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This is VAERS ID 1186471

History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1186471
VAERS Form:2
Age:45.0
Sex:Male
Location:Pennsylvania
Vaccinated:2021-04-07
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Cardioversion, Death, Diarrhoea, Hyperhidrosis, Life support, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-09
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: AMLODIPINE 10MG TABLET -- [TAKE 1 TABLET(S) ORALLY ONCE DAILY] -- 2021-02-23--2021-09-20 ATORVASTATIN 40MG TABLET -- [TAKE 1 TABLET(S) ORALLY ONCE DAILY] -- 2021-02-23--2021-09-20 LACTULOSE 10GM/15ML SOL -- [TAKE 30 MILLILITER(S) ORALLY TWI
Current Illness: D-4 - POST-OPERATIVE ANALGESIA, MILD-TO-MODERATE - 2020-09-03 E78.5 - HYPERLIPIDEMIA, UNSPECIFIED - 2021-02-23 I10 - HYPERTENSION, UNSPEC. - 2019-02-04 F10.20 - **[F10.20A]** ALCOHOL USE DISORDER, MODERATE - 2019-02-11 F14.20 - **[F14.20A]** COCAINE USE DISORDER, MODERATE - 2019-02-11 D-19 - FRACTURED TOOTH - 2020-08-24
Preexisting Conditions: D-4 - POST-OPERATIVE ANALGESIA, MILD-TO-MODERATE - 2020-09-03 E78.5 - HYPERLIPIDEMIA, UNSPECIFIED - 2021-02-23 I10 - HYPERTENSION, UNSPEC. - 2019-02-04 F10.20 - **[F10.20A]** ALCOHOL USE DISORDER, MODERATE - 2019-02-11 F14.20 - **[F14.20A]** COCAINE USE DISORDER, MODERATE - 2019-02-11 D-19 - FRACTURED TOOTH - 2020-08-24
Allergies: VANCOMYCIN RELATED
Diagnostic Lab Data: Resulted on 3/31/2021 FT4 - (NF) FT4 - FT4 L <0.25 (<0.25) 0.78-2.19 ng/dL T3 TOTAL - (NF) T3 TOTAL - T3 TOTAL LL 0.355 (0.355) 0.970-1.69 NG/ML TSH-HIGH SENSITIVITY - (NF) TSH-HIGH SENSITIVITY - TSH-HIGH SENSITIVITY HH 170.783 (171.219) 0.465-4.68 uU/mL
CDC 'Split Type':

Write-up: Complaints of diarrhea, sweating, weakness suffered sudden cardiac arrest. CPR, AED, Lucas device applied ACLS protocol initiated by EMS. Efforts terminated. Patient pronounced deceased at 1003am.


Changed on 5/7/2021

VAERS ID: 1186471 Before After
VAERS Form:2
Age:45.0
Sex:Male
Location:Pennsylvania
Vaccinated:2021-04-07
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Cardioversion, Death, Diarrhoea, Hyperhidrosis, Life support, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-09
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: AMLODIPINE 10MG TABLET -- [TAKE 1 TABLET(S) ORALLY ONCE DAILY] -- 2021-02-23--2021-09-20 ATORVASTATIN 40MG TABLET -- [TAKE 1 TABLET(S) ORALLY ONCE DAILY] -- 2021-02-23--2021-09-20 LACTULOSE 10GM/15ML SOL -- [TAKE 30 MILLILITER(S) ORALLY TWI
Current Illness: D-4 - POST-OPERATIVE ANALGESIA, MILD-TO-MODERATE - 2020-09-03 E78.5 - HYPERLIPIDEMIA, UNSPECIFIED - 2021-02-23 I10 - HYPERTENSION, UNSPEC. - 2019-02-04 F10.20 - **[F10.20A]** ALCOHOL USE DISORDER, MODERATE - 2019-02-11 F14.20 - **[F14.20A]** COCAINE USE DISORDER, MODERATE - 2019-02-11 D-19 - FRACTURED TOOTH - 2020-08-24
Preexisting Conditions: D-4 - POST-OPERATIVE ANALGESIA, MILD-TO-MODERATE - 2020-09-03 E78.5 - HYPERLIPIDEMIA, UNSPECIFIED - 2021-02-23 I10 - HYPERTENSION, UNSPEC. - 2019-02-04 F10.20 - **[F10.20A]** ALCOHOL USE DISORDER, MODERATE - 2019-02-11 F14.20 - **[F14.20A]** COCAINE USE DISORDER, MODERATE - 2019-02-11 D-19 - FRACTURED TOOTH - 2020-08-24
Allergies: VANCOMYCIN RELATED RELATED
Diagnostic Lab Data: Resulted on 3/31/2021 FT4 - (NF) FT4 - FT4 L <0.25 (<0.25) 0.78-2.19 ng/dL T3 TOTAL - (NF) T3 TOTAL - T3 TOTAL LL 0.355 (0.355) 0.970-1.69 NG/ML TSH-HIGH SENSITIVITY - (NF) TSH-HIGH SENSITIVITY - TSH-HIGH SENSITIVITY HH 170.783 (171.219) 0.465-4.68 uU/mL
CDC 'Split Type':

Write-up: Complaints of diarrhea, sweating, weakness suffered sudden cardiac arrest. CPR, AED, Lucas device applied ACLS protocol initiated by EMS. Efforts terminated. Patient pronounced deceased at 1003am.


Changed on 5/14/2021

VAERS ID: 1186471 Before After
VAERS Form:2
Age:45.0
Sex:Male
Location:Pennsylvania
Vaccinated:2021-04-07
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Cardioversion, Death, Diarrhoea, Hyperhidrosis, Life support, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-09
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: AMLODIPINE 10MG TABLET -- [TAKE 1 TABLET(S) ORALLY ONCE DAILY] -- 2021-02-23--2021-09-20 ATORVASTATIN 40MG TABLET -- [TAKE 1 TABLET(S) ORALLY ONCE DAILY] -- 2021-02-23--2021-09-20 LACTULOSE 10GM/15ML SOL -- [TAKE 30 MILLILITER(S) ORALLY TWI
Current Illness: D-4 - POST-OPERATIVE ANALGESIA, MILD-TO-MODERATE - 2020-09-03 E78.5 - HYPERLIPIDEMIA, UNSPECIFIED - 2021-02-23 I10 - HYPERTENSION, UNSPEC. - 2019-02-04 F10.20 - **[F10.20A]** ALCOHOL USE DISORDER, MODERATE - 2019-02-11 F14.20 - **[F14.20A]** COCAINE USE DISORDER, MODERATE - 2019-02-11 D-19 - FRACTURED TOOTH - 2020-08-24
Preexisting Conditions: D-4 - POST-OPERATIVE ANALGESIA, MILD-TO-MODERATE - 2020-09-03 E78.5 - HYPERLIPIDEMIA, UNSPECIFIED - 2021-02-23 I10 - HYPERTENSION, UNSPEC. - 2019-02-04 F10.20 - **[F10.20A]** ALCOHOL USE DISORDER, MODERATE - 2019-02-11 F14.20 - **[F14.20A]** COCAINE USE DISORDER, MODERATE - 2019-02-11 D-19 - FRACTURED TOOTH - 2020-08-24
Allergies: VANCOMYCIN RELATED RELATED
Diagnostic Lab Data: Resulted on 3/31/2021 FT4 - (NF) FT4 - FT4 L <0.25 (<0.25) 0.78-2.19 ng/dL T3 TOTAL - (NF) T3 TOTAL - T3 TOTAL LL 0.355 (0.355) 0.970-1.69 NG/ML TSH-HIGH SENSITIVITY - (NF) TSH-HIGH SENSITIVITY - TSH-HIGH SENSITIVITY HH 170.783 (171.219) 0.465-4.68 uU/mL
CDC 'Split Type':

Write-up: Complaints of diarrhea, sweating, weakness suffered sudden cardiac arrest. CPR, AED, Lucas device applied ACLS protocol initiated by EMS. Efforts terminated. Patient pronounced deceased at 1003am.

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