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This is VAERS ID 1075246

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1075246
VAERS Form:2
Age:67.0
Sex:Male
Location:Maine
Vaccinated:2021-03-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Chest pain, Electrocardiogram normal, Fall, Flank pain, Head injury, Hypotension, Syncope, Laboratory test normal, Renal function test normal, Neck injury, Troponin I normal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tramadol, Diltiazem, Potassium, Magnesium, Protonix, Dorzolamide, Tamsulosin, Atorvastatin, Xarelto, Metoprolol, Oxycontin, Oxycodone, Prazosin
Current Illness: Unknown
Preexisting Conditions: Hepatits C, Anxiety, A-Fib, A-Flutter, Kidney Disease, Diabetes, GERD, Hypotension, Cardiac Stent
Allergies: Januvia, Lyrica
Diagnostic Lab Data: 3/4/21, Emergency Department: Vital Signs: Noted to be hypotensive EKG: Paced, Heart Rate 84, confirmed pacer functioning normally Labs: Within Normal Limits, Troponin Negative, Renal Function = baseline Blood pressure improved with IV Fluids
CDC 'Split Type':

Write-up: (3) syncopal episodes following vaccination, one of which resulted in a fall with direct injury to the base of neck, head, and right flank. Pt reported chest pain prior to syncope.


Changed on 5/7/2021

VAERS ID: 1075246 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Maine
Vaccinated:2021-03-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Chest pain, Electrocardiogram normal, Fall, Flank pain, Head injury, Hypotension, Syncope, Laboratory test normal, Renal function test normal, Neck injury, Troponin I normal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tramadol, Diltiazem, Potassium, Magnesium, Protonix, Dorzolamide, Tamsulosin, Atorvastatin, Xarelto, Metoprolol, Oxycontin, Oxycodone, Prazosin
Current Illness: Unknown
Preexisting Conditions: Hepatits C, Anxiety, A-Fib, A-Flutter, Kidney Disease, Diabetes, GERD, Hypotension, Cardiac Stent
Allergies: Januvia, Lyrica Lyrica
Diagnostic Lab Data: 3/4/21, Emergency Department: Vital Signs: Noted to be hypotensive EKG: Paced, Heart Rate 84, confirmed pacer functioning normally Labs: Within Normal Limits, Troponin Negative, Renal Function = baseline Blood pressure improved with IV Fluids
CDC 'Split Type':

Write-up: (3) syncopal episodes following vaccination, one of which resulted in a fall with direct injury to the base of neck, head, and right flank. Pt reported chest pain prior to syncope.


Changed on 5/14/2021

VAERS ID: 1075246 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Maine
Vaccinated:2021-03-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Chest pain, Electrocardiogram normal, Fall, Flank pain, Head injury, Hypotension, Syncope, Laboratory test normal, Renal function test normal, Neck injury, Troponin I normal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tramadol, Diltiazem, Potassium, Magnesium, Protonix, Dorzolamide, Tamsulosin, Atorvastatin, Xarelto, Metoprolol, Oxycontin, Oxycodone, Prazosin
Current Illness: Unknown
Preexisting Conditions: Hepatits C, Anxiety, A-Fib, A-Flutter, Kidney Disease, Diabetes, GERD, Hypotension, Cardiac Stent
Allergies: Januvia, Lyrica Lyrica
Diagnostic Lab Data: 3/4/21, Emergency Department: Vital Signs: Noted to be hypotensive EKG: Paced, Heart Rate 84, confirmed pacer functioning normally Labs: Within Normal Limits, Troponin Negative, Renal Function = baseline Blood pressure improved with IV Fluids
CDC 'Split Type':

Write-up: (3) syncopal episodes following vaccination, one of which resulted in a fall with direct injury to the base of neck, head, and right flank. Pt reported chest pain prior to syncope.

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