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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1173868

Case Details

VAERS ID: 1173868 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: California  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808980 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Dizziness, Flushing, Nausea, Palpitations, Paraesthesia
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypersensitivity (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? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: pt reported having "borderline hypertension." He does not take any medication for it.
Allergies: pt denied hx of allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient received the vaccine at 12:20pm. He was observed per protocol for 15min until 12:35. At 12:35pm he denied feeling any response to the vaccine and ambulated away with a steady gait. At 12:41pm the patient reported back to the nursing area c/o "dizziness" and feeling like he does when he "drinks too much caffeine" and his left arm felt "tingly." Pt was asked to lay down. Vitals were checked at 12:45pm while patient was laying down. BP 180/90, Spo2 96%, HR 69 and regular rhythm per palpation, Temp 97.7, RR 16. Pt was AO x 4. At 12:50pm BP was reassessed 186/100. At 12:55pm pt reported still feeling "dizzy." His face was flushed. His left arm still felt "tingly." He reported feeling "nauseous" and described "heart palpitations." Pt was asked to sit up and given 50mg of Benadryl PO per policy and 911 was called at 12:56pm. Patient laid back down. At 1300 temp 98.5, pulse 63 and RN noted irregular rhythm by palpation, Spo2 97%, RR 16. The ambulance arrived at 1303 and the paramedics resumed care of the patient. The paramedics noted PVCs on their rhythm strip and BP 170/90. At 1311 patient started reporting "epigastric pain" 5/10 pain. At 1313 the paramedics transported the patient to a hospital (unknown which hospital).

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