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From the 6/4/2021 release of VAERS data:

This is VAERS ID 1184931



Case Details

VAERS ID: 1184931 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-04-09
Onset:2021-04-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Dry mouth, Vision blurred
SMQs:, Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Glaucoma (broad), Lens disorders (broad), Retinal disorders (broad), Hypoglycaemia (broad), Dehydration (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: Per patient, reaction to influenza. Date unknown.
Other Medications: Zyrtec, Vit D3, Tolteridine Tartrate ER, Synthroid, Nexium, Lisinopril, Hydrixizine, HCTZ, gabapentin, fluoxetidine, fluconazole, fentanyl patch, estradiol, ergocalciferol, diazapam, advair discus, flonase.
Current Illness: None
Preexisting Conditions: Unknown
Allergies: Propulsid, Iodine, latex, bee stings, steroids, tomatoes, shellfish, oral contrast, gatorade, amocicillin, avelox, baclofen, elmiron, erythromycin, hydrocodone, acetaminophen, mucinex, naratriptan, nasonex, oxycontin, prednisone, rizatriptan benzoate, sumatriptan, tetracycline, tramadol, zanaflex, influenza vaccine, higher dose penicillins.
Diagnostic Lab Data: Unknown, as patient was brought to the emergency department.
CDC Split Type:

Write-up: Patient complained of feeling a dry mouth and blurry vision. She felt that this was a sign of an allergic reaction. EPI pen was administered and patient was brought to the emergency room.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1184931


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