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This is VAERS ID 1126863

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1126863
VAERS Form:2
Age:85.0
Sex:Female
Location:Virginia
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Aphasia, Death, Hydronephrosis, Hypoxia, Intensive care, Pulmonary oedema, Vaccination complication, Mobility decreased, Pulseless electrical activity, Bladder mass, Mini-tracheostomy, Respiratory tract oedema, Gallbladder mass

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-10
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: acetaminophen (TYLENOL) 325 MG suppository acetic acid (VOSOL) 2 % otic solution amLODIPine (NORVASC) 2.5 MG tablet Cholecalciferol (VITAMIN D) 125 MCG (5000 UT) Cap ciprofloxacin-dexamethasone (CIPRODEX) otic suspension Cyanocobalamin (B-1
Current Illness: CVA Chronic Aspiration Chronic PNA
Preexisting Conditions: Chronic Aspiration Chronic PNA
Allergies: None on file
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was vaccinated in her home (COVID J&J) on 3/8. Vaccinator obtained consent and confirmed throughout the process that patient as at baseline since patient was nonverbal and bedbound. Later that same day she experienced an emergency and was take to the hospital and subsequently admitted to ICU. She died on 3/10, family present, on comfort care. Per HPI, "Patient is a 85 y.o. female with advanced dementia (non verbal, wheelchair bound at baseline), chronic aspiration, recurrent UTIs, voiding dysfunction currently self-straight cathing, has suspicious bladder and gallbladder masses (being worked up), has right sided hydronephrosis, BIBEMS for acute hypoxemia, difficult to bag en route, ED had difficulty intubating and so performed cricothroidotomy. Patient had brief PEA arrest due to hypoxia. ED provider noted "excessive pulmonary edema in airway, unfavorable anatomy, and airway swelling." Suspected insult stemming from J&J COVID vaccination reaction.


Changed on 5/7/2021

VAERS ID: 1126863 Before After
VAERS Form:2
Age:85.0
Sex:Female
Location:Virginia
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Aphasia, Death, Hydronephrosis, Hypoxia, Intensive care, Pulmonary oedema, Vaccination complication, Mobility decreased, Pulseless electrical activity, Bladder mass, Mini-tracheostomy, Respiratory tract oedema, Gallbladder mass

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-10
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: acetaminophen (TYLENOL) 325 MG suppository acetic acid (VOSOL) 2 % otic solution amLODIPine (NORVASC) 2.5 MG tablet Cholecalciferol (VITAMIN D) 125 MCG (5000 UT) Cap ciprofloxacin-dexamethasone (CIPRODEX) otic suspension Cyanocobalamin (B-1
Current Illness: CVA Chronic Aspiration Chronic PNA
Preexisting Conditions: Chronic Aspiration Chronic PNA
Allergies: None on file file
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was vaccinated in her home (COVID J&J) on 3/8. Vaccinator obtained consent and confirmed throughout the process that patient as at baseline since patient was nonverbal and bedbound. Later that same day she experienced an emergency and was take to the hospital and subsequently admitted to ICU. She died on 3/10, family present, on comfort care. Per HPI, "Patient is a 85 y.o. female with advanced dementia (non verbal, wheelchair bound at baseline), chronic aspiration, recurrent UTIs, voiding dysfunction currently self-straight cathing, has suspicious bladder and gallbladder masses (being worked up), has right sided hydronephrosis, BIBEMS for acute hypoxemia, difficult to bag en route, ED had difficulty intubating and so performed cricothroidotomy. Patient had brief PEA arrest due to hypoxia. ED provider noted "excessive pulmonary edema in airway, unfavorable anatomy, and airway swelling." Suspected insult stemming from J&J COVID vaccination reaction.


Changed on 5/14/2021

VAERS ID: 1126863 Before After
VAERS Form:2
Age:85.0
Sex:Female
Location:Virginia
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Aphasia, Death, Hydronephrosis, Hypoxia, Intensive care, Pulmonary oedema, Vaccination complication, Mobility decreased, Pulseless electrical activity, Bladder mass, Mini-tracheostomy, Respiratory tract oedema, Gallbladder mass

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-10
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: acetaminophen (TYLENOL) 325 MG suppository acetic acid (VOSOL) 2 % otic solution amLODIPine (NORVASC) 2.5 MG tablet Cholecalciferol (VITAMIN D) 125 MCG (5000 UT) Cap ciprofloxacin-dexamethasone (CIPRODEX) otic suspension Cyanocobalamin (B-1
Current Illness: CVA Chronic Aspiration Chronic PNA
Preexisting Conditions: Chronic Aspiration Chronic PNA
Allergies: None on file file
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was vaccinated in her home (COVID J&J) on 3/8. Vaccinator obtained consent and confirmed throughout the process that patient as at baseline since patient was nonverbal and bedbound. Later that same day she experienced an emergency and was take to the hospital and subsequently admitted to ICU. She died on 3/10, family present, on comfort care. Per HPI, "Patient is a 85 y.o. female with advanced dementia (non verbal, wheelchair bound at baseline), chronic aspiration, recurrent UTIs, voiding dysfunction currently self-straight cathing, has suspicious bladder and gallbladder masses (being worked up), has right sided hydronephrosis, BIBEMS for acute hypoxemia, difficult to bag en route, ED had difficulty intubating and so performed cricothroidotomy. Patient had brief PEA arrest due to hypoxia. ED provider noted "excessive pulmonary edema in airway, unfavorable anatomy, and airway swelling." Suspected insult stemming from J&J COVID vaccination reaction.

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