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This is VAERS ID 1104671

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1104671
VAERS Form:2
Age:39.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-12
Onset:2021-03-13
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Condition aggravated, Death, Malaise, Respiratory arrest, Seizure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: CoQ-10 200 mg twice a day, diazepam 10mg one as needed for seizures, Dilantin Infatabs 50mg 1 tab every morning. lamictal 150mg 2 tabs twice a day, midodrine 2.5mg 1 tab twice a day, vitamin D3 400IU daily.
Current Illness: Seizure disorder, severe mitochondrial myopathy, gastroesophageal reflux disease
Preexisting Conditions: Seizure disorder, severe mitochondrial myopathy
Allergies: IV lactated ringers, midazolam, morphine, vancomycin
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient has a long history of seizures. He has seizures on a daily basis. He lives with his family, who are his primary caregivers, they family provides all of his activities of daily living. Patient received vaccine on Friday morning, feeling well throughout the day according to the father. Went to bed, during the night in bed he had seizures which is typical for him, and during the episode the father noticed that he had stopped breathing. called 911 who came to the house and the patient died in the house. I do not believe he went to the hospital.


Changed on 5/7/2021

VAERS ID: 1104671 Before After
VAERS Form:2
Age:39.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-12
Onset:2021-03-13
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Condition aggravated, Death, Malaise, Respiratory arrest, Seizure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: CoQ-10 200 mg twice a day, diazepam 10mg one as needed for seizures, Dilantin Infatabs 50mg 1 tab every morning. lamictal 150mg 2 tabs twice a day, midodrine 2.5mg 1 tab twice a day, vitamin D3 400IU daily.
Current Illness: Seizure disorder, severe mitochondrial myopathy, gastroesophageal reflux disease
Preexisting Conditions: Seizure disorder, severe mitochondrial myopathy
Allergies: IV lactated ringers, midazolam, morphine, vancomycin vancomycin
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient has a long history of seizures. He has seizures on a daily basis. He lives with his family, who are his primary caregivers, they family provides all of his activities of daily living. Patient received vaccine on Friday morning, feeling well throughout the day according to the father. Went to bed, during the night in bed he had seizures which is typical for him, and during the episode the father noticed that he had stopped breathing. called 911 who came to the house and the patient died in the house. I do not believe he went to the hospital.


Changed on 5/14/2021

VAERS ID: 1104671 Before After
VAERS Form:2
Age:39.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-12
Onset:2021-03-13
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Condition aggravated, Death, Malaise, Respiratory arrest, Seizure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: CoQ-10 200 mg twice a day, diazepam 10mg one as needed for seizures, Dilantin Infatabs 50mg 1 tab every morning. lamictal 150mg 2 tabs twice a day, midodrine 2.5mg 1 tab twice a day, vitamin D3 400IU daily.
Current Illness: Seizure disorder, severe mitochondrial myopathy, gastroesophageal reflux disease
Preexisting Conditions: Seizure disorder, severe mitochondrial myopathy
Allergies: IV lactated ringers, midazolam, morphine, vancomycin vancomycin
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient has a long history of seizures. He has seizures on a daily basis. He lives with his family, who are his primary caregivers, they family provides all of his activities of daily living. Patient received vaccine on Friday morning, feeling well throughout the day according to the father. Went to bed, during the night in bed he had seizures which is typical for him, and during the episode the father noticed that he had stopped breathing. called 911 who came to the house and the patient died in the house. I do not believe he went to the hospital.

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