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This is VAERS ID 1082127

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1082127
VAERS Form:2
Age:34.0
Sex:Female
Location:Indiana
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Anaphylactic reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
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: unknown
Current Illness: unknown
Preexisting Conditions: diabetes
Allergies: penicillin, Keflex, ketoprofen, adipex, tree nut kiwi
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 7 hours post administration, patient had an anaphylactic reaction. she took liquid Benadryl, administered herself an EpiPen, used an albuterol inhaler and went to the er. Patient recovered while in the er and returned home. At pharmacy on the day of the vaccination clinic, patient stayed in a waiting area 15 mins after getting the vaccine. The way our set up was in the store, patient was sitting next to a kiwi plant in the garden and plant area. she is allergic to kiwi. patient is not certain what caused the reaction.


Changed on 5/7/2021

VAERS ID: 1082127 Before After
VAERS Form:2
Age:34.0
Sex:Female
Location:Indiana
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Anaphylactic reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
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: unknown
Current Illness: unknown
Preexisting Conditions: diabetes
Allergies: penicillin, Keflex, ketoprofen, adipex, tree nut kiwi kiwi
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 7 hours post administration, patient had an anaphylactic reaction. she took liquid Benadryl, administered herself an EpiPen, used an albuterol inhaler and went to the er. Patient recovered while in the er and returned home. At pharmacy on the day of the vaccination clinic, patient stayed in a waiting area 15 mins after getting the vaccine. The way our set up was in the store, patient was sitting next to a kiwi plant in the garden and plant area. she is allergic to kiwi. patient is not certain what caused the reaction.


Changed on 5/14/2021

VAERS ID: 1082127 Before After
VAERS Form:2
Age:34.0
Sex:Female
Location:Indiana
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Anaphylactic reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
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: unknown
Current Illness: unknown
Preexisting Conditions: diabetes
Allergies: penicillin, Keflex, ketoprofen, adipex, tree nut kiwi kiwi
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 7 hours post administration, patient had an anaphylactic reaction. she took liquid Benadryl, administered herself an EpiPen, used an albuterol inhaler and went to the er. Patient recovered while in the er and returned home. At pharmacy on the day of the vaccination clinic, patient stayed in a waiting area 15 mins after getting the vaccine. The way our set up was in the store, patient was sitting next to a kiwi plant in the garden and plant area. she is allergic to kiwi. patient is not certain what caused the reaction.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1082127&WAYBACKHISTORY=ON


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