacement, Illness
SMQs:, Supraventricular tachyarrhythmias (narrow), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 60 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Eliquis
Current Illness: None
Preexisting Conditions: None
Allergies: Cipro, garlic
Diagnostic Lab Data: The four cardiologists who worked together to diagnose the cause of my illmess: please contact them for any needed medical records
CDC Split Type:

Write-up: Four days after injection, I became very ill. First with afib and then with bacterial endocarditis, which led to open heart surgery and replacement of the valve, two months of hospitalization and a month in rehab.

VAERS ID:	1395094 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-02-04
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Other Purchased by: ?
Symptoms: Endodontic procedure, Headache, Hypoaesthesia, Laboratory test normal, Oral pain, Visual impairment
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydroxychloroquine 200mg BID Diclofenac 75mg BID Gabapentin 100mg BID Atenolol 25mg Daily Cyclobenzaprine 10mg TID Hydrocodone/APAP 5-325 TID
Current Illness: Lupus, Celiac Disease, PVCs,
Preexisting Conditions: Lupus, Celiac Disease PVCs
Allergies: Psyllium, wheat, barley, rye oats
Diagnostic Lab Data: Labs 2/17/21, normal
CDC Split Type:

Write-up: At approx 6 pm on the date of my second vaccine, the left side of my face became numb, my vision in the left eye became weak, and I had a headache. I text my doctor that I work for and we decided to monitor, I had labs drawn on 2/17/21, ordered by Dr.. I spoke with my family doctor on 3/15/21, no known cures at this time. My mouth began to hurt and I went to the dentist on 2/25 and needed a root canal for a dead nerve. It took 6 weeks for the numbness and headaches to go away but I never got my full vision back and will be seeing an eye doctor for a correction lens. I made an appointment for 7/23/21 The problem is, nobody knew how to treat the side effects or how long that I was expected to have them. I would never get a Moderna vaccine again

VAERS ID:	1396396 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-27
Onset:	2021-05-12
Days after vaccination:	15
Submitted:	0000-00-00
Entered:	2021-06-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-12
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: In assisted living facility
Preexisting Conditions: Unknown using nasal canula for oxygen
Allergies: None known
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient passed away on 5/12/2021 at assisted living facility

VAERS ID:	1396420 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-05-12
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-06-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-05-12
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown, She had been in the hospital recently before the vaccine dose was given.
Preexisting Conditions: Unknown
Allergies: Codeine, and Erythromycin
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Client passed away on 5/12/2021, she had been residing at assisted living facility.

VAERS ID:	1399287 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-28
Onset:	2021-04-28
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0170 / 1	RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0151 / 2	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Atrial fibrillation, Cardiac stress test, Echocardiogram, Electrocardiogram abnormal
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Patient had an echocardiogram on 5/17/2021 Then was seen by a cardiologist 5/25/2021 Had a stress test done on 6/2/2021 Patient will have a cardio conversion performed on 6/21/2021 to hopefully correct afib
CDC Split Type:

Write-up: Patient developed intermittent afib after first dose but was not seen by a physician at that time, the events were recorded on his smart watch. After second dose, patient went into continuous afib with a blood pressure of 200/120 and a pulse around 200. Went to the local emergency room and was put on cardiac meds, had an ecg that confirmed the diagnosis. Was seen by the primary the next morning and put on a different cardiac med. Still no change to the afib.

VAERS ID:	1399469 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-03-29
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-06-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Deep vein thrombosis
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Write-up: Deep vein Thrombosis

VAERS ID:	1400333 (history)
Form:	Version 2.0
Age:	77.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-29
Onset:	2021-02-05
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-06-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9264 / 1	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood test, Chest X-ray, Electrocardiogram, Hypoaesthesia, Lumbar puncture, Neuropathy peripheral, Paraesthesia
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: I started having numbness in my feet and tingling in my legs, especially my left leg. I went to the ER and they admitted me. I was in the hospital for 3 days. They ran a bunch of tests and they referred me to a specialist. I was diagnosed with some type of a neuropathy. He advised me not to get the second shot.

VAERS ID:	1402481 (history)
Form:	Version 2.0
Age:	15.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-12
Onset:	2021-06-14
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-06-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0182 / 2	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0182 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Adenovirus test, Angiogram normal, Brain natriuretic peptide increased, C-reactive protein increased, COVID-19, Chest pain, Cytomegalovirus test, Echocardiogram normal, Electrocardiogram ST segment elevation, Enterovirus test, Epstein-Barr virus test, Fibrin D dimer, Headache, Human herpes virus 6 serology, Liver function test increased, Parvovirus B19 test, Respiratory viral panel, SARS-CoV-2 antibody test positive, Troponin, Ultrasound scan normal
SMQs:, Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Myocardial infarction (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Received 2nd dose of Pfizer vaccine on 6/12/21. Intermittent headaches since that time. On morning of 6/14/21 developed chest pain (described as achy and in the center of the chest). Denies shortness of breath, radiation of pain, or fevers. 6/15/21-seen at Urgent Care , EKG completed and patient transferred to another hospital. From there he was transferred to one more hospital, given concern for myocarditis. Remains hospitalized as of 6/16/21

VAERS ID:	1402669 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-27
Onset:	2021-06-04
Days after vaccination:	69
Submitted:	0000-00-00
Entered:	2021-06-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	041L20A / 2	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Deep vein thrombosis, Myocardial strain, Pulmonary embolism, Scan with contrast abnormal, Thrombophlebitis superficial, Ultrasound Doppler abnormal
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Thrombophlebitis (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: amlodipine, loratadine, losartan, magnesium oxide, melatonin, meloxicam, omeprazole
Current Illness: none
Preexisting Conditions: GERD, hypertension, osteoarthritis
Allergies: Shellfish (anaphylaxis), tetracycline (angioedema)
Diagnostic Lab Data: 6/9/2021: Ultrasound Venous Duplex Lower extremity R: IMPRESSION: Right lower extremity deep vein thrombosis involving the proximal femoral vein through to the posterior tibial veins. Associated superficial thrombophlebitis involving the proximal to mid lesser saphenous vein. 6/9/2021 CT chest with IV contrast: Significant bilateral pulmonary emboli involving the distal main pulmonary arteries, both lower lobar pulmonary arteries and segmental branches, the left upper lobe are pulmonary artery, and the origins of the right middle lobar and right upper lobe are pulmonary arteries. No pulmonary infarct. There is slight convexity of the intraventricular septum towards the left, suggesting right heart strain.
CDC Split Type:

Write-up: Acute bilateral pulmonary embolus and right lower extremity DVT. No typical risk factors such as recent trauma or surgery and no personal history of DVT/PE. Received Moderna COVID-19 vaccination series in February and March of this year.

VAERS ID:	1403662 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-08
Onset:	2021-06-14
Days after vaccination:	67
Submitted:	0000-00-00
Entered:	2021-06-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Dizziness, Fall, Nausea
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad)

Write-up: developed nausea and dizziness leading to a fall, taken to the ER

VAERS ID:	1404494 (history)
Form:	Version 2.0
Age:	23.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-28
Onset:	2021-05-07
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-06-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Acoustic stimulation tests abnormal, Blood test, Computerised tomogram, Deafness unilateral, Magnetic resonance imaging, Vertigo
SMQs:, Hearing impairment (narrow), Vestibular disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None known
Diagnostic Lab Data: 5/9 ER at UW Health, CT scan, bloodwork 5/11 Hearing test at Hospital - ENT clinic 6/4 MRI at Health, hearing test
CDC Split Type:

Write-up: 9 days after 2nd dose experience sudden onset vertigo and hearing loss in left ear. Vertigo went away over next 48 hours, but hearing loss has persisted.

VAERS ID:	1406804 (history)
Form:	Version 2.0
Age:	34.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-04
Onset:	2021-06-13
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-06-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	035C21A / 2	LA / IM

Administered by: Public Purchased by: ?
Symptoms: Headache, Myalgia, Pharyngeal swelling, Pyrexia, Urticaria
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (narrow), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Daily vitamin
Current Illness: none
Preexisting Conditions: 3 shingles outbreaks ~8 years apart
Allergies: none
Diagnostic Lab Data: no test outside of visual inspection has occurred at this time. appointment being scheduled with allergen specialist.
CDC Split Type:

Write-up: Vaccine dose 2 caused severe fever, headache, muscle pain. Fever persisted for ~3-4 days, peaking on day 2. 9 days post vaccine developed sudden allergy and broke out in hives on neck, hands, belt line that spread to head, shoulders, chest, legs, groin, hands and arms. Throat swelling at day 10 post vaccination, and again on day 12. Now required to carry epi-pen. Sought medical treatment on day 10, and started on course of steroids and antihistamines. After sever throat swelling on evening of day 11, returned to dr. to receive more antihistamine prescriptions and epi-pen prescription.

VAERS ID:	1406859 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-01
Onset:	2021-06-01
Days after vaccination:	31
Submitted:	0000-00-00
Entered:	2021-06-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Pericarditis
SMQs:, Systemic lupus erythematosus (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Paracarditis

VAERS ID:	1407161 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-30
Onset:	2021-05-01
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	001C21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Cardiac stress test, Catheterisation cardiac, Chest pain, Dyspnoea, Echocardiogram, Electrocardiogram, Magnetic resonance imaging, Pericarditis, X-ray
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: chest pain, difficulty breathing, day following shot. ER hospital, admitted, pericarditis, discharged 05/04/2021

VAERS ID:	1407674 (history)
Form:	Version 2.0
Age:	76.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-11
Onset:	2021-03-24
Days after vaccination:	41
Submitted:	0000-00-00
Entered:	2021-06-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9267 / 2	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Infection
SMQs:

Write-up: Breakthrough infection

VAERS ID:	1407850 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-06
Onset:	2021-06-05
Days after vaccination:	150
Submitted:	0000-00-00
Entered:	2021-06-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	01/06/2021 / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Biopsy skin, Biopsy skin abnormal, Blood fibrinogen increased, Eosinophil count, Perivascular dermatitis, Red blood cell vacuolisation, Skin lesion, Urticarial vasculitis
SMQs:, Malignancy related therapeutic and diagnostic procedures (narrow), Vasculitis (narrow), Skin tumours of unspecified malignancy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Diagnosed with urticarial vasculitis on 06/09/2021 after biopsy of skin lesions

VAERS ID:	1407893 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-28
Onset:	2021-05-03
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-06-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / IM

Administered by: Unknown Purchased by: ?
Symptoms: Ischaemic stroke
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow)

Write-up: Ischemic stroke

VAERS ID:	1408656 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-29
Onset:	2021-02-01
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-06-17

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Antinuclear antibody negative, Audiogram abnormal, Autoimmune inner ear disease, Condition aggravated, Deafness neurosensory, Deafness unilateral, Fungal test negative, Hearing aid user, Hypoacusis, Immunology test, Magnetic resonance imaging head abnormal, Rash vesicular, Scan with contrast abnormal
SMQs:, Malignancy related therapeutic and diagnostic procedures (narrow), Hearing impairment (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Polycystic kidney disease, asthma, environmental allergies
Allergies: Carba mix
Diagnostic Lab Data: 03/02/2021 - audiometric testing showing pre-existing conductive hearing loss plus new sensorineural hearing loss. 03/02/2021 - Heat Shock Protein 70, IgG by Immunoblot was positive suggestive of an autoimmune inner ear disease 03/02/2021 - ANA was negative 03/17/2021 - audiometric testing showed no improvement 03/25/2021 - audiometric testing showed no improvement 04/12/2021 - MRI brain WWO contrast was unremarkable 04/20/2021 - audiometric testing showed no improvement 06/07/2021 - audiometric testing showed no improvement
CDC Split Type:

Write-up: A small vesicular rash appeared shortly after both doses, on the anterior left abdomen just below the waistline. Skin scraping was negative for fungus. It did not appear to be bacterial. It spontaneously resolved a few weeks after each dose. Sensorineural hearing loss occurred about two weeks after the second dose of the vaccine. This was confirmed by audiometric testing which showed a significant unilateral hearing loss in the right ear. A prednisone taper was started followed by two transtympanic injections of dexamethasone over the next six weeks. There was no improvement. A hearing aid is now required.

VAERS ID:	1409646 (history)
Form:	Version 2.0
Age:
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-05-27
Submitted:	0000-00-00
Entered:	2021-06-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0138 / 2	RA / -

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Diarrhoea, SARS-CoV-2 test, Vomiting
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), COVID-19 (broad)

Write-up: Hospitalized for uncontrollable vomiting, diarrhea and weakness; Hospitalized for uncontrollable vomiting, diarrhea and weakness; Hospitalized for uncontrollable vomiting, diarrhea and weakness; This is a spontaneous report from a contactable consumer (patient). An 18-year-old female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), dose 2 via an unspecified route of administration, administered in right arm on an unspecified date (Batch/Lot Number: EW0138) as 2ND DOSE, SINGLE for covid-19 immunisation. Patient not diagnosed with COVID-19 Prior to vaccination. Concomitant medication(s) included Bupropion; Sertraline; methylphenidate hydrochloride (CONCERTA). The patient had allergies on Prazosin and amoxicillin. Patient not receive any other vaccines within 4 weeks prior to the COVID vaccine. The patient was hospitalized for uncontrollable vomiting, diarrhea and weakness on 27May2021 16:00. Patient received 2 liters of IV and potassium treatment. Event outcome was recovering. Emergency Room and Physician Office Visited. Covid Nasal Swab tested Negative on 01Jun2021. Follow up attempts are needed. Further information is expected.

VAERS ID:	1410402 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-18
Onset:	2021-06-18
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025C21A / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Anxiety, Aphasia, Chest discomfort, Chest pain, Intensive care, Throat tightness, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Dementia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypersensitivity (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol-ipratropium (Combivent Respimat) 100-20 MCG/ACT inhaler Inhale 1 puff into the lungs every 4 hours as needed for Shortness of Breath. montelukast (SINGULAIR) 10 MG tablet Take 1 tablet by mouth nightly. fluticasone-umeclidin-vilan
Current Illness: COVID-19 (16 DAYS POST)
Preexisting Conditions: Iron malabsorption K90.9 Medium 5/1/2018 - Present Overview Signed 12/19/2018 5:14 PM by MD Allergic reaction to transfusion Acute pain of right knee M25.561 Low 3/24/2021 - Present Diabetes mellitus type 2, uncontrolled (CMS/HCC) E11.65 Low 3/10/2021 - Present Insulin use (long-term) in type 2 diabetes (CMS/HCC) E11.9, Z79.4 Low 3/10/2021 - Present Annual wellness visit, subsequent Z00.00 Low 9/9/2020 - Present Acute right ankle pain M25.571 Low 6/3/2020 - Present Tension type headache G44.209 Low 2/19/2020 - Present Stress incontinence, female N39.3 Low 10/22/2019 - Present Vasovagal syncope R55 Low 10/10/2019 - Present Status asthmaticus J45.902 Low 10/7/2019 - Present Severe persistent asthma with acute exacerbation J45.51 Low 10/4/2019 - Present Hypokalemia E87.6 Low 10/4/2019 - Present Severe persistent asthma without complication J45.50 Low 4/29/2019 - Present Right foot pain M79.671 Low 4/22/2019 - Present Cough R05 Low 3/20/2019 - Present Diarrhea of presumed infectious origin R19.7 Low 1/17/2019 - Present Respiratory failure, acute-on-chronic (CMS/HCC) J96.20 Low 1/10/2019 - Present COPD with acute exacerbation (CMS/HCC) J44.1 Low 1/4/2019 - Present Anaphylaxis T78.2XXA Low 10/10/2018 - Present Chest pain on exertion R07.9 Low 10/10/2018 - Present Right elbow pain M25.521 Low 10/1/2018 - Present Morbid obesity (CMS/HCC) E66.01 Low 9/19/2018 - Present Conversion disorder F44.9 Low 9/19/2018 - Present
Allergies: Covid-19 Mrna Vacc (Moderna) ANAPHYLAXIS High Benralizumab PRURITUS, Cough, Other (See Comments) High Ferric Carboxymaltose SHORTNESS OF BREATH, ANAPHYLAXIS, Dermatitis High Iron Sucrose SHORTNESS OF BREATH High Systemic 5/7/2018 Zithromax [Azithromycin] SWELLING High 5/2/2017 Throat Dilaudid [Hydromorphone Hcl] PRURITUS Not Specified 6/14/2017 Dust Other (See Comments) Not Specified 6/7/2017 Asthma Erythromycin RASH Not Specified 4/17/2012 Fentanyl PRURITUS Not Specified 4/12/2017 Hydromorphone RASH Not Specified 4/17/2017 Mold (Environmental) Other (See Comments) Not Specified 6/7/2017 Sneezing and asthma Morphine RASH, PRURITUS Not Specified 4/17/2017 Piperacillin PRURITUS Not Specified 2/16/2018 Pollen Extract Other (See Comments) Not Specified 2/16/2018 Ragweed Other (See Comments) Not Specified 6/7/2017
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reported chest pain and feeling like chest/throat is closing off - consistent with pt previous hx of anaphalyaxis. STAT team called - Patient rapidly assessed - audible wheezing and visible anxiety and inability to speak followed rapidly - epi 0.3 mg administered in L thigh at 0905 - MD arrived at 0909 - 50mg IM given R deltoid @ 0910, Pt not improving - 2nd dose 0.3mg epi IM R thigh given per MD at 0912. Pt transferred to ED cot and sent to ER STAT. No V/S obtained d/t rapid interventions needed. Chart review indicates treatment in ED with solumedrol, Pepcid, additional Benadryl IVP, DUONEB, ALBUTEROL, MAD SULFATE, HYDRALAZINE - and placed on BiPap. Transferred to ICU bed currently

VAERS ID:	1410448 (history)
Form:	Version 2.0
Age:	49.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-10
Onset:	2021-05-11
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-06-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	027C21A / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Blood potassium decreased, Blood test, Cardiac stress test, Chest discomfort, Cough, Diarrhoea, Dyspnoea, Electrocardiogram, Fatigue, Hypertension, Malaise, Pain, Pyrexia, X-ray
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (narrow)

Write-up: pt says she was very sick the day after taking the vax. She had fever, body aches, chest pressure, diarhea, fatigue, cough, and SOB. She went to her PCP and was prescribed medicine. She did not get any better so went to Hospital ER. She was admitted for testing. She had blood work, EKG, stress test, X-rays. Her potassium is low. BP high. She was discharged to FU w/ PCP and Cardiologist. She is still not well and has to get a MRI of her heart.

VAERS ID:	1410780 (history)
Form:	Version 2.0
Age:	34.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2019-12-29
Onset:	2021-01-04
Days after vaccination:	372
Submitted:	0000-00-00
Entered:	2021-06-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EK5730 / 1	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Cerebral haemorrhage, Headache, Magnetic resonance imaging head abnormal
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Write-up: I was exercising and I started having a really bad headache. I got a scan and had blood in my brain

VAERS ID:	1412913 (history)
Form:	Version 2.0
Age:	48.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-15
Onset:	2021-03-20
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-06-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6206 / 1	LA / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	- / -

Administered by: Private Purchased by: ?
Symptoms: Acupuncture, Fibula fracture, Gait disturbance, Gait inability, Joint dislocation, Muscle contracture, Muscle spasms, Pain, Tibia fracture
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin Hydrochloroquine Hydrochlorothzide Levothyroxine Valicyclovir Cyclobenzaprine Naproxen Hair restore Vitamin d Prednisone CBD Thc
Current Illness: RA Fibro Sjogrens Spondylitis
Preexisting Conditions: See above
Allergies: None
Diagnostic Lab Data: 3/31 booster shot for prednisone ER visit 4/5 ortho 4/20 - now PT 2x per week ascension 3/30 - now Dr 1x per week 5/27 acupuncture
CDC Split Type:

Write-up: Bad spasms in back and right side. Muscles contracted so much I popped my right patella and displaced my tibia and fibula. Could not walk for 4 days. Still in tons of pain and walk with limp. Can barely walk stairs.

VAERS ID:	1415048 (history)
Form:	Version 2.0
Age:	82.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-22
Onset:	2021-06-13
Days after vaccination:	83
Submitted:	0000-00-00
Entered:	2021-06-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	UN / UN

Administered by: Private Purchased by: ?
Symptoms: Angiogram, Back pain, Cardiac assistance device user, Chest X-ray abnormal, Chest pain, Cough, Echocardiogram abnormal, Pain, Painful respiration, Pericardial effusion, Pericardial fibrosis, Pericarditis, Scan with contrast
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: apixaban, colchicine, famotidine, ibuprofen, ketoconazole topical dream, levothyroxine, metoprolol succinate, ocular lubricant, omeprazole, sodium chloride nasal spray, triamcinolone,
Current Illness: n/a
Preexisting Conditions: atrial fibrillation, gastroesophageal reflux disease, low back pain, osteopenia, Bowen''s disease, squamous cell carcinoma of skin, breast cancer history, spinal stenosis, acne rosacea, neuralgia, menopausal symptoms, hypothyroidism, arthritis, insomnia, hyperlipidemia, ventral hernia.
Allergies: amoxicillin, clindamycin, codeine, doxycycline, Keflex, latex, penicillin
Diagnostic Lab Data: Pertinent Diagnostics (06/13/2021 21:44 CDT XR Chest 1 View Frontal) IMPRESSION: 1. Mildly increased interstitial opacities, which could reflect mild edema. 2. ICD battery pack has rotated 180 degrees from the prior exam. [2] (06/13/2021 22:37 CDT CT Angiography Chest/Abdomen/Pelvis w/ C) IMPRESSION: 1. No dissection, aneurysm, or intramural hematoma. 2. Mild to moderate diffuse pericardial thickening, new from the 2017 CT. Given chest pain, please correlate for signs or symptoms of pericarditis. [3] 6/14/2021 Echocardiogram verbal report: LVEF 60%, no significant valvular abnormalities. The pericardium is thick, with trace right sided pericardial effusion. No tamponade physiology.
CDC Split Type:

Write-up: Patient came to emergency department with complaints of midsternal chest pain radiating to the back that started on 6/13/21. Patient discussed pain as severe sharp chest pain that worsens with taking a deep breathe, movement, and coughing, Patient was diagnosed with pericarditis. Patient was admitted to the hospital for observation, monitoring, and evaluation. Patient was given Toradol 15mg IV and monitor chest pain.

VAERS ID:	1415095 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-18
Onset:	2021-03-21
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-06-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	046A21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Asthenia, Auditory disorder, Fatigue, Gait disturbance, Guillain-Barre syndrome, Muscle disorder, Muscular weakness, Neuralgia, Vestibular disorder
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (narrow), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalopathy/delirium (broad), Demyelination (narrow), Hearing impairment (narrow), Vestibular disorders (narrow), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Flu vaccine 11-2012
Other Medications:
Current Illness: Sinus and Migraine issues
Preexisting Conditions: Chronic multifactorial issues. 3 failed cervical spine surgeries. Obese. Vestibular dysfunction. GI issues. Chronic Migraine
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: I was having extreme difficulty walking for a week. Wobbly legs (muscle and nerve impairment) severe fatigue and weakness. Vestibular dysfunction and Auditory issues. I suspect a Guillain-Barre type immune system response to second injection? I verified this on CDC website. I am trying to get in to a neurologist ( 3 month wait) My Primary care Dr. is aware of issues. Original response was to give it time. I have started PT as of 6-8-21. I need to have a Neurologist investigate and I believe doing an NCV test will "reset"{ the nerves. This worked several years ago after neck surgery issues.

VAERS ID:	1416883 (history)
Form:	Version 2.0
Age:	12.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-05
Onset:	2021-06-21
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-06-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Acute respiratory failure, Alanine aminotransferase normal, Anal incontinence, Analgesic drug level, Anticonvulsant drug level increased, Apnoea, Aspartate aminotransferase increased, Basophil count decreased, Basophil percentage, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium decreased, Blood chloride increased, Blood creatine phosphokinase normal, Blood creatinine normal, Blood ethanol normal, Blood glucose increased, Blood potassium decreased, Blood sodium normal, Blood urea increased, Bradycardia, C-reactive protein increased, Carbon dioxide normal, Cardioversion, Encephalopathy, Endotracheal intubation, Eosinophil count normal, Eosinophil percentage increased, Granulocyte percentage, Haematocrit normal, Haemoglobin normal, Hypophagia, Immature granulocyte count, Lymphocyte count increased, Lymphocyte percentage increased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume normal, Monocyte count, Monocyte percentage increased, N-terminal prohormone brain natriuretic peptide increased, Nasal congestion, Nasopharyngitis, Neutrophil count, Neutrophil percentage decreased, Platelet count normal, Protein total normal, Red blood cell count decreased, Red blood cell nucleated morphology, Red cell distribution width normal, Respiration abnormal, Sneezing, Somnolence, Troponin I increased, Unresponsive to stimuli, Ventricular tachycardia, Vomiting, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (narrow), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Agranulocytosis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Noninfectious diarrhoea (broad), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Hypokalaemia (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vimpat, Valproic Acid, OTC cold medication (mother unsure of name)
Current Illness: None known
Preexisting Conditions: History of developmental delay, seizure disorder
Allergies: None known
Diagnostic Lab Data: Results for patient 6/21/2021 21:12 Sodium Blood: 141 Potassium Blood: 2.7 (L) Chloride Blood: 110 (H) Carbon Dioxide: 20.9 (L) Glucose Blood: 150 (H) BUN: 22 (H) Creatinine Blood: 0.55 Calcium Blood: 9.3 Albumin Blood: 3.9 AST: 81 (H) ALT: 26 Bilirubin Total: 0.3 Total Protein Blood: 6.8 Alkaline Phosphatase: 100 (L) WBC: 13.0 (H) RBC: 3.61 (L) Hemoglobin: 11.7 (L) Hematocrit: 34.8 (L) MCV: 96.4 (H) MCH: 32.4 (H) MCHC: 33.6 Platelet Count: 159 MPV: 9.6 (H) RDW: 13.0 Nucleated RBC Automated: 0.0 Differential Type: AUTOMATED DIFF % Neutrophils: 29.1 (L) % Imm Gran: 0.3 % Lymphocytes: 50.9 (H) % Monocytes: 10.6 (H) % Eosinophils: 8.6 (H) % Basophils: 0.5 Absolute Neutrophils: 3.760 Abs Imm Gran: 0.04 (H) Absolute Lymphocytes: 6.59 (H) Absolute Monocytes: 1.37 (H) Absolute Eosinophils: 1.12 (H) Absolute Basophils: 0.07 Valproic Acid Level: 209 (HH) NT Pro Brain Natriuretic Peptide: 113 Troponin I Result: <0.012 (L) Creatine Kinase: 98 Alcohol Ethyl: <0.010 Salicylate Level: <1.0 Acetaminophen Level: <10.0 C Reactive Protein: 1.4 (H) Results for patient 6/21/2021 22:35 Sodium Blood: 143 Potassium Blood: 2.6 (L) Chloride Blood: 112 (H) Carbon Dioxide: 20.2 (L) Glucose Blood: 211 (H) BUN: 21 (H) Creatinine Blood: 0.47 Calcium Blood: 8.1 (L) Troponin I Result: 0.280 (H)
CDC Split Type:

Write-up: 12 y.o. male patient with history of developmental delay, seizure disorder who presented to the emergency department today with acute encephalopathy, unresponsive with bradycardia, V-tach requiring defibrillation, and acute respiratory failure requiring intubation. The family had been traveling and vacationing with extended family members and recently returned Saturday night. No sick contacts during the trip and he recently received his second COVID-19 vaccine on June 5th. On Sunday, June 20th, he had cold symptoms with stuffy nose, sneezing and minimal oral intake. Mother gave him 10ml of a multi-symptom OTC cold medication that evening. Unsure what is in the medication or if it contains Benadryl. This morning, he had an 11am swim lesion and then came back and slept on the couch. Still minimal oral intake and was resting all day long but awake most of the time. This evening at 5:43pm per mother, he received another 10ml of the multi-symptom cold medication. He was given his Vimpat and Valproic Acid medications around 7:30pm. Around 8:20/8:25pm, he was asleep and had an emesis and was not responding In the ED, he was unresponsive and poor respiratory effort with episodes of apnea and was incontient of stool during the exam. He was brought to the resuscitation room, PIV placed x2. Placed on oxygen initially. Ativan given once for possible seizure. Epinephrine given for bradycardia. Noted V-tach on rhythm. Second Epi given, started Epinephrine infusion and Shock given 2J/kg. Cardiology at bedside. Rocuronium and Etomidate given for intubation. He was intubated on the second attempt with 6.0c ETT.

VAERS ID:	1417752 (history)
Form:	Version 2.0
Age:	85.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-11
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-06-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3248 / 1	AR / SYR

Administered by: Private Purchased by: ?
Symptoms: Cardiac failure, Cardiac failure congestive, Cough, Death, Dyspnoea, Fatigue, General physical health deterioration, Loss of personal independence in daily activities
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

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

Write-up: Severe cough, shortness of breath, exhaustion leading to emergency room visit followed by hospitalization wherein it was discovered Pt was diagnosed with acute congestive heart failure. Prior to this vaccine he was living alone, preparing meals, driving to errands, etc. Over the following few weeks after release he became unable to live at home so he was moved to an assisted living facility where he rapidly declined and was put on hospice less than 2 weeks after his second Covid shot on 3/2/21 (Lot EN9581) (which he only took because his doctor pressured him). He died on 6/2/21 of heart failure.

VAERS ID:	1418083 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-19
Onset:	2021-05-19
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Magnetic resonance imaging spinal normal, Magnetic resonance imaging thoracic normal, Myalgia, Polyneuropathy
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Write-up: Incidence of myalgia with the Pfizer vaccine is between 38.3% to 42.2% and typically at the injection site. This patient developed myalgia and polyneuropathy 2-3 weeks prior to inpatient admission and attributed the symptom onset with the administration of the first COVID vaccine. Vaccine administered 5/19/2021 and admitted 6/8/2021. Patient also has diabetic neuropathy for which she takes gabapentin and the symptoms may be related to the that. MRI thoracic & lumbar spine showed no central cause of symptoms. Added this pain to the allergy list for the patient as the etiology is unclear. Reported to VAERS.

VAERS ID:	1419023 (history)
Form:	Version 2.0
Age:	43.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-06-06
Days after vaccination:	46
Submitted:	0000-00-00
Entered:	2021-06-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	045A21A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Catheterisation cardiac normal, Chest pain, Dyspnoea, Myocarditis, Troponin increased
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Chest pain/ shortness of breath caused patient to go to the ER and was admitted with elevated troponin levels, had cardiac cath that was normal, diagnosis was myocarditis. Started on metoprolol and full aspirin with cardiology follow up. Colchicine added and symptoms resolved but then he developed drug reaction rash and it has to be stopped

VAERS ID:	1423526 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-05-01
Submitted:	0000-00-00
Entered:	2021-06-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	AR / SYR

Administered by: Private Purchased by: ?
Symptoms: Angina pectoris, Blood test normal, Inflammation, Pericarditis, SARS-CoV-2 test negative
SMQs:, Systemic lupus erythematosus (broad), Other ischaemic heart disease (narrow), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? Yes
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Rheumatoid arthritis/back fusion/hyper coagulation blood clotting disorder (lupus-based)/cateracts/
Preexisting Conditions: See above
Allergies: Morphine/sulfa
Diagnostic Lab Data: Too many to count?check with facility.
CDC Split Type:

Write-up: On May 1, 2021 I started to experience serious heart pain over a period of about 6 hours. I proceeded to the emergency room thereafter and was diagnosed with pericarditis. The inflammation appears to have been caused by the autoimmune disease I have as multiple blood tests showed no Covid nor other infectious agents present. I?m currently on a high-dose steroid to serve as treatment till they can get me on a new biological drug (Orencia).

VAERS ID:	1423638 (history)
Form:	Version 2.0
Age:	29.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-12
Onset:	2021-06-24
Days after vaccination:	12
Submitted:	0000-00-00
Entered:	2021-06-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0180 / 2	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Menstruation delayed, Menstruation irregular
SMQs:, Fertility disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: Sulfa
Diagnostic Lab Data: Non existent period
CDC Split Type:

Write-up: Period is a week late. It?s never irregular. I was perfectly healthy before this. There is no reason for my period to be late.

VAERS ID:	1425862 (history)
Form:	Version 2.0
Age:	98.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-02-18
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Blood pressure measurement, Chills, Hypertension, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Write-up: in and out of consciousness; blood pressure was 170/112; severe chills; This spontaneous case was reported by a consumer and describes the occurrence of LOSS OF CONSCIOUSNESS (in and out of consciousness) and HYPERTENSION (blood pressure was 170/112) in a 98-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included UTI and Chronic heart failure. Concomitant products included APIXABAN (ELIQUIS) for an unknown indication. On 18-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 18-Feb-2021, the patient experienced LOSS OF CONSCIOUSNESS (in and out of consciousness) (seriousness criteria hospitalization prolonged and medically significant), HYPERTENSION (blood pressure was 170/112) (seriousness criterion hospitalization prolonged) and CHILLS (severe chills). At the time of the report, LOSS OF CONSCIOUSNESS (in and out of consciousness), HYPERTENSION (blood pressure was 170/112) and CHILLS (severe chills) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Blood pressure measurement: 170/112 (High) Increased. No treatment information was provided. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Patients underlying chronic heart failure and advanced age are confounders. Most recent FOLLOW-UP information incorporated above includes: On 27-Apr-2021: Follow-up information was received on 27-Apr-2021 contains information regarding follow-up consent (follow-up and consent was denied for follow-up).; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Patients underlying chronic heart failure and advanced age are confounders.

VAERS ID:	1426504 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-10
Onset:	2021-04-24
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-06-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / 1	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Cubital tunnel syndrome, Impaired work ability, Muscular weakness, Pain in extremity
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Occasional hawthorn, acetaminophen
Current Illness: none
Preexisting Conditions: none
Allergies: none known
Diagnostic Lab Data: not applicable
CDC Split Type:

Write-up: Cubital tunnel syndrome in injected arm. Hands "fall asleep" occasionally, but this time it did not resolve, resulting in weakness in hand and arm that have only partially recovered in the weeks following. Unable to use left hand since onset to use most tools, turn a valve, etc. Uncertain at this point whether full recovery is possible, but progress seems to be stalled at perhaps 50%-75% capacity. Icing helps with pain, along with regular acetaminophen and occasional ibuprofen. Exercise (including ulnar nerve "flossing") helps with recovery but has plateaued.

VAERS ID:	1426836 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-09
Onset:	2021-06-20
Days after vaccination:	11
Submitted:	0000-00-00
Entered:	2021-06-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	- / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Abdominal pain, Aspiration, Death, Sepsis
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-23
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: acetaminophen, amlodipine, carvedilol, lisinopril, melatonin, memantine, quetiapine, terazosin, warfarin
Current Illness:
Preexisting Conditions: dementia, hypertension, atrial flutter, BPH
Allergies: quinine, sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient received his first dose of Pfizer COVID vaccine 6/9/21 at pharmacy. He was then admitted 6/20/21 at hospital with abdominal pain, sepsis and a suspected aspiration event and expired on 6/23/21. This was felt by the treating physicians to be most likely not related to or associated with the vaccine, but given the close proximity it was asked that this be reported.

VAERS ID:	1428441 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-24
Onset:	2021-06-12
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-06-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Anticoagulant therapy, Blood test, Inflammation, Myocarditis, Pain, Pyrexia, Troponin increased
SMQs:, Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Diagnosed with Myocarditis - was hospitalized for 3 days. Now taking one colchocine everyday for the next 3 months and taking 2 tablets of 325mg aspirin 3 times a day.

VAERS ID:	1429700 (history)
Form:	Version 2.0
Age:	24.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-02
Onset:	2021-05-01
Days after vaccination:	29
Submitted:	0000-00-00
Entered:	2021-06-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	026B21A / 1	LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	RA / SYR

Administered by: Public Purchased by: ?
Symptoms: Asthenia, Blood test abnormal, Myositis, Pain, Rhabdomyolysis, Skin swelling, Tenderness
SMQs:, Rhabdomyolysis/myopathy (narrow), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: I felt really weak after my second dose. I was very sore and tender to even move. I was also stated to look puffy in my neck and chest area. I was diagnosed with Myositis and Rhabdomyolysis. I was hospitalized overnight to keep fluids flushing through me due to the muscle count found in my blood.

VAERS ID:	1429848 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-11
Onset:	2021-06-17
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-06-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	PNS#360 / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Chest pain, Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Write-up: Chest pain which started 6/17, improved 6/19 and 6/20. Chest pain worsened 6/21 and persisted through the week. Became acutely short of breath and passed away 6/25 at hospital

VAERS ID:	1433166 (history)
Form:	Version 2.0
Age:	88.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-26
Onset:	2021-03-26
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-06-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	016B21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Audiogram abnormal, Deafness, Deafness neurosensory, Deafness unilateral, Tinnitus
SMQs:, Hearing impairment (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cholecalciferol 5,000 units by mouth once daily. Dopa Mucuna 800 mg by mouth twice daily. Ginger Root 1 capsule by mouth once daily. Healthy thyroid 1 tablet by mouth twice daily. Magnesium oxide 500 mg by mouth three times daily. meclizine
Current Illness: Lower extremity edema. Osteoporosis. Uses hearing aid.
Preexisting Conditions: Lower extremity edema. Osteoporosis. Uses hearing aid.
Allergies: No known Allergies.
Diagnostic Lab Data: Audiogram. April 21, 2021. Audiogram May 14, 2021. On May 14, her audiogram showed profound hearing loss in the left ear with 0% word recognition. Mild to severe sensorineural hearing loss in the right ear with 100% word recognition. Outside audiogram from 2018. Hearing somewhat improved from May 14, 2021 to April 21, 2021.
CDC Split Type:

Write-up: Loss of hearing four hours after receiving the vaccine (second dose). Developed ringing in the ears. Left ear hearing loss. April 21 hearing evaluation showed approximately 30 dB hearing loss at 2,000 and 3,000 in the left ear only. Right ear hearing is similar to prior to the vaccination.

VAERS ID:	1433215 (history)
Form:	Version 2.0
Age:	47.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-30
Onset:	2021-05-07
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-06-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal pain upper, Blood prolactin, Gastrointestinal pathogen panel, Lipase, Troponin, Viral test
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Write-up: Pain Abdominal: Pt reports that he has had left upper quad pain since yesterday. Reports pain was getting progressively worse. Orignally pt reports he thought he had pulled a muscle, but now doubts that.

VAERS ID:	1433498 (history)
Form:	Version 2.0
Age:	30.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-04
Onset:	2021-06-28
Days after vaccination:	55
Submitted:	0000-00-00
Entered:	2021-06-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0179 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Discomfort, Exposure during pregnancy, Foetal monitoring normal, Pain, Pelvic discomfort, Premature labour
SMQs:, Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow)

Write-up: Estimated date of delivery is 8/23/21. Patient was admitted on 6/28/2021 for painful contractions and increased pelvic pressure. She was diagnosed with pre-term delivery. Patient was tested following the hospital''s admission protocol. Patient was asymptomatic at the time of testing. This the is mother''s 3rd pregnancy. She has a history of pre-term contractions with previous deliveries. No concerns noted about the fetus. Fetal movement and monitoring are normal.

VAERS ID:	1433970 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-06-25
Days after vaccination:	107
Submitted:	0000-00-00
Entered:	2021-06-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 1	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	LA / IM

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

Write-up: Re infection after being vaccinated

VAERS ID:	1437933 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-25
Onset:	2021-06-29
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-06-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0196 / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-06-29
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patients daughter called on 6/29/21 to inform pharmacy that patient had passed away. It is unclear what patient passed away from as patients family did not leave that information with the floater pharmacist who was working.

VAERS ID:	1438019 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-01
Onset:	2021-06-29
Days after vaccination:	120
Submitted:	0000-00-00
Entered:	2021-06-30

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 2	- / SYR

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

Write-up: 11/09/2020 - Tested positive for COVID-19 02/08/2021 & 03/01/2021 - Received Pfizer COVID-19 vaccines 06/29/2021 - Tested positive for COVID-19 at Hospital 06/29/2021 - Admitted to Medical Center / Hospital 06/30/2021 - Tested negative for COVID-19 at Medical Center / Hospital 06/30/2021 - Discharged from Medical Center / Hospital

VAERS ID:	1440872 (history)
Form:	Version 2.0
Age:	21.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-22
Onset:	2021-05-13
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-07-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8736 / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Allergy to vaccine, Anti-aquaporin-4 antibody negative, Anti-myelin-associated glycoprotein antibodies positive, Blindness, CSF oligoclonal band absent, Infectious mononucleosis, Optic neuritis, Plasmapheresis, Urinary tract infection
SMQs:, Peripheral neuropathy (broad), Glaucoma (broad), Optic nerve disorders (narrow), Demyelination (narrow), Retinal disorders (broad), Ocular infections (broad), Hypersensitivity (narrow), Immune-mediated/autoimmune disorders (broad)

Write-up: Ophthalmology consult was subsequently obtained with diagnosis of acute optic neuritis. First dose of Pfizer Covid vaccine on 4/22/2021 with onset of symptoms approximately 2 to 3 weeks thereafter. Bilateral vision loss 2/2 optic neuritis that is new. Initially involving only the right eye, transient improvement with Solu-Medrol approximately 1 month prior to admission, but with recurrence and later with development of vision loss in the left eye as well for approximately 1 week prior to admission. Unclear etiology. MS felt less likely with negative oligoclonal bands, NMO antibody negative, though per neuro, still potential for neuromyelitis optica, MOG 1:40. Also consideration that may be a complication of having received COVID-19 vaccine, though relationship remains unclear. 2-3 weeks prior to symptoms patient received vaccine. Short time after was also diagnosed with Mono and UTI. Got IV methylprednisolone of 1 g daily x4 doses without significant improvement. Then required total plasma exchange over 2 weeks, resulted in mild symptom improvement. CDC reports optic neuritis may be related to vaccinations in general (52.4% of cases within 8 weeks of vaccination). No evidence for COVID vaccines at this time. Added Pfizer vaccine to allergy list per neuro recommendations.

VAERS ID:	1440927 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-16
Onset:	2021-06-16
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-01

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	205A21A / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Acute kidney injury, Blood creatinine increased, Dehydration, Emphysematous cystitis, Malaise, Nausea, Pain, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow)

Write-up: patient received J&J vaccine during the day on 6/16. reports to ED on 6/18 for evaluation of Nausea and vomiting. She reported feeling ill on same day as vaccination with one vomiting episode same day, also reports generalize malaise and body aches. 3 additional non bloody non bilious vomiting episodes 6/17 with inability to keep anything down with constant nausea. found to have acute emphysematous cystitis and admitted at observation to our hospital. Diagnosed with worsening AKI due to dehydration.

VAERS ID:	1442657 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-06
Onset:	2021-05-06
Days after vaccination:	120
Submitted:	0000-00-00
Entered:	2021-07-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1284 / 2	LA / -

Administered by: Private Purchased by: ?
Symptoms: Contusion, Rash macular, Rash pruritic, Swelling of eyelid, Urticarial vasculitis
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow), Vasculitis (narrow), Periorbital and eyelid disorders (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Urticarial vasculitis; Pruritic raised bullseyes blotches with bruises in the middle; Pruritic raised bullseyes blotches with bruises in the middle; Pruritic raised bullseyes blotches with bruises in the middle; Pruritic raised bullseyes blotches with bruises in the middle; This is a spontaneous report received from a contactable nurse (patient). A 60-year-old non-pregnant female patient (not pregnant at the time of vaccination) received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Lot Number: el1284 expiration date: unknown), via an unspecified route of administration in left arm on 06Jan2021 at 10:00 AM (at the age of 60 years old), as single dose for covid-19 immunization. Medical history included gastrooesophageal reflux disease from an unknown date and unknown if ongoing. The patient had known allergies to sulfa and Wellbutrin. Concomitant medications the patient received within 2 weeks of vaccination included famotidine; and vitamin d for an unspecified indication, start and stop date were not reported. Historical vaccine included first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Lot Number: EK5730 expiration date: unknown), via an unspecified route of administration in right arm on 16Dec2020 at 10:00 AM (at the age of 60 years old) for covid-19 immunization. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient had not been tested for COVID-19. The patient experienced urticarial vasculitis developed symptoms On 06May2021, with pruritic raised bullseyes blotches with bruises in the middle. Treated with unspecified iv steroid, antihistamines and continued steroids and taper to colchicine. The adverse event result in: Doctor or other healthcare professional office/clinic visit, emergency room/department or urgent care, hospitalization. The patient was hospitalized for one day. The outcome of events of Urticarial vasculitis, Pruritic raised bullseyes blotches with bruises in the middle was recovering. Reporter considered events as serious. Information on Lot/Batch number was available. Additional information has been requested. ; Sender''s Comments: Based on the information in the case report and a plausible temporal relationship, a possible causal relationship between the events and suspect drug BNT162B2 cannot be excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.

VAERS ID:	1443034 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-21
Onset:	2021-05-19
Days after vaccination:	28
Submitted:	0000-00-00
Entered:	2021-07-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 2	- / -

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: ED to Hospital admission within 6 weeks of receiving COVID vaccination.

VAERS ID:	1443041 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-05-25
Days after vaccination:	39
Submitted:	0000-00-00
Entered:	2021-07-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	044B21A / 2	- / -

Administered by: Private Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Write-up: Multiple ED visits/Hospitalizations within 6 weeks of COVID vaccination.

VAERS ID:	1443199 (history)
Form:	Version 2.0
Age:	33.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-25
Onset:	2021-06-30
Days after vaccination:	36
Submitted:	0000-00-00
Entered:	2021-07-02

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0179 / 1	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Exposure during pregnancy, Foetal death, Foetal hypokinesia, Headache, Induced labour
SMQs:, Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow), Foetal disorders (narrow), Termination of pregnancy and risk of abortion (narrow)

Write-up: Subjective: 33-year-old G4 P3 @36w5d presents for admission due to fetal demise diagnosed in clinic earlier today. Her pregnancy is complicated by hypothyroid, obesity, h/o LTCS with subsequent VBAC x 2, h/o GDM with normal screen this pregnancy, h/o preeclampsia in prior prgnancy, COVID this pregnancy. PNC with doctor. Patient called the office this morning noting lack of fetal movement. She believes she felt baby last night but is unsure. Possibly the last time was this weekend. She denies contractions, vaginal bleeding, LOF, fever, chills. Has mild HA now but that just started since being admitted. BP in office 160/94. Now normal.

VAERS ID:	1446183 (history)
Form:	Version 2.0
Age:	19.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-29
Onset:	2021-04-30
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-07-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Anticoagulant therapy, Arteriogram coronary normal, Chest pain, Echocardiogram normal, Ejection fraction, Ejection fraction normal, Electrocardiogram ST segment elevation, Fatigue, Myocarditis, Troponin increased
SMQs:, Myocardial infarction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: He presented with symptoms of fatigue and chest pain on 5/2/2021 to the Emergency room at the hospital. Troponin was 6.273 ng/ml. EKG demonstrated diffuse ST segment elevation. No pericardial rub on exam. Coronary arteriography was normal. Echocardiography demonstrated an LV ejection fraction of 57%. There was no pericardial effusion. Troponin peaked at 11.729. He responded well to treatment with high dose aspirin and colchicine. He was discharged from the hospital on 5/4/2021 with a diagnosis of myopericarditis. Repeat echo on 5/14/2021 normal LVEF of 55% and no pericardial effusion. Follow up outpatient visit on 5/17/2021 at health clinic. He was asymptomatic. Normal exam. Tape was tapering aspirin. To stop colchicine on 7/2/2021. Patient is a college student. Planned to return to his home in late June or July 2021. His mother is listed as a contact person. Her phone number is (redacted) Thank you., MD MS FACC FSCAI.

VAERS ID:	1446344 (history)
Form:	Version 2.0
Age:	91.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-01
Onset:	2021-04-01
Days after vaccination:	59
Submitted:	0000-00-00
Entered:	2021-07-03

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9263 / UNK	- / IM

Administered by: Private Purchased by: ?
Symptoms: Blood test, Computerised tomogram abnormal, Echocardiogram, Fungal test, Lung opacity, Oxygen saturation decreased, Pulmonary oedema, SARS-CoV-2 antibody test negative, X-ray
SMQs:, Cardiac failure (narrow), Interstitial lung disease (narrow), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-05
   Days after onset: 65
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations: fever, chills, from 1st vaccine
Other Medications: Eliquis Vitamin D Synthro Lasix Metapropol
Current Illness: none
Preexisting Conditions: TAVR 2/2020 no other health issues
Allergies: none
Diagnostic Lab Data: CT O2 Echo Cardio Gram PT OT Xrays Blood work Fungal tests
CDC Split Type:

Write-up: Lungs filled up - CT scan looked like glass - similar to COVID19 patients Had multiple COVID 19 tests all negative o2 levels very low in hospital for 12 nights to stablezize

VAERS ID:	1450208 (history)
Form:	Version 2.0
Age:	41.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-03
Onset:	2021-06-18
Days after vaccination:	76
Submitted:	0000-00-00
Entered:	2021-07-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808980 / UNK	- / -

Administered by: Public Purchased by: ?
Symptoms: Abdominal pain, Anosmia, Chest X-ray normal, Chest pain, Diarrhoea, Headache, Intensive care, Oropharyngeal pain, Pain, Polymerase chain reaction positive, Vomiting
SMQs:, Acute pancreatitis (broad), Taste and smell disorders (narrow), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Immune-mediated/autoimmune disorders (broad)

Write-up: Lab test first on 6/20/2021. No Sample available for further testing from this date. 6/25/2021 - Chest pain, Xray (-). Received albuterol treatments and discharged. Told she did not qualify for Regeneron 6/30/2021 - Visit to healthcare facility 07/01/2021 ? Admitted Interview on 7/2/2021 case stated she was going to receive Remdesivir Sx onset ? 06/18/2021 ? Sore throat. Achy, sever headache; worse by 6/20/2021 6/22/2021 ? abdominal cramping, vomiting, diarrhea 6/23/2021 ? anosmia 6/25/2021 ? chest pain On 7/2/21, case was admitted, on O2 (no vent), not in ICU. Chest Xray negative for pleural effusion, blood clots. 7/6/21 case was transferred to ICU.

VAERS ID:	1450375 (history)
Form:	Version 2.0
Age:	35.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-09
Onset:	2021-06-11
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-07-06

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1816022 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal pain, Angioedema, Antinuclear antibody negative, Blood thyroid stimulating hormone normal, Complement factor C3, Complement factor C4, Computerised tomogram abdomen normal, Computerised tomogram pelvis, Double stranded DNA antibody, Eosinophil count decreased, Feeling abnormal, Full blood count normal, Hysterectomy, Laparoscopic surgery, Metabolic function test normal, Pain in extremity, Pain of skin, Pruritus, Rash macular, Respiratory viral panel, Salpingectomy, Skin burning sensation, Total complement activity test, Urticaria, White blood cell count increased
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (narrow), Haematopoietic leukopenia (narrow), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Oropharyngeal allergic conditions (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Uterine and fallopian tube malignant tumours (broad), Uterine and fallopian tube tumours of unspecified malignancy (broad), Hypersensitivity (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: The patient is a 35 year old female with PMH remarkable for Chron''s disease in remission, seasonal allergies, s/p R adrenal schwannoma s/p resection who presented to the ER with ongoing problem with urticaria for the past 3 weeks. She reports feeling well when she developed scalp itching which progressed to diffuse intermittent hives and angioedema 2 days after receiving Covid J&J vaccination. She has been taking oral steroids, antihistames and h2 blocker for weeks. She reports no improvement in symptoms with these interventions. She also reports itching, but this has progressed to burning and stinging skin. She notes her palms and soles have been sore, and have purplish blotches. Evaluation in the ER was non revealing for a cause but as the patient has been so miserable, admission was recommended for IV treatment. Currently she is standing in her room,

VAERS ID:	1454174 (history)
Form:	Version 2.0
Age:	24.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-06
Onset:	2021-01-06
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011L20A / 1	- / IM

Administered by: Private Purchased by: ?
Symptoms: Blood thyroid stimulating hormone, Diagnostic aspiration, Neck mass, Paraesthesia, Thyroidectomy, Thyroxine free, Tri-iodothyronine free, Ultrasound thyroid
SMQs:, Peripheral neuropathy (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Guillain-Barre syndrome (broad), Hypothyroidism (broad), Hyperthyroidism (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Benadryl prn, OCP daily; Ibuprofen prn; Ketotifen bid; loratadine prn
Current Illness: n/a
Preexisting Conditions: allergies-environmental
Allergies: NKDA
Diagnostic Lab Data: TSH, Free T3, Free T4, Thyroid US and FNA of Thyroid Lump was ordered by our clinic. Healthcare facility has ordered other studies
CDC Split Type:

Write-up: Pt was in for her physical on 8/5/2020 w/ no noted abnormality of her neck/thyroid. She was then in on 2/15 after receiving her 1st and 2nd dose (2/3/21) of Moderna. She presented w/ concerns of a lump on her neck. Upon exam she stated to the provider that she and noticed tingling in her neck after the first injection. She then had labs done that day w/ our clinic, this was followed by a biopsy of the lump. She was then referred over to a healthcare facility for treatment/surgical intervention. To our knowledge she had a thyroidectomy done and is now following with the healthcare facility.

VAERS ID:	1454186 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-27
Onset:	2021-07-03
Days after vaccination:	126
Submitted:	0000-00-00
Entered:	2021-07-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6202 / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Asymptomatic COVID-19, Back pain, COVID-19, Compression fracture, Condition aggravated, SARS-CoV-2 RNA
SMQs:, Retroperitoneal fibrosis (broad), Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient admitted to hospital on 06/29/2021 with non COVID reasons (compression fractures). Was (-) on admission. Discharged and readmitted on 07/03/2021 with admission screen of COVID (+). Asymptomatic. Hospital admission for non COVID reasons (back pain due to compression fractures). Had 2 subsequent (-) COVID tests on 7/4 & 7/6. Per clinic, patient still considered a (+) case but does not have to isolate. Being discharged to long term care on 7/7/21 to the rehab unit.

VAERS ID:	1454194 (history)
Form:	Version 2.0
Age:	86.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-27
Onset:	2021-07-03
Days after vaccination:	98
Submitted:	0000-00-00
Entered:	2021-07-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EP6955 / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Back pain, COVID-19, Compression fracture, SARS-CoV-2 test positive
SMQs:, Retroperitoneal fibrosis (broad), Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient admitted to hospital on 06/29/2021 with non COVID reasons (compression fractures). Was (-) on admission. Discharged and readmitted on 07/03/2021 with admission screen of COVID (+). Asymptomatic. Hospital admission for non COVID reasons (back pain due to compression fractures). Had 2 subsequent (-) COVID tests on 7/4 & 7/6. Per WI DHS patient still considered a (+) case but does not have to isolate. Being discharged on 7/7/21 to the rehab unit.

VAERS ID:	1454207 (history)
Form:	Version 2.0
Age:	53.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-29
Onset:	2021-01-30
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-07-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	LA / IM

Administered by: Other Purchased by: ?
Symptoms: COVID-19, Electroencephalogram abnormal, Gait inability, Ischaemic stroke, Magnetic resonance imaging abnormal, Petit mal epilepsy, SARS-CoV-2 test positive
SMQs:, Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Convulsions (narrow), Embolic and thrombotic events, arterial (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: On Friday 1/29/2021 my wife tested negative for COVID19, and received thePfizer vaccine. Then over the weekend she developed petit mal seizures and went by ambulance to the hospital unable to walk on Monday morning, and also on Monday 2/1/2021 she was diagnosed with having had a stroke and also was tested positive for COVID19.

VAERS ID:	1454245 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-01-30
Onset:	2021-07-05
Days after vaccination:	156
Submitted:	0000-00-00
Entered:	2021-07-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	004M20A / 1	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Anxiety, COVID-19 pneumonia, Oxygen saturation decreased, SARS-CoV-2 RNA, SARS-CoV-2 test
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt called EMS for "impending doom". Upon arrival EMS found oxygen saturations 80%, patient just states he feels like he is dying. Seen in ED and admitted for pneumonia due to COVID-19.

VAERS ID:	1454270 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-26
Onset:	2021-07-05
Days after vaccination:	40
Submitted:	0000-00-00
Entered:	2021-07-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	054C21A / 2	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Anxiety, COVID-19, Pneumonia, SARS-CoV-2 RNA, SARS-CoV-2 test, SARS-CoV-2 test positive
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt called EMS for "impending doom" on 7/5/2021. Upon arrival EMS found oxygen saturations 80%, patient just states he feels like he is dying. Seen in ED and admitted for pneumonia due to COVID-19. Previously tested (+) for COVID-19 on 12/22/2020 prior to hospital admission for SI, with left proximal humeral fracture complicated by H. pylori PUD. Tested (-) on 12/7/2020 in ED when evaluated initially for pain due to humeral fracture from fall on 12/3/2020. Tested (-) for COVID on 12/12/2020 prior to EGD.

VAERS ID:	1454397 (history)
Form:	Version 2.0
Age:	33.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-14
Onset:	2021-06-10
Days after vaccination:	27
Submitted:	0000-00-00
Entered:	2021-07-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	017C21A / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Exposure during pregnancy
SMQs:, Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow)

Write-up: Pt hosp within 6 weeks of vaccine to give birth

VAERS ID:	1457452 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-10
Onset:	2021-04-12
Days after vaccination:	2
Submitted:	0000-00-00
Entered:	2021-07-08

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Completed suicide, Suicidal ideation
SMQs:, Suicide/self-injury (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-04-29
Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: tizanidine, hydrocodone/acetaminophen, lisinopril, midodrine, esomeprazole, trazodone, valacyclovir, tramadol, metoprolol, mirtazapine, venlafaxine, gabapentin, baclofen, atorvastatin, mirtazapine, tolterodine, ondansetron, ciprofloxacin,
Current Illness:
Preexisting Conditions: Multiple sclerosis, cardiomyopathy, depression
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Completed suicide on 04/29/2021. Family reported an increase in suicidal ideations after the vaccination.

VAERS ID:	1459837 (history)
Form:	Version 2.0
Age:	65.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-07-06
Onset:	2021-07-06
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0179 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood gases, Blood magnesium, Electrocardiogram, Fatigue, Flushing, Full blood count, Hyperhidrosis, Metabolic function test, Palpitations, Tachycardia, Troponin, Urine analysis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Hypoglycaemia (broad), Dehydration (broad)

Write-up: Heart palpitations starting shortly after the COVID vaccine. Patient called EMS to take her to emergency room. Patient states heart rate has been consistently around 124-125. Associated intermittent diaphoresis, a flushed appearance, and fatigue. Similar episodes of tachycardia in the past that resolve independently. Patient transferred to a facility with Cardiology.

VAERS ID:	1460255 (history)
Form:	Version 2.0
Age:	49.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-30
Onset:	2021-07-07
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-07-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Blood alkaline phosphatase increased, Condition aggravated, Death, Dyspnoea, Glycosylated haemoglobin, Haemoglobin normal, Loss of consciousness, Metabolic function test normal, Nausea, Oedema peripheral, Platelet count normal, Vomiting, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-07-07
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Sertraline ProAir inhaler Oxycodone/acetaminophen Omeprazole Hydroxyzine Gabapentin
Current Illness: Lower extremity edema, increasing shortness of breath prior to vaccination
Preexisting Conditions: COPD fibromyalgia deconditioning tobacco use
Allergies: Azithromycin Bee allergy (anaphylaxis) Zolpidem
Diagnostic Lab Data: Labs obtained 7/6/21 with elevated WBC 16,000. Hgb 16.0. Platelets normal. Complete metabolic panel normal aside from elevated alkaline phosphatase of 205. Hemoglobin A1c 6.5.
CDC Split Type:

Write-up: Patient received COVID vaccine on 6/30/21. She had been experiencing chronic dyspnea, lower extremity edema. On 7/7 had some nausea, vomiting at home. Found unconscious by her spouse a few hours later and subsequently died.

VAERS ID:	1460326 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-29
Onset:	2021-06-30
Days after vaccination:	93
Submitted:	0000-00-00
Entered:	2021-07-09

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6199 / 1	RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8733 / 2	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-06-30
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Other significant conditions: Chronic A-Fib, HTN, Chronic systolic heart failure, COPD
Allergies:
Diagnostic Lab Data: Covid testing 06/30/2021 08:30 Nasal swab- reported SARS-CoV-2 RNA detected
CDC Split Type:

Write-up: Medical Examiner at time of autopsy ordered Covid testing 06/30/2021 08:30 Nasal swab- reported SARS-CoV-2 RNA detected and confirmed at lab. Cause of death: Complication of Covid-19 Other significant conditions: Chronic A-Fib, HTN, Chronic systolic heart failure, COPD

VAERS ID:	1462043 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-07
Onset:	2021-03-09
Days after vaccination:	30
Submitted:	0000-00-00
Entered:	2021-07-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ELI283 / 2	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Blood test, Computerised tomogram, Computerised tomogram thorax abnormal, Pulmonary embolism, Respiration abnormal
SMQs:, Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levoyhyrozied Amiloride Rosavastatin
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: A lot of tests pulmonary tests cat scan blood tests Still being checked by pulmonary and cardiology dr.
CDC Split Type:

Write-up: Breathing had a ctscan and found I had a pulmonary embollism

VAERS ID:	1462092 (history)
Form:	Version 2.0
Age:	68.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-05-07
Days after vaccination:	43
Submitted:	0000-00-00
Entered:	2021-07-10

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6205 / 2	- / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Chest pain, Pericarditis
SMQs:, Systemic lupus erythematosus (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: chest pain diagnosed as Pericarditis at hospital on Approx May 14, 2021

VAERS ID:	1463659 (history)
Form:	Version 2.0
Age:	39.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-01-05
Onset:	2021-01-25
Days after vaccination:	20
Submitted:	0000-00-00
Entered:	2021-07-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Arrhythmia, Atrial fibrillation, Blood test, Cardiac monitoring, Cardiac stress test, Chest discomfort, Dizziness, Dyspnoea, Echocardiogram, Therapy change
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Vestibular disorders (broad)

Write-up: I developed uncontrolled afib, the first instance was a few weeks after my second vaccine- chest tightness. short of breath, dizziness. these episodes were occurring monthly, and lasting 2-4 hours. Did not seek care until the 3rd episode, was seen at PCP, ended up in ER 2 weeks later. the arrhythmia has been extremely hard to control with 7 medication changes. I am now on 5 medications, prior to this I was on none.

VAERS ID:	1464528 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-06
Onset:	2021-04-24
Days after vaccination:	18
Submitted:	0000-00-00
Entered:	2021-07-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	LA / SYR

Administered by: Other Purchased by: ?
Symptoms: Guillain-Barre syndrome, Lumbar puncture abnormal
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Write-up: Gullain Barre Syndrome

VAERS ID:	1464544 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-17
Onset:	2021-04-19
Days after vaccination:	123
Submitted:	0000-00-00
Entered:	2021-07-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EJ1685 / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Anticoagulant therapy, Arthralgia, Cardiac imaging procedure abnormal, Chills, Computerised tomogram normal, Echocardiogram, Echocardiogram normal, Electrocardiogram normal, Headache, Influenza like illness, Injection site pain, Myalgia, Myocarditis, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Eight hours after receiving the first dose, I experienced flu like symptoms, muscle aches, joint pain, chills, headache, and a fever. Then those symptoms went away. I had pain in the injection site for two days. In April 2021, I spent 4 nights in the hospital. I was diagnosed with Myocarditis. I was also hospitalized for 3 days in May as well. On the 8th of July, I spent 1 day in the hospital. I received blood thinners when I was in the hospital. I am currently taking anti inflammatory medication.

VAERS ID:	1465138 (history)
Form:	Version 2.0
Age:	27.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-26
Onset:	2021-04-26
Days after vaccination:	59
Submitted:	0000-00-00
Entered:	2021-07-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9264 / 1	RA / -
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6201 / 2	RA / -

Administered by: Public Purchased by: ?
Symptoms: Exposure during pregnancy, Foetal death, Stillbirth
SMQs:, Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow), Termination of pregnancy and risk of abortion (narrow)

Write-up: Adverse Event: Stillbirth at 36 weeks gestation First pregnancy, normal previously Due date: 5/26/21 Delivery Date: 4/28/21 Fetal Demise determined on 4/26/21 Birth Weight: 6lbs, 2oz

VAERS ID:	1465377 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-07-12
Onset:	2021-07-12
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	022B21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Angiogram cerebral, Balance disorder, Computerised tomogram head, Echocardiogram, Hemiparesis, Muscular weakness
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Vestibular disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: multivitamin, fish oil ,D3
Current Illness: none
Preexisting Conditions: none
Allergies: none known
Diagnostic Lab Data: CT head Stroke protocol July 1, 2021 Angiogram cerebral July 1, 2021 Echocardiogram July 2, 2021 Echocardiogram TEE, July 3,2021
CDC Split Type:

Write-up: loss of balance, left arm and left leg weakness

VAERS ID:	1465780 (history)
Form:	Version 2.0
Age:	59.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-05
Onset:	2021-06-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-12

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER	- / 1	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Asthenia, Blister, Cellulitis, Feeling abnormal, Headache, Herpes zoster, Impaired work ability, Induration, Joint swelling, Laboratory test, Neuralgia, Pain, Pain in extremity, Peripheral swelling, Pyrexia, Rash, Skin warm, Skin weeping, Sleep disorder, Somnolence, Swelling
SMQs:, Cardiac failure (broad), Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Angioedema (broad), Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Opportunistic infections (broad)

Write-up: 5 hours after getting vaccine my left ankle developed a rash. I felt achy and slight headache. The next day the rash had spread up and began to swell. I also had a low fever,99.9 degrees. On Monday my leg and foot were swollen and very pain and warm. I got in to see my Dr. He wasn''t sure what it''s cause was. He put me on antibiotics. That night when my boyfriend got home he couldn''t wake me up. I had a fever of 103, so he called an ambulance and I went to the hospital. They found no blood clots. I was admitted for IV antibiotics and pain meds. I was released Wednesday afternoon. I have severe swelling of my leg and foot. I got blisters and oozing spots on the back of my leg. I am still in a lot of pain and have shingles that I believe was brought on by covid shot. I couldn''t work. I have nerve pain that shoots up my leg. I have no energy to do anything. One Dr. said it could be from shot others said it was cellulitis.I still am having major problems with pain and nerve pain. I just don''t feel good. I can''t sleep at night because of pain. I was on antibiotics for 3 weeks. The swelling is down but my ankle where the rash was is still hard and very, very painful.

VAERS ID:	1466131 (history)
Form:	Version 2.0
Age:
Sex:	Unknown
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-07-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / -

Administered by: Unknown Purchased by: ?
Symptoms: Retinal vein thrombosis
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Retinal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021813663

Write-up: I had two of my patients lose their eyes due to central retinal vein thrombosis after the second dose of the Pfizer BioNTech COVID-19 vaccine; This is a spontaneous report received from a contactable physician. A patient of unspecified age and gender received second dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Lot number and Expiration date: unknown), via an unknown route of administration on an unknown date as dose 2, single for covid-19 immunisation. The patient medical history was not reported. The patient''s concomitant medications were not reported. The patient previously took first dose of bnt162b2 on an unknown date. The physician reported that, two of my patients lose their eyes due to central retinal vein thrombosis after the second dose of the Pfizer-biontech covid-19 vaccine. Outcome of event was unknown. Information on Lot/Batch number has been requested.; Sender''s Comments: Based on the available information in the case, a possible contributory role of the suspect BNT162B2 cannot be excluded for the reported event retinal vein thrombosis. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.

VAERS ID:	1466526 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-13
Onset:	2021-05-20
Days after vaccination:	7
Submitted:	0000-00-00
Entered:	2021-07-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / UNK	- / -

Administered by: Private Purchased by: ?
Symptoms: Blood test, Computerised tomogram, Gait inability, Hypoaesthesia, Immunoglobulin therapy, Lumbar puncture, Magnetic resonance imaging, Muscle spasms, Paraesthesia
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad)

Write-up: Numbness , Tingling in my feet, severe leg cramps and now i can''t walk came to the ER on June 22 2021 still here in rehab July 13th 2021

VAERS ID:	1466536 (history)
Form:	Version 2.0
Age:	83.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-07
Onset:	2021-07-03
Days after vaccination:	87
Submitted:	0000-00-00
Entered:	2021-07-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012A21A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	030B21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received both doses of the Moderna COVID-19 vaccine (on 3/1/2021 and 4/7/2021). She subsequently developed COVID, testing positive via PCR on 7/3/2021 and was admitted to our hospital on 7/3/2021. She was never ill enough to be in the ICU, instead staying in the general med/surg COVID unit until she was discharged on 7/7/2021. Her primary discharge diagnosis was "COVID-19 pneumonia with mild hypoxemic respiratory failure".

VAERS ID:	1466712 (history)
Form:	Version 2.0
Age:	22.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-31
Onset:	2021-04-22
Days after vaccination:	22
Submitted:	0000-00-00
Entered:	2021-07-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	1808978 / N/A	LA / SYR

Administered by: Private Purchased by: ?
Symptoms: Antibody test normal, Blood copper increased, Blood count normal, Blood creatine phosphokinase normal, Blood electrolytes normal, Blood folate normal, Blood lactate dehydrogenase normal, Blood magnesium normal, Bradykinesia, C-reactive protein normal, Fibrin D dimer normal, Laboratory test, Limb discomfort, Magnetic resonance imaging head normal, Magnetic resonance imaging neck, Magnetic resonance imaging spinal normal, Metabolic function test normal, Movement disorder, Musculoskeletal discomfort, Pain, Pregnancy test negative, Sensory disturbance, Thyroid function test normal, Urine analysis normal, Vitamin B12 normal, Vitamin B6 normal, Vitamin E
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (narrow), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad)

Write-up: When I woke up around 7am I couldn?t move my legs. I thought maybe I slept on them weird so I tried to wait it out. At 7:45 my legs still felt really heavy and hard to move. The nurses hotline said to go to the emergency room so I did. I had a lot of discomfort in my hips and my ankles felt like they had weights on them. I could walk unaided but it was slow and painful. I couldn?t pick up my feet. All tests run were within normal levels with the exception on copper levels. However it was decided that the heightened levels were not statistically significant.

VAERS ID:	1466812 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-12
Onset:	2021-04-28
Days after vaccination:	16
Submitted:	0000-00-00
Entered:	2021-07-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Diplegia, Guillain-Barre syndrome, Laboratory test, Oesophageal motility test
SMQs:, Peripheral neuropathy (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Immune-mediated/autoimmune disorders (narrow)

Write-up: GBS, paralyzed arms and legs

VAERS ID:	1466948 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-07-12
Days after vaccination:	124
Submitted:	0000-00-00
Entered:	2021-07-13

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6200 / 1	LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 2	RA / IM

Administered by: Senior Living Purchased by: ?
Symptoms: Asthenia, COVID-19, Chest X-ray abnormal, Feeling abnormal, Infection, Loss of personal independence in daily activities, Pneumonia, SARS-CoV-2 test positive, Urinary tract infection
SMQs:, Dementia (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received both doses of the Pfizer COVID-19 vaccine, on 2/18/2021 and 3/10/2021. On 7/12/2021, pt presented to our ED for "feeling crumy" with a decline in ADLs. Pt tested positive for COVID 19 via PCR. Chest Xray positive for pneumonia, suspected UTI also contributing. Pt admitted to inpatient due to weakness and suspected underlying infection.

VAERS ID:	1469687 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-30
Onset:	2021-05-01
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-07-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / OT

Administered by: Unknown Purchased by: ?
Symptoms: Catheterisation cardiac, Chest pain, Dyspnoea, Eructation, Flatulence, Pain in extremity, Pericarditis, Product dose omission issue
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Medication errors (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: pericarditis; Has not had second dose of vaccine.; Pain in arm; chest pain; shortness of breath,difficult breathing; thought it was gas; burp; This spontaneous case was reported by a patient and describes the occurrence of PERICARDITIS (pericarditis) in a 54-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concomitant products included AMLODIPINE BESILATE (AMLODIPINE BESYLATE) for Blood pressure, SIMVASTATIN for Cholesterol, OMEPRAZOLE for an unknown indication. On 30-Apr-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 01-May-2021, the patient experienced CHEST PAIN (chest pain), DYSPNOEA (shortness of breath,difficult breathing), FLATULENCE (thought it was gas), ERUCTATION (burp) and PAIN IN EXTREMITY (Pain in arm). On 02-May-2021, the patient experienced PERICARDITIS (pericarditis) (seriousness criteria hospitalization and medically significant). On an unknown date, the patient experienced PRODUCT DOSE OMISSION ISSUE (Has not had second dose of vaccine.). The patient was hospitalized from 02-May-2021 to 04-May-2021 due to PERICARDITIS. The patient was treated with COLCHICINE (COLCHICINE A) on 04-May-2021 at an unspecified dose and frequency and ACETYLSALICYLIC ACID (ASPIRIN 81) on 04-May-2021 at an unspecified dose and frequency. At the time of the report, PERICARDITIS (pericarditis), CHEST PAIN (chest pain), DYSPNOEA (shortness of breath,difficult breathing), FLATULENCE (thought it was gas), ERUCTATION (burp), PRODUCT DOSE OMISSION ISSUE (Has not had second dose of vaccine.) and PAIN IN EXTREMITY (Pain in arm) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 02-May-2021, Catheterisation cardiac: pericarditis (abnormal) Pericarditis. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. Patient received the first dose of the vaccine on 03-Apr-2021 , Batch number 001C2(Z)1A( patient can''t distinguish)and on the next day she experienced chest pain( started around 7 pm), shortness of breath, difficulty breathing. Patient did not go to ER right away thought it was gas, When she drink water she would burp. It got worse that night.. Patient had pain in the arm that was occurring before chest pain and can''t remember what she took which was either Tylenol or ibuprofen. On the following day on 02-May-2021patient went to ER, they tried to control the pain and was admitted to hospital and had blood work done but no result was reported. On the next day, 03-May-2021 patient had stress test done but no result was reported and was transferred to another hospital for emergency Cath lab procedure, finding that she had pericarditis. Patient discharge on 04-May-2021 and was prescribed Colchicine and low dose baby aspirin. Patient has not had the second dose of vaccine. Company Comment : Very limited information regarding the events has been provided at this time. Further information is expected.; Sender''s Comments: Very limited information regarding the events has been provided at this time. Further information is expected.

VAERS ID:	1470124 (history)
Form:	Version 2.0
Age:	40.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-03-25
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ER8732 / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal discomfort, Angiogram pulmonary normal, Antinuclear antibody increased, Back pain, Band neutrophil count increased, Blood electrolytes normal, Blood lactate dehydrogenase increased, Blood thyroid stimulating hormone normal, Blood urine present, Brain natriuretic peptide, Bronchial hyperreactivity, C-reactive protein increased, Cardiac operation, Cardiac pacemaker replacement, Chest X-ray normal, Chest pain, Chills, Computerised tomogram abdomen abnormal, Condition aggravated, Cough, Culture urine, Cytomegalovirus test, Electrocardiogram normal, Endocarditis bacterial, Epstein-Barr virus antibody positive, Epstein-Barr virus test, Fibrin D dimer increased, Full blood count normal, Gastrooesophageal reflux disease, Glomerular filtration rate decreased, HIV test, Headache, Heart valve replacement, Hepatitis viral test, Hiatus hernia, Hyperhidrosis, Laboratory test, Lipase normal, Liver function test normal, Metabolic function test normal, Nausea, Painful respiration, Pertussis, Pregnancy test negative, Red blood cell sedimentation rate increased, Renal cyst, Renal infarct, SARS-CoV-2 antibody test, Sensation of foreign body, Sleep disorder, Splenic infarction, Splenomegaly, Throat clearing, Ultrasound abdomen abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Renovascular disorders (narrow), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Write-up: Chills, sweats, nausea, headache, chest pain with deep inspiration, contacted 1 week after vaccination. Continued for another week, contacted clinic. Recommended ER, patient did not go. Reached out to her cardiologist who ordered labs and chest xray. CMP, CBC and Chest xray all normal on 4/12/21. Reached out after she returned from vacation and reported lingering cough. Rx''d Cheratussin and Albuterol inhaler. Patient was recommended respiratory clinic, instead she made her own appt to go to ENT. Patient had also reported worsening GERD symptoms- upset stomach and throat clearing- referred to her GI specialist who manages her GERD/Hiatal hernia. ENT saw patient on 4/30/21- dx''d with cough, reactive airway, GERD, globus sensation. Rx''d- Advair- 2 puffs BID, Nasal saline spray, Allegra 180 mg- daily, continue Protonix and referred back to GI. Called 5/5- reported mid right back pain that woke her up on Saturday AM (4 days prior). Recommend ER due to pain awakening her and also to follow up with her GI MD. She reports her GI ordered an Ultrasound but couldn''t see her until August. Went to ER on 5/5 with dx of right sided thoracic pain. Sent home with no Rx, recommend NSAIDs, ice/heat, lidocaine patches. Patient reached out on 5/18 to discuss US results- informed there was mild splenomegaly. Continued with cough, upset stomach, back pain. PCP received US results on 5/24. Patient recommended to come in to see PCP for further management. Saw PCP on 6/2/21- Labs ordered today are ANA screen, BNP, CRP, CMP, COVID IgG, UA macro/mirco and culture, CMV antibody, EBV panel, D-Dimer, CBC, hepatitis panel, HIV, LDH, lipase, Quantiferon, TSH, RF and ESR. Referred to respiratory clinic- informed patient it was Pertussis- placed on Azithromycin. PCP switched RX to Levaquin. Healthline reached out to patient for elevated D-Dimer- patient refused ER. 6/9/21- CT- renal infarct, splenic infarct 6/10/21- Admitted. Bacterial endocarditis, renal and splenic infarct, ended with open heart surgery, valve replaced, replaced pacemaker

VAERS ID:	1470194 (history)
Form:	Version 2.0
Age:	84.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-02
Onset:	2021-03-03
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-07-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	013A21A / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Anticoagulant therapy, Blood test, Computerised tomogram thorax abnormal, Echocardiogram, Electrocardiogram, Erythema, Pain, Pain in extremity, Pulmonary pain, Pulmonary thrombosis, Thrombosis, Urine analysis
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Write-up: Thursday and Friday my arm was red and sore and over the weekend on Monday I have terrible pains in the lungs I called the nurse and she said to go to the hospital. I have a pressure of 102 with terrible pain. They thought I was having a heart attack and they did an electro, echo cardiogram. They did a Ct scan and they found I have clots in the lungs. They admitted me into the hospital and stayed for 2 night and then on 3/11 they sent me home and they gave me a Blood thinner (take it twice a day).

VAERS ID:	1470420 (history)
Form:	Version 2.0
Age:	39.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-29
Onset:	2021-07-02
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-07-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	009021A / 2	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Blood test, Dyspnoea, Headache, Hypoaesthesia, Lumbar puncture, Magnetic resonance imaging, Musculoskeletal stiffness, Paraesthesia
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Arthritis (broad)

Write-up: Starting on July 2nd my feet started tingling and going numb. On July 3rd my feet and lower legs were tingling and going numb in the evening. On the 3rd, I also got the worst headache I have ever experienced in my life. On the 4th I woke up with a lingering headache and the back of my neck was kind of stiff. My feet and legs were tingling/feeling numb on and off during the day and my left arm started to go tingly/numb as well. At about 2:30 a.m. on July 5th, I woke up with difficulty breathing and all 4 legs and arms were numb and tingly, and I was very weak. I was taken to the E.R. by my family. At the E.R. they did a lumbar puncture and blood work and sent me by ambulance to larger hospital. While there, I went through further testing including an MRI and additional blood work. The conclusion was that I was experiencing paresthesia possibly caused by a strong autoimmune reaction.

VAERS ID:	1470689 (history)
Form:	Version 2.0
Age:	73.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-19
Onset:	2021-07-11
Days after vaccination:	114
Submitted:	0000-00-00
Entered:	2021-07-14

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	UNKNOWN AND NO / 2	UN / UN
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	ENTERED IN ERRO / UNK	- / -

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Chest X-ray normal, Cough, Malaise, Oropharyngeal pain, Pain, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client presented to ED on 7/11/2021 with concerns for fever, malaise, cough, sore throat and diffuse body aches. Client placed in Observation status and not admitted as an inpatient. Client left the hospital on 7/12/2021. Follow up call by Public Health on 7/13/2021 - client reported symptoms continued, but milder.

VAERS ID:	1474478 (history)
Form:	Version 2.0
Age:	34.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-21
Onset:	2021-06-09
Days after vaccination:	19
Submitted:	0000-00-00
Entered:	2021-07-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0186 / 2	RA / IM

Administered by: Other Purchased by: ?
Symptoms: Caesarean section, Exposure during pregnancy
SMQs:, Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow)

Write-up: Patient hospitalized for cesarean section within 6 weeks of receiving COVID vaccination. Per notes both mom and baby were healthy at that time.

VAERS ID:	1474581 (history)
Form:	Version 2.0
Age:	89.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-07-14
Days after vaccination:	132
Submitted:	0000-00-00
Entered:	2021-07-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 2	UN / UN

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Gene sequencing, Malaise, Nucleic acid test, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Client admitted to hospital on 7/14/2021 with COVID-19 symptoms, she was not admitted to ICU or intubated. Writer does not have access to any further details on this case. Please contact admitting hospital if further information is needed.

VAERS ID:	1474661 (history)
Form:	Version 2.0
Age:	93.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-10
Onset:	2021-07-10
Days after vaccination:	122
Submitted:	0000-00-00
Entered:	2021-07-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN6207 / 2	RA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Asthenia, Blood culture negative, COVID-19, Chest X-ray abnormal, Chills, Cough, Culture urine positive, Lung opacity, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Received covid (Pfizer) vaccine on 2/18/21 and 3/10/21. Presented to hospital on 7/12/21 with chills, fevers, cough and weakness (symptom onset was a few days prior to admission). CXR = Right basilar airspace opacity concerning for pneumonia. No hypoxia or need for O2. Started on antibiotics for CAP and possible UTI. Urine culture showed $g100K mixed skin flora. Blood cultures x2 were negative. SARS-CoV-2 PCR resulted positive.

VAERS ID:	1475006 (history)
Form:	Version 2.0
Age:	35.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-27
Onset:	2021-06-22
Days after vaccination:	26
Submitted:	0000-00-00
Entered:	2021-07-15

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0167 / 1	AR / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0187 / 2	AR / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Abnormal behaviour, Abscess drainage, Blood test, Computerised tomogram thorax abnormal, Cough, Death, Increased appetite, Lung abscess, Pneumonia, Skin warm, Somnolence, X-ray
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-06-30
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Divalproex, Vyvanse, Risperidone, multivitamin, vitamin D3
Current Illness: None
Preexisting Conditions: ADHD, Epilepsy, Anxiety, Microcephalus, Autism, urinary incontinence, incontinence of feces
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt. started coughing Tuesday, June 22, 2021, in the afternoon and it worsened through the rest of day. She also was beginning to be drowsy. Wednesday, June 23, 2021, coughing continued, she became drowsier, she felt warm to the touch (forehead, face, arms, back) and was not acting like herself. Thursday, June 24, 2021, 9am she was at the clinic. The doctor ordered an x-ray and blood work. After results arrived, we were advised to go to the emergency room. There the doctor ordered CT scan. The results showed an abscess and fluid in her left lung and pneumonia. Her lung was drained, was not able to get all of it out. They discussed surgery but needed to send pt. to ER. The discussion for surgery was a daily thing but never happened. They tried multiple procedures, CT scans, etc. On Tuesday, June 29, 2021 there was a meeting called with her doctor to discuss palliative care. The risk of surgery and all the complications following were high risk. Pt. did not understand that she needed to leave the IV and drainage tube in as well as leaving the oxygen on. Based on the complications and pts. quality of life after surgery and the fact that the fluid and pneumonia spread quickly throughout her body - the doctors were leaning towards end-of-life comfort. It all happened so fast! The evening of the 29th, pt. was transported home to end her life on hospice. On Wednesday, June 30, 2021 pt. passed away in the afternoon. Pt. was rarely ever sick. Once in a great while she would get a runny nose or little cough. Everyone around her would catch a virus and she simply would not. We had a member of our family test positive for COVID-19 in November 2020, and pt. never showed any symptoms of being ill. This was all before she received the COVID-19 Vaccine. About a week or two after she received the second vaccine, on May 27,2021. she had increased behaviors with eating and daily ADLs. But the behaviors were her ?normal? behaviors that would occasionally come and go. Nothing was ever persistent. Then on Tuesday June 22, 2021 when sick like symptoms started to appear it was less then four weeks after the second vaccine.

VAERS ID:	1478463 (history)
Form:	Version 2.0
Age:	63.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-06
Onset:	2021-05-10
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-07-16

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 1	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Abdominal pain, Angiogram peripheral abnormal, Anticoagulant therapy, Atrial thrombosis, Blood creatine increased, Chest pain, Computerised tomogram abdomen, Condition aggravated, Dyspnoea, Echocardiogram, Echocardiogram abnormal, Ejection fraction decreased, Electrocardiogram T wave abnormal, Femoral artery embolism, Headache, Hepatic infarction, International normalised ratio, Magnetic resonance imaging abnormal, Pain in extremity, Pericardial effusion, Splenic infarction, Troponin normal
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Other ischaemic heart disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 13 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, Albuterol,Brilinta, Clopidogrel, Diltiazem, Furosemide,Metoprolol,Pantoprazole, Spironolactone
Current Illness: Hospital Course summary: Patient is a 63 y/o F with past medical history of paroxysmal A. fib, CAD s/p several stenting, CKD stage III with baseline creatinine 1.1- 1.4, hypertension, COPD, diastolic heart failure, anxiety. Patient admitted with chest pain & SOB 5/10/21. Eliquis held on admission and patient started on therapeutic Lovenox 1 mg/kg twice daily. Troponin was negative x3 initially, EKG showed T wave inversion in precordial leads. Plan was to do cardiac catheterization. Starting on the night of 5/13, patient had more chest pain, elevated trended up to 2.195 and then 0.205, repeat EKG without acute changes. On 5/14, patient started having sudden abdominal pain, left leg pain and cath was canceled. CTA abdomen and peripherals was done and found to have multifocal infarct of spleen and liver. Also found to have new embolism more proximal left deep femoral artery without acute limb ischemia. Surgery and IR consulted and no intervention other than anticoagulation recommended. Patient suspected to have Lovenox failure, patient switched heparin with Coumadin after consultation with hematology. MRI at the time showed likely infarct: 8 mm focus of diffusion restriction in the left splenium of the corpus callosum. TEE showed left atrial appendage thrombus on May 19, 2021 with EF of 45% -Patient continued on heparin drip till INR more than 2 for more than 24 hours. Patient now ready for discharge home with close outpatient follow-up at Coumadin clinic. Patient also to follow-up with hematology Dr in couple weeks. Current consensus is that patient will likely require lifelong anticoagulation therapy. -Follow-up echocardiogram with cardiology in 2-3 weeks is already arranged. -For A. fib: Patient was given Cardizem drip, transitioned to p.o. Cardizem 180 mg twice daily and metoprolol. Discussed with cardiology about the dosing at discharge. -Small pericardial effusion, no tamponade
Preexisting Conditions: Cardiac and Vasculature Paroxysmal atrial fibrillation (ZARLING) CAD (coronary artery disease) (ZARLING) (*) HTN, goal below 130/80 (*) Pericardial effusion Acute on chronic diastolic (congestive) heart failure (*) Chest pain Abnormal EKG Thrombus of left atrial appendage Genitourinary and Reproductive CKD (chronic kidney disease), stage III
Allergies: Lisinopril
Diagnostic Lab Data: Hospital Course summary: Patient is a 63 y/o F with past medical history of paroxysmal A. fib, CAD s/p several stenting, CKD stage III with baseline creatinine 1.1- 1.4, hypertension, COPD, diastolic heart failure, anxiety. Patient admitted with chest pain & SOB. Eliquis held on admission and patient started on therapeutic Lovenox 1 mg/kg twice daily. Troponin was negative x3 initially, EKG showed T wave inversion in precordial leads. Plan was to do cardiac catheterization. Starting on the night of 5/13, patient had more chest pain, elevated trended up to 2.195 and then 0.205, repeat EKG without acute changes. On 5/14, patient started having sudden abdominal pain, left leg pain and cath was canceled. CTA abdomen and peripherals was done and found to have multifocal infarct of spleen and liver. Also found to have new embolism more proximal left deep femoral artery without acute limb ischemia. Surgery and IR consulted and no intervention other than anticoagulation recommended. Patient suspected to have Lovenox failure, patient switched heparin with Coumadin after consultation with hematology. MRI at the time showed likely infarct: 8 mm focus of diffusion restriction in the left splenium of the corpus callosum. TEE showed left atrial appendage thrombus on May 19, 2021 with EF of 45% -Patient continued on heparin drip till INR more than 2 for more than 24 hours. Patient now ready for discharge home with close outpatient follow-up at Coumadin clinic. Patient also to follow-up with hematology Dr in couple weeks. Current consensus is that patient will likely require lifelong anticoagulation therapy. -Follow-up echocardiogram with cardiology in 2-3 weeks is already arranged. -For A. fib: Patient was given Cardizem drip, transitioned to p.o. Cardizem 180 mg twice daily and metoprolol. Discussed with cardiology about the dosing at discharge. -Small pericardial effusion, no tamponade
CDC Split Type:

Write-up: Daily headaches- in process of treatment

VAERS ID:	1482840 (history)
Form:	Version 2.0
Age:	57.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-20
Onset:	2021-05-20
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0183 / 2	LA / OT

Administered by: Public Purchased by: ?
Symptoms: Alopecia, Decreased appetite, Fatigue, Insomnia, Migraine, Myalgia, Nausea, Weight increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Allergy
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021612030

Write-up: hair loss; migraine; Nausea; Fatigue; increase weight gain; no appetite; shooting pain in the muscles; Insomnia for 9 days; This is a spontaneous report from a contactable nurse. A 57-year-old female nurse (patient) reported for herself. A 57-years-old non pregnant female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Batch/Lot Number: EW0183, Expiration date: Unknown), via intramuscular route, administered in left arm (deltoid) on 20May2021 16:00 (at the age of 57-years-old) as dose 2, single for covid-19 immunisation in public health clinic/veterans administration facility. Medical history included known allergies. The concomitant medications were none. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. Prior to vaccination, the patient was not diagnosed with COVID-19. The patient previously received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Batch/Lot Number: EW0179, Expiration date: Unknown), via intramuscular route, administered in deltoid on 29Apr2021 (at the age of 57-years-old) as dose 1, single for covid-19 immunisation and no problem with first injection. On 20May2021 at 02:00 Am, the patient experienced insomnia for 9 days. On 21May2021 at 02:00, the patient experienced, hair loss, migraine, nausea For 4 weeks, fatigue, increase weight gain, no appetite, shooting pain in the muscles. Since the vaccination, the patient has not been tested for COVID-19. Therapeutic measures were taken as a result of insomnia for 9 days, migraine with smudging with SAGE disease and Tylenol 500 mg respectively. The event Insomnia and nausea were reported as Persistent/ Significant disability/ Incapacity, Important medical event, migraine was reported as Persistent/ Significant disability/ Incapacity, and hair loss was reported as Important medical event. The outcome of the event migraine was resolved on an unspecified date in 2021 and nausea was resolved on 15Jun2021, hair loss was not resolved and other events were resolving. Follow-up attempts are needed. Further information is requested. Follow-up: This is a follow up-spontaneous report from a contactable other HCP (nurse). This other HCP (nurse) reported in response to HCP letter via follow-up letter:; Sender''s Comments: Considering a plausible temporal relationship, a possible contributory role of suspect product BNT162B2 to the reported Insomnia, hair loss and Migraine cannot be excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees, and Investigators, as appropriate.

VAERS ID:	1483925 (history)
Form:	Version 2.0
Age:	39.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-06-29
Onset:	2021-07-04
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-07-18

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	009D21A / 2	RA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Asthenia, CSF test abnormal, Dizziness, Dyspnoea, Fatigue, Hypoaesthesia, Inflammatory marker increased, Lumbar puncture, Magnetic resonance imaging normal
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Write-up: Numbness in arms and legs Difficulty breathing Severe body weakness and fatigue Dizziness

VAERS ID:	1484717 (history)
Form:	Version 2.0
Age:	25.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-29
Onset:	2021-07-07
Days after vaccination:	8
Submitted:	0000-00-00
Entered:	2021-07-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / UNK	- / IM

Administered by: Private Purchased by: ?
Symptoms: Pain, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Write-up: Pt presented to ED 8 days after second covid injection due to pain for 5 days and diagnosed with PE

VAERS ID:	1484798 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-05-13
Onset:	2021-06-06
Days after vaccination:	24
Submitted:	0000-00-00
Entered:	2021-07-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	017C21A / 2	LA / IM

Administered by: Other Purchased by: ?
Symptoms: Tibia fracture
SMQs:, Accidents and injuries (narrow)

Write-up: Patient presented to the ED and was subsequently hospitalized for Closed fracture of right tibial plateau within 6 weeks of receiving COVID vaccination.

VAERS ID:	1484811 (history)
Form:	Version 2.0
Age:	79.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-07-17
Days after vaccination:	163
Submitted:	0000-00-00
Entered:	2021-07-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	OIIL2OA / UNK	LA / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Cough, Fall, SARS-CoV-2 test positive, Transfusion
SMQs:, Anaphylactic reaction (broad), Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Tested prior to hospital admission. Started with a cough on 7/17/21 and fell at home. Was brought to ER for evaluation. Per nurse on the floor, he was admitted for fall and COVID, and has no issues from fall so continued admission is due to COVID treatment. Currently receiving plasma treatment and oxygen.

VAERS ID:	1484816 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-04
Onset:	2021-07-17
Days after vaccination:	135
Submitted:	0000-00-00
Entered:	2021-07-19

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	LA / IM

VAERS ID:	1487508 (history)
Form:	Version 2.0
Age:	52.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-14
Onset:	2021-03-15
Days after vaccination:	1
Submitted:	0000-00-00
Entered:	2021-07-20

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	LA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Arthralgia, Colonoscopy, Pyrexia, Rectal haemorrhage, Tendon injury, Tendon pain, Tenoplasty
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal haemorrhage (narrow), Accidents and injuries (narrow), Ischaemic colitis (broad), Arthritis (broad), Tendinopathies and ligament disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bleed pressure meds Baby aspirin
Current Illness: APS
Preexisting Conditions: APS diagnosed in 2011
Allergies: Seasonal
Diagnostic Lab Data: Colonoscopy and re attachment of hamstrings
CDC Split Type:

Write-up: Low fevers tendon joint pain Rectal bleeding and blowout of my prixamal hamstring tendon completely seporated and to partially seporated hamstring tendons

VAERS ID:	1490371 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-05-12
Onset:	2021-05-29
Days after vaccination:	17
Submitted:	0000-00-00
Entered:	2021-07-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0186 / 2	UN / IM

Administered by: Other Purchased by: ?
Symptoms: Road traffic accident
SMQs:, Accidents and injuries (narrow)

Write-up: Patient presented to the ED and was subsequently hospitalized for a motorcycle accident within 6 weeks of receiving covid vaccination.

VAERS ID:	1490545 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	1963-03-15
Onset:	2021-07-19
Days after vaccination:	21311
Submitted:	0000-00-00
Entered:	2021-07-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	AR / SYR

Administered by: Other Purchased by: ?
Symptoms: COVID-19, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient Contracted COVID-19 even though he had received both shots in his vaccination. Patient ended up in-patient at hospital with respiratory distress

VAERS ID:	1490840 (history)
Form:	Version 2.0
Age:	23.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-09
Onset:	2021-04-09
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-21

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	- / 1	- / SYR

Administered by: Unknown Purchased by: ?
Symptoms: Angina pectoris, Computerised tomogram, Dyspnoea, Electrocardiogram, Fatigue, Heart rate increased, Hyperhidrosis, Parosmia, Pyrexia, Taste disorder, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data: EKG, CT scan
CDC Split Type:

Write-up: High fever of 105, vomiting, sweats for multiple days. Then after that, my taste and smell have been strange for months. Constant heart pain, fast heartbeat, fatigue, out of breath

VAERS ID:	1493971 (history)
Form:	Version 2.0
Age:	75.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-26
Onset:	2021-07-21
Days after vaccination:	86
Submitted:	0000-00-00
Entered:	2021-07-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0150 / 1	UN / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0172 / 2	UN / SYR

Administered by: Private Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Computerised tomogram thorax abnormal, Cough, Fatigue, Headache, Lung disorder, Lung opacity, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Received Pfizer vaccines on 4/5/21, 4/26/21 tested positive for COVID-19 by PCR on 7/21/21. Hospitalized on 7/21/21. 3 weeks of pulmonary symptoms, fever, H/A, fatigue, dry cough, CT chest shows peripheral ground glass infiltrates. Diagnosed w/ pneumonia d/t COVID-19 but has not required oxygen. Plan on administering monoclonal antibodies as an outpatient as patient is not a candidate for remdesivir. Patient has h/o kidney transplant in 2019.

VAERS ID:	1494022 (history)
Form:	Version 2.0
Age:	38.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-05
Onset:	2021-03-05
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / UNK	- / -

Administered by: Work Purchased by: ?
Symptoms: Injection site indentation, Injection site muscle atrophy
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: omeprazole, citalopram,
Current Illness: none
Preexisting Conditions: Chron''s Disease, GERD, anxiety
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: patient developed bruising to the right deltoid initially after having COVID injection on 3/5/2021. she subsequently had the second injection on 4/1/2021 to the right deltoid. Now has indentation to the said area and appears to have muscle atrophy to the area.

VAERS ID:	1494157 (history)
Form:	Version 2.0
Age:	56.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-01
Onset:	2021-06-05
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-07-22

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Amnesia, Borrelia test negative, CSF protein increased, CSF white blood cell count increased, Confusional state, Encephalitis, Herpes simplex test negative, Immunology test normal, Lumbar puncture, Magnetic resonance imaging head abnormal, Polymerase chain reaction, Pyrexia, Treponema test negative
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (narrow), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Write-up: Developed what we believe was an encephalitis with confusion, memory loss, fever. MRI with abnormal enhancement of the mesial termporal lobes bilaterally. No other obvious etiology found. Slowly over several weeks improve.

VAERS ID:	1498057 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-04
Onset:	2021-02-18
Days after vaccination:	14
Submitted:	0000-00-00
Entered:	2021-07-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL9269 / 2	AR / IM

Administered by: Private Purchased by: ?
Symptoms: Arthritis, Condition aggravated, Inflammation, Intervertebral disc disorder, Laboratory test, Spinal operation, Vasectomy
SMQs:, Systemic lupus erythematosus (broad), Arthritis (narrow), Immune-mediated/autoimmune disorders (broad)

Write-up: My left elbow exp inflammation that I''m still exp today. On March 20 started having irritation of my disc caused by my inflammation caused by the vaccine.I had a vasectomy of lower back L4, L5 on June 29. I''m only 3 weeks post surgery for my back still having concerns.

VAERS ID:	1498253 (history)
Form:	Version 2.0
Age:	33.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2020-12-23
Onset:	2021-01-13
Days after vaccination:	21
Submitted:	0000-00-00
Entered:	2021-07-23

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL1284 / 1	RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL0142 / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Anticoagulant therapy, Appendiceal abscess, Appendicectomy, Appendicitis perforated, Back pain, Computerised tomogram abdomen abnormal, Computerised tomogram thorax abnormal, Diarrhoea, Dyspnoea, Gastrointestinal disorder, Laparoscopic surgery, Nausea, Pulmonary embolism, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Embolic and thrombotic events, venous (narrow), Gastrointestinal perforation (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow)

Write-up: I''m not sure if this is a result of the vaccine or not. Beginning 4/25/21, I had intense GI issues, NVD, resulting in a trip to Urgent Care on 4/26. The PA thought it was gastroenteritis and to follow-up if I wasn''t feeling well later in the week. The following Monday, I went to the ER as I wasn''t better, had a CT scan which showed my appendix had burst and abscessed. I had an emergency laproscopic appendectomy on 5/3, released from the hospital 5/4. On 5/10 I felt a sharp pain in my lower back that I attributed to a pulled muscle. After several days of difficulty breathing, intense periodic back pain, I went back to the ER on 5/14 and I was diagnosed with a small PE in my right lung after CT scan.

VAERS ID:	1500614 (history)
Form:	Version 2.0
Age:	64.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-06-11
Onset:	2021-06-17
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-07-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EW0180 / 2	LA / -

Administered by: Pharmacy Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Fluid retention, Myocardial infarction
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-06-25
Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Allergy; Chromosomal abnormality NOS; Diabetes; Endocrine disorder (including diabetes); Immune system disorder; Obesity; Respiratory disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021864579

Write-up: myocardial infarction; Fluid; Shortness of breath; Chest pain; This is a spontaneous report from a contactable nurse (patient''s wife). A 64-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot Number: EW0180), via an unspecified route of administration, administered in left arm on 11Jun2021 10:00 (64-year-old at time of vaccination) as single dose for COVID-19 immunization. The patient''s medical history included diagnosed allergies, compromised immune status, respiratory illness, genetic/chromosomal abnormalities, endocrine abnormalities (including diabetes) and obesity. There was no family medical history relevant to adverse event. There were no concomitant medications. The patient previously received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot Number: EW0186), via an unspecified route of administration, administered in left arm on 21May2021 (64-year-old at time of vaccination) for COVID-19 immunization. There were no vaccines administered on same date with the Pfizer vaccine considered as suspect. There were no other vaccinations within four weeks prior to the first administration date of the suspect vaccine. The patient experienced chest pain on 17Jun2021, fluid and shortness of breath on 25Jun2021, and myocardial infarction on an unspecified date. Patient''s wife (a registered nurse, recently retired) just wanted to report this. She can''t say that it is the vaccine or anything. Her husband received the second COVID-19 Vaccine on 11Jun2021 and he died at the emergency room 2 weeks later of a cardiac event. She couldn''t do the report online because it was making her the one she was reporting on. Chest pain: She took him to the emergency room on 25Jun2021. He had been having chest pain that he reported to her that Monday before. He told her that it actually started the Thursday before on 17Jun2021. He had some chest pain that felt a little better over the weekend, then Monday it was worse. He wasn''t a complainer, but he was obviously having chest pain. He was very stubborn and so he just kind of let it progress and it got worse during the week. He wouldn''t go to the doctor. She kept telling him she read about myocarditis mostly with adolescent males. She thought what if it is something like that. Time of Onset of Chest pain: He reported it on Monday that he had chest pain on Thursday. She became aware when he woke up at 06:30 on 21Jun2021 and she knew something was wrong when he went for the Ibuprofen. Fluid and shortness of breath: The day she took him to the emergency room the chest pain had worsened and he had fluid and shortness of breath. The fluid and shortness of breath started on 25Jun2021. Death: He died on 25Jun2021. The cause of death was a myocardial infarction. They didn''t do an autopsy. The reason they gave for not being able to do an autopsy was they were overwhelmed with drug overdoses and homicides. Indication for COVID-19 Vaccine: He didn''t want it, but he needed to go back to the office and didn''t want to wear a mask. Adverse events required a visit to emergency room. Investigations: She doesn''t have his medical records yet. Essentially they were recording him. She can''t believe she got him in in a wheelchair. Immediately they were doing resuscitation efforts. Relevant Tests was reported as none. The outcome of myocardial infarction was fatal; outcome of other events was unknown. The patient died on 25Jun2021. No autopsy was performed. The cause of death was a myocardial infarction. Causality: the reporting nurse has no opinion. She just thinks that the patient didn''t randomly die any of his other 64 years. It may be a coincidence.; Sender''s Comments: The event myocardial infarction with fatal outcome is considered unrelated to suspect product (PFIZER-BIONTECH COVID-19 VACCINE, Lot Number: EW0180). The compromised immune status, respiratory illness, genetic/chromosomal abnormalities, endocrine abnormalities (including diabetes) and obesity may explain as alternative cause.; Reported Cause(s) of Death: Myocardial infarction

VAERS ID:	1500865 (history)
Form:	Version 2.0
Age:	61.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-23
Onset:	2021-04-26
Days after vaccination:	3
Submitted:	0000-00-00
Entered:	2021-07-24

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	023M20A / 1	LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	025C21A / 2	LA / IM

Administered by: Pharmacy Purchased by: ?
Symptoms: Aphasia, Apraxia, Cerebrovascular accident, Communication disorder, Computerised tomogram, Craniectomy, Cranioplasty, Hemiplegia, Impaired self-care, Impaired work ability, Intensive care, Loss of personal independence in daily activities, Wheelchair user
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Depression (excl suicide and self injury) (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 89 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Dorzolamide Timolo eye drops for glaucoma pressure prevention
Current Illness: None
Preexisting Conditions: None
Allergies: Bee stings
Diagnostic Lab Data: MCA stroke, TPA blood thinner given, countless CT scans, craniectomy, cranioplasty, and entering his 4th month of 24/7 care. Weekly rehab therapies of speech, occupational and physical therapies. Wheelchair dependent, requires total assistance for daily needs. Can''t communicate orally.
CDC Split Type:

Write-up: 3 days after Moderna C19 vaccination on 4/23/21 Patient suffered a massive stroke on 04/26/21. He is now a hemi-plegic with severe apraxia and aphasia, unable to work, communicate or care for himself. He had no health issues prior to the vaccination. He was in ICU, Intensive care and hospital for 2 months and rehab continues.

VAERS ID:	1501207 (history)
Form:	Version 2.0
Age:	60.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-12
Onset:	2021-03-22
Days after vaccination:	10
Submitted:	0000-00-00
Entered:	2021-07-25

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 2	LA / IM

Administered by: Military Purchased by: ?
Symptoms: Blood test, Bone pain, Bone scan, Chest X-ray, Chills, Computerised tomogram, Computerised tomogram abdomen, Computerised tomogram head, Computerised tomogram thorax, Echocardiogram, Lumbar puncture, Nausea, Pyrexia, Streptococcal infection, Streptococcus test positive, Tremor
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Osteonecrosis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Omeprazole, ranitidine, duloxetine, Novolog, Lantus, celecoxib, metoprolol succinate, valsartan, HCTZ/spironolactone, amlodipine besylate
Current Illness: None
Preexisting Conditions: Ulcerative colitis (since age 13), high blood pressure, type 2 diabetes, GERD, depression
Allergies: Penicillin.
Diagnostic Lab Data: During 9-day hospitalization from 3/17 to 3/26: Blood work, CT of arm, foot, abdomen, chest, head, lumbar puncture x2, whole body bone scan, TEE, chest x-ray.
CDC Split Type:

Write-up: Bone pain. Hospitalized with group B strep four days later (3/25/21) - fever, shakes, chills, nausea

VAERS ID:	1501794 (history)
Form:	Version 2.0
Age:	44.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-30
Onset:	2021-07-13
Days after vaccination:	105
Submitted:	0000-00-00
Entered:	2021-07-26

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	RA / IM

Administered by: Private Purchased by: ?
Symptoms: COVID-19, Chest X-ray abnormal, Diarrhoea, Fatigue, Hyposmia, Hypoxia, Lethargy, Lung infiltration, Myalgia, Nausea, Productive cough, SARS-CoV-2 test positive, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Taste and smell disorders (narrow), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient received full COVID vaccine series on 3/9/2021 and 3/30/2021. Patient became symptomatic with COVID symptoms on 7/13/2021. Symptoms include mild productive cough, fatigue, muscle aches, decreased smell. patient was tested for COVID-19 on 7/20/2021 via RT-PCR which returned positive. Patient was offered monoclonal antibody therapy and declined. Patient was seen in Emergency SErvices on 7/23/2021 for increased nausea, vomiting and diarrhea and increasing lethargy. She received IV fluids and Zofran. Oxygen saturations in mid-90s on room air. Patient discharged home. Patient returned to emergency services on 7/24/2021 and found to be significantly hypoxic requiring supplemental oxygen via nasal cannula at 2 Liters. Patient was subsequently admitted to the hospital for additional treatment. Chest x-ray with bilateral patchy infiltrates, being trearted with dexamethason/remdesivir. Patient remains admitted to the hospital at the time of this report.

VAERS ID:	1505392 (history)
Form:	Version 2.0
Age:	70.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-18
Onset:	2021-07-26
Days after vaccination:	158
Submitted:	0000-00-00
Entered:	2021-07-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	N/A / 2	UN / IM

Administered by: Unknown Purchased by: ?
Symptoms: COVID-19, Chest X-ray, Hypoxia, Pneumonia, SARS-CoV-2 test positive
SMQs:, Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Patient received Pfizer vaccine on 1/26 and 2/18/21. She was admitted to the hospital on 7/26, diagnosed with COVID-19, hypoxia and pneumonia

VAERS ID:	1505777 (history)
Form:	Version 2.0
Age:	54.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-08
Onset:	2021-03-15
Days after vaccination:	35
Submitted:	0000-00-00
Entered:	2021-07-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	007M20A / 2	LA / IM

Administered by: Unknown Purchased by: ?
Symptoms: Blood test, Computerised tomogram, Dry eye, Eyelid disorder, Myasthenia gravis
SMQs:, Anticholinergic syndrome (broad), Corneal disorders (broad), Conjunctival disorders (narrow), Lacrimal disorders (narrow), Periorbital and eyelid disorders (narrow), Dehydration (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: synthroid, atorvastatin, amlodipine, ozempic
Current Illness: none
Preexisting Conditions: High blood pressure & cholesterol, hypothyroidism, type 2 diabetes
Allergies: none
Diagnostic Lab Data: CT scan and blood test
CDC Split Type:

Write-up: Diagnosis of myasthenia gravis after symptoms of dry eyes and eye lid drooping and inability to open eyes.

VAERS ID:	1505977 (history)
Form:	Version 2.0
Age:	46.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-03-25
Onset:	2021-03-25
Days after vaccination:	0
Submitted:	0000-00-00
Entered:	2021-07-27

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 1	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Bronchitis, Cardiovascular examination, Chest X-ray, Dyspnoea, Illness, Laboratory test, Pneumonia, Pulmonary congestion, Quality of life decreased
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: albuterol, flonase, buspirone, amlodipine, effexor, wellbutrin, multivitamin, vitamin D, fish oil, tizanidine, fiber pills, naproxen, acetomeniphen, omeprazole, zofran, benzonatate
Current Illness: n/a
Preexisting Conditions: allergies, athsma
Allergies: n/a
Diagnostic Lab Data: Many heart tests and lung x-rays, many visits to the doctor
CDC Split Type:

Write-up: I have been constantly sick since the day of the vaccine, first with pneumonia then consecutive cases of bronchitis. I have been through 3 courses of antibiotics, and 3 of steroids. Nothing clears my lungs up now. I have to do at least one albuterol treatment per day. I can hardly leave the house when it is humid outside, because I just cannot breathe. I have no quality of life anymore. I got the vaccine to keep from getting sick, and as a result I''m more sick than I''ve ever been in my whole life!!

VAERS ID:	1509179 (history)
Form:	Version 2.0
Age:	51.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	0000-00-00
Onset:	2021-04-01
Submitted:	0000-00-00
Entered:	2021-07-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN	043A21A / UNK	- / -

Administered by: Other Purchased by: ?
Symptoms: Abdominal distension, Amenorrhoea, Anaphylactic reaction, Body temperature, Body temperature decreased, Electrocardiogram, Erythema, Fatigue, Feeling abnormal, Fluid retention, Heavy menstrual bleeding, Hypoaesthesia, Hypomenorrhoea, Infusion site extravasation, Intermenstrual bleeding, Malaise, Menstrual disorder, Menstruation irregular, Oedema peripheral, Peripheral swelling, Pyrexia
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Dementia (broad), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Fertility disorders (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Alcohol use; Allergic asthma; Allergic reaction to bee sting; Allergic to cats; Allergic to dogs; Drug allergy; House dust mite allergy; Non-smoker; Pain in arm
Preexisting Conditions: Medical History/Concurrent Conditions: Heavy menstrual bleeding; Swelling; Water retention; Comments: Patient had no menstruation changes since 13 years. Patient was uses medications prn. Patient had no drug abuse or illicit drug usage.
Allergies:
Diagnostic Lab Data: Test Date: 20210410; Test Name: EKG; Result Unstructured Data: Normal; Test Name: Body temperature; Result Unstructured Data: Low
CDC Split Type: USJNJFOC20210745140

Write-up: PERIOD NOT AS HEAVY AS NORMAL; SPOTTING CONTINUED FOR 3 WEEKS; LOW BODY TEMPERATURE; DOES NOT FEEL NORMAL OR RIGHT; SWELLING IN LEGS AND FEET; DID NOT FEEL GREAT; FELT FEVERISH; HEAVY MENSTRUAL BLEEDING FOR 2.5 WEEKS; WATER RETENTION IN LEGS AND FEET DAILY; WEIRD BLOATING; PERIOD (BLOOD VOLUME) UP AND DOWN; 28 TO 30-DAY CYCLE ERRATIC, PERIOD WOULD START AND STOP AND MONTHLY CYCLES THROWN OFF; DID NOT HAVE A PERIOD AND PERIOD STOPPED; ANAPHYLAXIS REACTION; HEAD AND NECK NUMB; IV INFILTRATED; RED ARM; SWOLLEN ARM; FATIGUE; This spontaneous report received from a patient concerned a 51 year old white female of not hispanic or latino ethnicity. The patient''s weight was 179 pounds, and height was 64 inches. The patient''s past medical history included 28 to 30-day menstruation cycles with heavy bleeding for the first 4 days then tapers off, water retention, and swelling, and concurrent conditions included daily over the conter medication allergy, allergy related to asthma, flu shot has similar sore arm, bees allergy, dust mites allergy, cats allergy, dogs allergy, alcohol drinker (occasionally, special occasions, 2 per month), and non smoker, and other pre-existing medical conditions included patient had no menstruation changes since 13 years. patient was uses medications prn and patient had no drug abuse or illicit drug usage. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: 043A21A, expiry: UNKNOWN) dose was not reported, 1 total administered on 10-APR-2021 to right arm for prophylactic vaccination. No concomitant medications were reported. On 10-APR-2021, the patient experienced anaphylaxis reaction. Before the needle got out of the patient''s arm the patient experienced hives on wrist and arm on the same arm used for vaccination after that the patient''s throat began to close. On the same day the patient head and neck numb. Patient further described that it was not numbness but rather the blocked of oxygen due to her throat swelling. Soon after patient was taken to the emergency room through ambulance and treated her with diphenhydramine hydrochloride, epinephrine, and prednisone. Patient experienced iv infiltrated while in the ambulance ride. Patient remained in the emergency room for the protocol specified number of hours for monitoring. Patient had electrocardiogram (NR: not provided) Normal. Patient got released from hospital the same day when stable and normalized. On10-APR-2021, the patient experienced common vaccine reaction of a red and swollen arm, the patient did not have a period and period stopped and patient experienced fatigue. On MAY-2021, the patient experienced 28 to 30-day cycle erratic and period would start and stop and monthly cycles thrown off. On JUN-2021, the patient experienced spotting, water retention in legs and feet daily, weird bloating and period (blood volume) up and down. On JUL-2021, the patient experienced heavy menstrual bleeding for 2.5 weeks. On an unspecified date, the patient experienced low body temperature. period not as heavy as normal, spotting continued for 3 weeks, more menstrual bleeding, extensive time frame for period, does not feel normal or right, swelling in legs and feet, did not feel great, and felt feverish. Laboratory data (dates unspecified) included: Body temperature (NR: not provided) Low. Additional treatment medications (dates unspecified) included: hyetellose. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient recovered from anaphylaxis reaction, and head and neck numb on 10-APR-2021, period not as heavy as normal, and weird bloating, and fatigue, and felt feverish on 21-JUN-2021, was recovering from did not have a period and period stopped, 28 to 30-day cycle erratic, period would start and stop and monthly cycles thrown off, water retention in legs and feet daily, and swelling in legs and feet, had not recovered from spotting continued for 3 weeks, and period (blood volume) up and down, and the outcome of iv infiltrated, red arm, did not feel great, low body temperature, heavy menstrual bleeding for 2.5 weeks, does not feel normal or right and swollen arm was not reported. This report was serious (Life Threatening). This case, from the same reporter is linked to 20210757746. .; Sender''s Comments: V0: 20210745140- Covid-19 vaccine ad26.cov2.s-Anaphylaxis reaction. This event(s) is labeled per RSI and is therefore considered potentially related.

VAERS ID:	1509571 (history)
Form:	Version 2.0
Age:	50.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-02-10
Onset:	2021-07-19
Days after vaccination:	159
Submitted:	0000-00-00
Entered:	2021-07-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EL3249 / 1	- / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EN5318 / 2	- / IM

Administered by: Private Purchased by: ?
Symptoms: Asthma, Bronchitis, COVID-19, Condition aggravated, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Pt received both doses of the Pfizer COVID vaccine on 1/20/2021 and 2/10/2021. She tested positive for COVID 19 (collected 7/18/2021 in urgent care), then presented to the ED on 7/20 with asthma exacerbation, bronchitis, and fever thought to be related to the COVID diagnosis. She was admitted 7/21/2021 and discharged 7/22/2021 after improvement of symptoms.

VAERS ID:	1509782 (history)
Form:	Version 2.0
Age:	28.0
Sex:	Female
Location:	Wisconsin

Vaccinated:	2021-04-16
Onset:	2021-04-20
Days after vaccination:	4
Submitted:	0000-00-00
Entered:	2021-07-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	002C21A / 1	LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	023C21A / 2	RA / SYR

Administered by: Pharmacy Purchased by: ?
Symptoms: Loss of personal independence in daily activities, Musculoskeletal disorder, Musculoskeletal injury, Plantar fasciitis, Soft tissue disorder, Vaccination site pain
SMQs:, Rhabdomyolysis/myopathy (broad), Dementia (broad), Accidents and injuries (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Birth control; Multivitamin
Current Illness: No.
Preexisting Conditions: No.
Allergies: No.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Soft tissue pain started at vaccination site about three days after vaccination and spread to other body parts in time. Plantar Fasciitis started two weeks after first vaccination while I have the opposite of all risk factors of plantar fasciitis. My workout and daily activities did not change after vaccination. Various musculoskeletal injuries during light workouts with similar intensity than before vaccination. Pain has lasted since April and still affects my daily activities. Chiropractor confirms that patients'' musculoskeletal injuries/disorders increased significantly after vaccination.

VAERS ID:	1509886 (history)
Form:	Version 2.0
Age:	55.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-04-01
Onset:	2021-07-01
Days after vaccination:	91
Submitted:	0000-00-00
Entered:	2021-07-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	- / 2	LA / IM

Administered by: Private Purchased by: ?
Symptoms: Pulmonary thrombosis
SMQs:, Embolic and thrombotic events, venous (narrow)

Write-up: I formed blood clots that went to my lungs.

VAERS ID:	1510127 (history)
Form:	Version 2.0
Age:	69.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-09
Onset:	2021-02-18
Days after vaccination:	9
Submitted:	0000-00-00
Entered:	2021-07-28

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH	EM 9810 / 1	RA / SYR

Administered by: Private Purchased by: ?
Symptoms: Acute cardiac event, Antibody test, Asthenia, Autoimmune haemolytic anaemia, Bilirubin conjugated, Blood bilirubin, Blood fibrinogen, Blood lactate dehydrogenase, Blood thyroid stimulating hormone, Calcium ionised, Chest X-ray, Chromaturia, Computerised tomogram abdomen, Computerised tomogram thorax, Coombs direct test, Culture urine, Differential white blood cell count, Dyspnoea exertional, Echocardiogram, Electrocardiogram, Full blood count, Haemoglobin decreased, Haptoglobin, Hepatitis viral test, Intensive care, International normalised ratio, Laboratory test, Lipase, Metabolic function test, Platelet morphology, Red blood cell count decreased, Reticulocyte count, SARS-CoV-2 test negative, Serum ferritin, Transfusion, Ultrasound abdomen, Urine analysis, Vaccination complication, Yellow skin
SMQs:, Rhabdomyolysis/myopathy (broad), Cholestasis and jaundice of hepatic origin (broad), Haemolytic disorders (narrow), Haematopoietic erythropenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Other ischaemic heart disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 13 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Centrum Silver (Men 50+); Niacinamide (1000 mg/day)
Current Illness: None
Preexisting Conditions: t-cell large granular lymphocytic leukemia (in remission)
Allergies: None
Diagnostic Lab Data: From 02/19/2021 to 03/04/2021, one or more of the following medical tests and lab results: urinalysis, basic metabolic panel, ECG 12-lead, immature platelet fraction, fibrinogen,
CDC Split Type:

Write-up: Urine turned red, skin turned yellow, lost significant strength & got winded walking to the bathroom. Went to ER at Hospital on 02/20/2021. Hemoglobin level had plummeted to 7.6; it eventually fell to below 5.0. I was admitted to the ICU and, after a couple days, was transferred to the med/surg unit. I was administered whole blood, but my hemoglobin level would not stay above 7.0. On 02/27 I experienced a cardiac event due to my low RBC count and was moved back to ICU. From there, I was transferred by ambulance to ICU at Hospital in order to start Rituxan therapy. I was in ICU for a day and then transferred to the cancer care unit. I remained there until

VAERS ID:	1511608 (history)
Form:	Version 2.0
Age:	74.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-02-14
Onset:	2021-02-01
Submitted:	0000-00-00
Entered:	2021-07-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	- / 1	- / OT

Administered by: Unknown Purchased by: ?
Symptoms: Cerebrovascular accident, Product dose omission issue
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Medication errors (broad)

Write-up: 2 weeks after getting the 1st dose, he had a stroke; He did not get the 2nd dose because of medical problems; This spontaneous case was reported by a pharmacist (subsequently medically confirmed) and describes the occurrence of CEREBROVASCULAR ACCIDENT (2 weeks after getting the 1st dose, he had a stroke) in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No medical history was provided by the reporter. Concomitant products included ACETYLSALICYLIC ACID (BABY ASPIRIN), TAMSULOSIN, ATORVASTATIN CALCIUM (LIPITOR) and RIVAROXABAN (XARELTO) for an unknown indication. On 14-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 14-Feb-2021, the patient experienced PRODUCT DOSE OMISSION ISSUE (He did not get the 2nd dose because of medical problems). In February 2021, the patient experienced CEREBROVASCULAR ACCIDENT (2 weeks after getting the 1st dose, he had a stroke) (seriousness criteria hospitalization and medically significant). At the time of the report, CEREBROVASCULAR ACCIDENT (2 weeks after getting the 1st dose, he had a stroke) outcome was unknown and PRODUCT DOSE OMISSION ISSUE (He did not get the 2nd dose because of medical problems) had resolved. mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was withdrawn on an unknown date. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medications included OTC preservision. No treatment information was reported. Caller was a Pharmacist who has a patient debating whether or not to receive his 2nd dose of the Moderna COVID-19 vaccine. The patient received the 1st dose of the Moderna COVID-19 vaccine on 14-FEB-2021. He did not get the 2nd dose because of medical problems. Per the Pharmacist, 2 weeks after receiving the 1st dose, the patient experienced a stroke and was hospitalized. The caller did not know the details of patient''s experience after the 1st dose. It has been 5 months since the patient received his 1st dose. This report refers to a case of vaccine administered at inappropriate site for mRNA-1273 (lot # unknow) with AE reported of CVA. Based on the current available information and temporal association between the use of the product and the start date of the event, CVA, a causal relationship cannot be excluded.; Sender''s Comments: This report refers to a case of vaccine administered at inappropriate site for mRNA-1273 (lot # unknow) with AE reported of CVA. Based on the current available information and temporal association between the use of the product and the start date of the event, CVA, a causal relationship cannot be excluded.

VAERS ID:	1513085 (history)
Form:	Version 2.0
Age:	80.0
Sex:	Male
Location:	Wisconsin

Vaccinated:	2021-03-08
Onset:	2021-07-16
Days after vaccination:	130
Submitted:	0000-00-00
Entered:	2021-07-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	UNKNOWN / 2	UN / UN

Administered by: Unknown Purchased by: ?
Symptoms: Acute kidney injury, Aspiration pleural cavity, Atrial fibrillation, Bilevel positive airway pressure, Cardiac failure congestive, Chest X-ray abnormal, Coronary artery bypass, Cough, Endotracheal intubation, Fall, Hypervolaemia, Hypoxia, Intensive care, Lung infiltration, Pneumonia, Post procedural complication, Pyrexia, SARS-CoV-2 antibody test negative, SARS-CoV-2 test positive, Vertigo
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Vestibular disorders (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Write-up: Per records submitted by the hospital: Symptoms began 7/16, went to urgent care 7/19 with fever and cough, treated with albuterol and doxycycline. Hospital ED 7/22 after vertigo and a fall, hypoxic, placed on bipap. Diagnosed with CHF and pneumonia. Intubated 7/24/2021 and in ICU. Client had CABG 5/23/2021 and had post op complications with a-fib, AKI, hypervolemia and had 3 thoracentesis. Submitter does not have access to full medical record.

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https://medalerts.org/vaersdb/findfield.php?TABLE=ON&GROUP1=AGE&EVENTS=ON&PERPAGE=1000&VAX=COVID19&SERIOUS=ON&STATE=WI

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Sunday, August 8, 2021

Wisconsin: 743 Series Adverse Reactions To The Jab, And They Are All Listed Here, Adverse Events Are More Common, Went Up 10% if One Week, Even Though Less Are Getting VXX

From the 7/30/2021 release of VAERS data:

Found 743 cases where Location is Wisconsin and Vaccine is COVID19 and Serious

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