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This is VAERS ID 1168970

History of Changes from the VAERS Wayback Machine

First Appeared on 4/8/2021

VAERS ID: 1168970
VAERS Form:2
Age:95.0
Sex:Female
Location:New Jersey
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Atrial fibrillation, Death, Dysphagia, Hypotension, Peripheral embolism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Atrial fibrillation
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USJNJFOC20210400509

Write-up: ATRIAL FIBRILLATION; INABILITY TO SWALLOW; BLOOD CLOT IN RIGHT ARM; LOW BLOOD PRESSURE; DEATH 4 DAYS AFTER RECEIVING VACCINE; This spontaneous report received from a vaccine facility via a company representative concerned a 95-year-old female. The patient''s height, and weight were not reported. The patient''s concurrent conditions included atrial fibrillation. The patient received COVID-19 VACCINE AD26.COV2.S (suspension for injection, route of admin not reported, batch number: Unknown) dose was not reported, administered on 2021 for prophylactic vaccination. No concomitant medications were reported. The batch number was not reported and has been requested. It was reported that on an unspecified date in 2021 the patient received Janssen Covid-19 Vaccine and within 6hrs she had a major atrial fibrillation episode, then several the following day. The next day, she lost her ability to swallow. Two days later she was on oxygen. Three days later she developed a blood clot in her right arm, was still on oxygen and blood pressure was falling. On an unspecified date, the patient died 4 days after receiving vaccine. The action taken with COVID-19 VACCINE AD26.COV2.S was not applicable. The patient died 4 days after receiving vaccine on an unspecified date, and the outcome of atrial fibrillation, inability to swallow, blood clot in right arm and low blood pressure was not reported. This report was serious (Death, Hospitalization Caused / Prolonged, and Other Medically Important Condition).; Sender''s Comments: V0: 20210400509: This spontaneous report received from a vaccine facility via a company representative involved a 95-year-old female with the past medical history remarkable for atrial fibrillation who received the Janssen COVID-19 Vaccine for prevention of COVID-19 infection and within 6hrs had a major atrial fibrillation episode. No concomitant medications were reported. The next day, she lost her ability to swallow. Two days later she was on oxygen. Three days later she developed a blood clot in her right arm, was still on oxygen and blood pressure was falling. On an unspecified date, the patient died 4 days after receiving vaccine. No information was provided regarding the cause of death. Considering the patient''s past medical history of atrial fibrillation, the causality for the event of atrial fibrillation, as well the consequent events is assessed not related to the Janssen COVID-19 Vaccine.; Reported Cause(s) of Death: DEATH 4 DAYS AFTER RECEIVING VACCINE


Changed on 5/7/2021

VAERS ID: 1168970 Before After
VAERS Form:2
Age:95.0
Sex:Female
Location:New Jersey
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Atrial fibrillation, Death, Dysphagia, Hypotension, Peripheral embolism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Atrial fibrillation
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USJNJFOC20210400509

Write-up: ATRIAL FIBRILLATION; INABILITY TO SWALLOW; BLOOD CLOT IN RIGHT ARM; LOW BLOOD PRESSURE; DEATH 4 DAYS AFTER RECEIVING VACCINE; This spontaneous report received from a vaccine facility via a company representative concerned a 95-year-old female. The patient''s height, and weight were not reported. The patient''s concurrent conditions included atrial fibrillation. The patient received COVID-19 VACCINE AD26.COV2.S (suspension for injection, route of admin not reported, batch number: Unknown) dose was not reported, administered on 2021 for prophylactic vaccination. No concomitant medications were reported. The batch number was not reported and has been requested. It was reported that on an unspecified date in 2021 the patient received Janssen Covid-19 Vaccine and within 6hrs she had a major atrial fibrillation episode, then several the following day. The next day, she lost her ability to swallow. Two days later she was on oxygen. Three days later she developed a blood clot in her right arm, was still on oxygen and blood pressure was falling. On an unspecified date, the patient died 4 days after receiving vaccine. The action taken with COVID-19 VACCINE AD26.COV2.S was not applicable. The patient died 4 days after receiving vaccine on an unspecified date, and the outcome of atrial fibrillation, inability to swallow, blood clot in right arm and low blood pressure was not reported. This report was serious (Death, Hospitalization Caused / Prolonged, and Other Medically Important Condition).; Sender''s Comments: V0: 20210400509: This spontaneous report received from a vaccine facility via a company representative involved a 95-year-old female with the past medical history remarkable for atrial fibrillation who received the Janssen COVID-19 Vaccine for prevention of COVID-19 infection and within 6hrs had a major atrial fibrillation episode. No concomitant medications were reported. The next day, she lost her ability to swallow. Two days later she was on oxygen. Three days later she developed a blood clot in her right arm, was still on oxygen and blood pressure was falling. On an unspecified date, the patient died 4 days after receiving vaccine. No information was provided regarding the cause of death. Considering the patient''s past medical history of atrial fibrillation, the causality for the event of atrial fibrillation, as well the consequent events is assessed not related to the Janssen COVID-19 Vaccine.; Reported Cause(s) of Death: DEATH 4 DAYS AFTER RECEIVING VACCINE


Changed on 5/14/2021

VAERS ID: 1168970 Before After
VAERS Form:2
Age:95.0
Sex:Female
Location:New Jersey
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Atrial fibrillation, Death, Dysphagia, Hypotension, Peripheral embolism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Atrial fibrillation
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USJNJFOC20210400509

Write-up: ATRIAL FIBRILLATION; INABILITY TO SWALLOW; BLOOD CLOT IN RIGHT ARM; LOW BLOOD PRESSURE; DEATH 4 DAYS AFTER RECEIVING VACCINE; This spontaneous report received from a vaccine facility via a company representative concerned a 95-year-old female. The patient''s height, and weight were not reported. The patient''s concurrent conditions included atrial fibrillation. The patient received COVID-19 VACCINE AD26.COV2.S (suspension for injection, route of admin not reported, batch number: Unknown) dose was not reported, administered on 2021 for prophylactic vaccination. No concomitant medications were reported. The batch number was not reported and has been requested. It was reported that on an unspecified date in 2021 the patient received Janssen Covid-19 Vaccine and within 6hrs she had a major atrial fibrillation episode, then several the following day. The next day, she lost her ability to swallow. Two days later she was on oxygen. Three days later she developed a blood clot in her right arm, was still on oxygen and blood pressure was falling. On an unspecified date, the patient died 4 days after receiving vaccine. The action taken with COVID-19 VACCINE AD26.COV2.S was not applicable. The patient died 4 days after receiving vaccine on an unspecified date, and the outcome of atrial fibrillation, inability to swallow, blood clot in right arm and low blood pressure was not reported. This report was serious (Death, Hospitalization Caused / Prolonged, and Other Medically Important Condition).; Sender''s Comments: V0: 20210400509: This spontaneous report received from a vaccine facility via a company representative involved a 95-year-old female with the past medical history remarkable for atrial fibrillation who received the Janssen COVID-19 Vaccine for prevention of COVID-19 infection and within 6hrs had a major atrial fibrillation episode. No concomitant medications were reported. The next day, she lost her ability to swallow. Two days later she was on oxygen. Three days later she developed a blood clot in her right arm, was still on oxygen and blood pressure was falling. On an unspecified date, the patient died 4 days after receiving vaccine. No information was provided regarding the cause of death. Considering the patient''s past medical history of atrial fibrillation, the causality for the event of atrial fibrillation, as well the consequent events is assessed not related to the Janssen COVID-19 Vaccine.; Reported Cause(s) of Death: DEATH 4 DAYS AFTER RECEIVING VACCINE

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