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This is VAERS ID 1202019

History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1202019
VAERS Form:2
Age:67.0
Sex:Male
Location:Massachusetts
Vaccinated:2021-04-12
Onset:2021-04-12
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
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? 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.


Changed on 5/7/2021

VAERS ID: 1202019 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Massachusetts
Vaccinated:2021-04-12
Onset:2021-04-12
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
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? 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 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.


Changed on 5/14/2021

VAERS ID: 1202019 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Massachusetts
Vaccinated:2021-04-12
Onset:2021-04-12
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
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? 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 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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