National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1177248

History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1177248
VAERS Form:2
Age:86.0
Sex:Female
Location:Alabama
Vaccinated:2021-04-02
Onset:2021-04-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / N/A LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Chills, Malaise, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alpahgan P 0.1% eye drops Amlodipine 5mg tablet Aspirin 81 mg tablet Delayed release Betimol 0.5% eye drops Calmoseptine 0.44%-20.6% topical ointment Carvedilol 12.5 mg tablet Hydralazine 50mg tablet lidocaine-prilocaine 2.5%-2.5% topical
Current Illness: none that I am aware of.
Preexisting Conditions: Patient was placed on Hospice care the week of 3/29/2021.
Allergies: Betadine- skin rash
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Family reports general malaise post treatment, followed by fever and chills 4/3/2021, and cardiac arrest 4/4/2021.


Changed on 5/7/2021

VAERS ID: 1177248 Before After
VAERS Form:2
Age:86.0
Sex:Female
Location:Alabama
Vaccinated:2021-04-02
Onset:2021-04-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / N/A LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Chills, Malaise, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alpahgan P 0.1% eye drops Amlodipine 5mg tablet Aspirin 81 mg tablet Delayed release Betimol 0.5% eye drops Calmoseptine 0.44%-20.6% topical ointment Carvedilol 12.5 mg tablet Hydralazine 50mg tablet lidocaine-prilocaine 2.5%-2.5% topical
Current Illness: none that I am aware of.
Preexisting Conditions: Patient was placed on Hospice care the week of 3/29/2021.
Allergies: Betadine- skin rash rash
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Family reports general malaise post treatment, followed by fever and chills 4/3/2021, and cardiac arrest 4/4/2021.


Changed on 5/14/2021

VAERS ID: 1177248 Before After
VAERS Form:2
Age:86.0
Sex:Female
Location:Alabama
Vaccinated:2021-04-02
Onset:2021-04-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / N/A LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Chills, Malaise, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alpahgan P 0.1% eye drops Amlodipine 5mg tablet Aspirin 81 mg tablet Delayed release Betimol 0.5% eye drops Calmoseptine 0.44%-20.6% topical ointment Carvedilol 12.5 mg tablet Hydralazine 50mg tablet lidocaine-prilocaine 2.5%-2.5% topical
Current Illness: none that I am aware of.
Preexisting Conditions: Patient was placed on Hospice care the week of 3/29/2021.
Allergies: Betadine- skin rash rash
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Family reports general malaise post treatment, followed by fever and chills 4/3/2021, and cardiac arrest 4/4/2021.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1177248&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166