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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1202019



Case Details

VAERS ID: 1202019 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-04-12
Onset:2021-04-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 043A21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood glucose decreased, Condition aggravated, Death, Lethargy, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone PO daily, Apixaban 5mg PO BID, Budesonide 0.5mg Inhaled BID, Clopidogrel 75 mg PO daily, Klor-Con M20 MEQ ER PO daily, Lantus insulin SC injection 24 units daily, Lipitor 40 mg PO daily, Metformin 500mg PO BID, Prednisone 20mg PO
Current Illness: CHF, Atrial Fibrillation, Hypertensive Heart Disease, Ischemic Cardiomyopathy
Preexisting Conditions: Type 2 diabetes, COPD
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: This patient was under hospice care at home with Nursing Service and Hospice. He received the J&J vaccination at noon by local public health nurse on Mon 4/12/21. The patient''s wife, reported to hospice team that he had been sleepy during the day and had received a dose of Ativan earlier that morning (PRN medication at 0750). The primary hospice nurse reported wife noted he became more lethargic throughout the day after vaccination with his condition worsening at 1720; at that time his blood sugar levels were noted to be low at "47" but patient was alert enough to drink orange juice, eat ice cream. The patient continued to deteriorate so MD was consulted and he was transported to the ED where he later expired at 1930.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1202019


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