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This is VAERS ID 1112122

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1112122
VAERS Form:2
Age:43.0
Sex:Male
Location:California
Vaccinated:2021-03-13
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Aggression, Mood altered, Pulmonary embolism, Respiratory arrest, Sudden death, Pulseless electrical activity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-15
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: Macrobid 100 mg po BID Cefepime 2g daily (3/12-3/19) Dilaudid 2 mg po PRN pain gabapentin 600 mg BID Methotrexate qFriday Metoprolol 25 mg BID Odefsey (HAART) Mirtazipine daily Glipizide, insulin for DM2
Current Illness: Complicated lower UTI (hospitalized for this- received vaccine in house) - MDR bacteria
Preexisting Conditions: Neurosarcoidosis Transverse myelitis with lower paraplegia HIV positive (on HAART) DM2 MDD
Allergies: PCN Cipro Ertapenem Fosfomycin
Diagnostic Lab Data: None. Patient was being discharged. I suspected a massive PE however pt was on DVT prophylaxis. The coroner refused to do an autopsy so cause of death was not known but it was a highly unusual and unexpected outcome.
CDC 'Split Type':

Write-up: Patient was admitted for Multi drug resistant UTI (for which he has been admitted many times before). Was hospitalized for 3 days while awaiting cultures, hemodynamically stable, with no lab abnormalities. On the day of discharge (sensitivities to UTI came back, pt to be discharged on cefepime, had PICC line) pt got up from bed, sat on the edge of the bed and was being given belongings by the nurse, alert and oriented and in a pleasant mood, when suddenly pt grabbed at his chest and stated "I can''t breathe" and became combative and altered when O2 was attempted to be placed on pt''s face; then pt had PEA arrest x3 and unable to achieve ROSC.


Changed on 5/7/2021

VAERS ID: 1112122 Before After
VAERS Form:2
Age:43.0
Sex:Male
Location:California
Vaccinated:2021-03-13
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Aggression, Mood altered, Pulmonary embolism, Respiratory arrest, Sudden death, Pulseless electrical activity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-15
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: Macrobid 100 mg po BID Cefepime 2g daily (3/12-3/19) Dilaudid 2 mg po PRN pain gabapentin 600 mg BID Methotrexate qFriday Metoprolol 25 mg BID Odefsey (HAART) Mirtazipine daily Glipizide, insulin for DM2
Current Illness: Complicated lower UTI (hospitalized for this- received vaccine in house) - MDR bacteria
Preexisting Conditions: Neurosarcoidosis Transverse myelitis with lower paraplegia HIV positive (on HAART) DM2 MDD
Allergies: PCN Cipro Ertapenem Fosfomycin Fosfomycin
Diagnostic Lab Data: None. Patient was being discharged. I suspected a massive PE however pt was on DVT prophylaxis. The coroner refused to do an autopsy so cause of death was not known but it was a highly unusual and unexpected outcome.
CDC 'Split Type':

Write-up: Patient was admitted for Multi drug resistant UTI (for which he has been admitted many times before). Was hospitalized for 3 days while awaiting cultures, hemodynamically stable, with no lab abnormalities. On the day of discharge (sensitivities to UTI came back, pt to be discharged on cefepime, had PICC line) pt got up from bed, sat on the edge of the bed and was being given belongings by the nurse, alert and oriented and in a pleasant mood, when suddenly pt grabbed at his chest and stated "I can''t breathe" and became combative and altered when O2 was attempted to be placed on pt''s face; then pt had PEA arrest x3 and unable to achieve ROSC.


Changed on 5/14/2021

VAERS ID: 1112122 Before After
VAERS Form:2
Age:43.0
Sex:Male
Location:California
Vaccinated:2021-03-13
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Aggression, Mood altered, Pulmonary embolism, Respiratory arrest, Sudden death, Pulseless electrical activity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-15
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: Macrobid 100 mg po BID Cefepime 2g daily (3/12-3/19) Dilaudid 2 mg po PRN pain gabapentin 600 mg BID Methotrexate qFriday Metoprolol 25 mg BID Odefsey (HAART) Mirtazipine daily Glipizide, insulin for DM2
Current Illness: Complicated lower UTI (hospitalized for this- received vaccine in house) - MDR bacteria
Preexisting Conditions: Neurosarcoidosis Transverse myelitis with lower paraplegia HIV positive (on HAART) DM2 MDD
Allergies: PCN Cipro Ertapenem Fosfomycin Fosfomycin
Diagnostic Lab Data: None. Patient was being discharged. I suspected a massive PE however pt was on DVT prophylaxis. The coroner refused to do an autopsy so cause of death was not known but it was a highly unusual and unexpected outcome.
CDC 'Split Type':

Write-up: Patient was admitted for Multi drug resistant UTI (for which he has been admitted many times before). Was hospitalized for 3 days while awaiting cultures, hemodynamically stable, with no lab abnormalities. On the day of discharge (sensitivities to UTI came back, pt to be discharged on cefepime, had PICC line) pt got up from bed, sat on the edge of the bed and was being given belongings by the nurse, alert and oriented and in a pleasant mood, when suddenly pt grabbed at his chest and stated "I can''t breathe" and became combative and altered when O2 was attempted to be placed on pt''s face; then pt had PEA arrest x3 and unable to achieve ROSC.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1112122&WAYBACKHISTORY=ON

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