Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Magnetic resonance imaging spinal, Nausea, Neurological examination, Orthopaedic examination, Pain
Clinical narrative: The adverse events being reported and documented below are death from unexplained spontaneous bleeding (thinning of the blood) that followed acute inflammation and excruciating pain that began less than 48 hours after the second dose of the Moderna vaccine.Timeline of events from March 4 - May 2, 2021; 3/4/21  - Second dose of Moderna Covid-19 vaccine received. 3/5/21  - Mom) reported being very tired and nauseous. 3/6/21  - (Mom) reported being in extreme pain which turned into excruciating pain. Timeline of events from March 4 - May 2, 2021  Note:  (Mom) had a very high tolerance for pain, evidenced by previous major falls & fractured bones (pelvis, hip, both femurs, 9 ribs, 3 cracked vertebrae), the lingering results of which she lived with every day without constant mention of the chronic pain.  In contrast, the pain that began on March 6 was excruciating, incapacitating, and resulted in her barely being able to walk and was, therefore, new, noteworthy, different and unusual.  3/08/21 - Visit #1 to the ER  for excruciating pain. - Pelvic x-ray done, nothing broken; IV morphine given. - Examination by ER physician. - Released from hospital; sent home with script for Norco for pain; did not take because it made her unable to function.  Note:   (Mom) identified the source of her excruciating pain to the ER physician as being in her lower left back region, just at the top of her left pelvic bone, as witnessed by a family member.   3/22/21 - Visit #2 to the ER  Hospital for same excruciating pain (as March 8) and ultimately admitted. - EKG, CT scan, MRI spine, MRI pelvis and whole-body bone scan done during length of stay.  No new findings, only evidence of old fractures and spondylolisthesis, all of which were known, old diagnoses.  3/23/21 - Examination by PA-C for Chief of Orthopedics and subsequently by Hospital.  Note:  Despite the fact that this was the second admission in three weeks for the same pain that was originating from the same source, the orthopedic specialists focused on old compression fractures, old pelvic fractures, and degenerative spinal changes, which (Mom) lived with every day with little complaint.  The source of the excruciating pain that began on March 6, and that was reported on March 8 in the ER, appeared to have been excluded from consideration or discussion.  3/26/21 - Released from hospital with short course of steroids for pain; minute reduction in pain until steroid dose was weaned and the same excruciating pain, that began on March 6, immediately emerged again.  4/7/21   - Visit #3 to the ER  for same excruciating pain (as March 8) and ultimately admitted. - Lumbar/AP spine and dorsal/thoracic spine x-rays, front pelvic & 2 view left hip x-rays, front chest & 3 bilateral rib x-rays, EKG, Echo done during length of stay. - Examination by Hospitalist Internal Medicine.   - Examination by Orthopedic Surgeon.   - Examination by Pain Management Specialist/Neurologist.  4/10/21 - (Mom's) acute inflammation and excruciating pain were diagnosed as Trochanteric Bursitis.  A Depo-Medrol steroid shot was given in left hip area by Pain Management Specialist/Neurologist for the acute inflammation and pain (Mom) had been experiencing for the five weeks since the second Covid-19 shot; pain relief within hours after the steroid shot.  By the end of the day, she went from not being able to walk to walking to the end of the hallway within the hospital.   4/13/21 -  (Mom) was to be transferred Hospital  for rehab program, however, due to spontaneous bleeding of her fistula, she was kept at Hospital for observation.  (Mom's) Vascular Surgeon was called in to help stop the bleeding.    Note:  The spontaneous bleeding from (Mom's) fistula seemed highly unusual as it had never occurred in six years of receiving dialysis.    4/15/21 - Fistulogram performed by Vascular & Interventional Radiology Specialist to ensure fistula was in good working order.  Results showed no stenosis.                  4/16/21 - Transferred to Hospital  for inpatient physical therapy rehab program.  4/23/21 - Released from hospital after successful completion of the rehab program. (Mom) had a positive frame of mind and was looking forward to future plans.  She was able to walk again with the aid of her walker and to function independently; in-home therapy began 4/29 to build up strength she had lost during the 5 weeks of excruciating pain and time spent in the hospital.  5/2/21 -  Spontaneous bleeding from fistula, no blood pressure, heart stopped.  Cause of death ruled (spontaneous) bleeding from fistula.