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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1089419



Case Details

VAERS ID: 1089419 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Oklahoma  
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 (JANSSEN)) / JANSSEN 1805018 / N/A LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood creatinine increased, Blood culture, Blood urine present, Bloody discharge, Brain natriuretic peptide, Culture urine, Diarrhoea, Full blood count, Headache, Hypotension, Malaise, Metabolic function test abnormal, Nausea, Tachycardia, Urinary tract infection, Urine analysis abnormal, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (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, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zanaflex, Percocet, Xanax, Brilinta, Insulin
Current Illness:
Preexisting Conditions: Stage 4 kidney disease, nephrostomy, ulcerative colitis with colostomy, CAD with 2 CABG & 7 cardiac stents,
Allergies: Influenza Vaccine, Pneumonia vaccine, Ambien, Lisinopril, PCNs
Diagnostic Lab Data: CMP, CBC UA with C&S, BNP, blood cultures
CDC Split Type:

Write-up: Received COVID-19 Vaccine on 03/08/2021. About 7:00 am the next morning began having N/V x4 past 12 hrs, diarrhea x 6, headache and blood in urine. Chronic illness of stage 4 kidney disease with bilateral nephrostomy and acute bloody discharge, ulcerative colitis with colostomy and acute high output, CAD with 7 cardiac stents and 2 CABG. A&Ox4, Malaise, tachycardia and hypotension, afebrile. Patient reports chronic abdominal pain unchanged today. Denies back pain, chest pain, cough, or SHOB. Afebrile. Patient has new diagnosis of UTI. IV fluids administered, IV Zofran, Meropenem, and po Hydrocodone/APAP. Transferred due to creatinine of 4.3, bloody urine, and UTI. T: 98.1 HR 91, R-14 BP 106/71, O2 sat 97%


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1089419


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