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This is VAERS ID 1221425

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1221425
VAERS Form:2
Age:50.0
Sex:Male
Location:Indiana
Vaccinated:2021-03-18
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Abdominal pain upper, Asthenia, Death, Dehydration, Dyspnoea, Echocardiogram, Feeling abnormal, Intensive care, Pyrexia, Laboratory test, Dialysis, Mechanical ventilation, Multiple organ dysfunction syndrome, Illness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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: None known
Current Illness: shortness of breath, fatigue, swelling in legs
Preexisting Conditions: obesity, only one functioning kidney
Allergies: None known
Diagnostic Lab Data: Full septic work up April 3-4, 2021, TEE on April 8, dialysis on April 11, 2021
CDC 'Split Type':

Write-up: Patient felt ok the day of the shot, next day got very sick. Said he felt terrible, felt like the vaccine was going to "do him in." He complained of weakness and shortness of breath. He was dehydrated and worried about his kidney function. Said he had a hard time going to the bathroom with stomach pains. On Mar 31, 2021, said he had fever, but didn''t go to doctor. Was taken by ambulance April 3 to ER, admitted that night, transferred to ICU on April 4, on ventilator, proceeded to experience multiple organ failure and died on April 11, 2021


Changed on 5/7/2021

VAERS ID: 1221425 Before After
VAERS Form:2
Age:50.0
Sex:Male
Location:Indiana
Vaccinated:2021-03-18
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Abdominal pain upper, Asthenia, Death, Dehydration, Dyspnoea, Echocardiogram, Feeling abnormal, Intensive care, Pyrexia, Laboratory test, Dialysis, Mechanical ventilation, Multiple organ dysfunction syndrome, Illness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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: None known
Current Illness: shortness of breath, fatigue, swelling in legs
Preexisting Conditions: obesity, only one functioning kidney
Allergies: None known known
Diagnostic Lab Data: Full septic work up April 3-4, 2021, TEE on April 8, dialysis on April 11, 2021
CDC 'Split Type':

Write-up: Patient felt ok the day of the shot, next day got very sick. Said he felt terrible, felt like the vaccine was going to "do him in." He complained of weakness and shortness of breath. He was dehydrated and worried about his kidney function. Said he had a hard time going to the bathroom with stomach pains. On Mar 31, 2021, said he had fever, but didn''t go to doctor. Was taken by ambulance April 3 to ER, admitted that night, transferred to ICU on April 4, on ventilator, proceeded to experience multiple organ failure and died on April 11, 2021


Changed on 5/14/2021

VAERS ID: 1221425 Before After
VAERS Form:2
Age:50.0
Sex:Male
Location:Indiana
Vaccinated:2021-03-18
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Abdominal pain upper, Asthenia, Death, Dehydration, Dyspnoea, Echocardiogram, Feeling abnormal, Intensive care, Pyrexia, Laboratory test, Dialysis, Mechanical ventilation, Multiple organ dysfunction syndrome, Illness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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: None known
Current Illness: shortness of breath, fatigue, swelling in legs
Preexisting Conditions: obesity, only one functioning kidney
Allergies: None known known
Diagnostic Lab Data: Full septic work up April 3-4, 2021, TEE on April 8, dialysis on April 11, 2021
CDC 'Split Type':

Write-up: Patient felt ok the day of the shot, next day got very sick. Said he felt terrible, felt like the vaccine was going to "do him in." He complained of weakness and shortness of breath. He was dehydrated and worried about his kidney function. Said he had a hard time going to the bathroom with stomach pains. On Mar 31, 2021, said he had fever, but didn''t go to doctor. Was taken by ambulance April 3 to ER, admitted that night, transferred to ICU on April 4, on ventilator, proceeded to experience multiple organ failure and died on April 11, 2021

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