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This is VAERS ID 1258608

History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1258608
VAERS Form:2
Age:18.0
Sex:Male
Location:Washington
Vaccinated:2021-04-11
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / SYR

Administered by: Other      Purchased by: ??
Symptoms: Blood creatine phosphokinase normal, Blood magnesium normal, Differential white blood cell count normal, Erythema, Fatigue, Fibrin D dimer normal, Full blood count normal, Headache, Blood test normal, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? No
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: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: Blood test for blood clots - negative result on 4/21/2021 These test were normal: CBC w/ auto diff, CPK, Comprehensive Metabolic Panel, D DIMER, Mg. D DIMER, QUANTITATIVE Magnesium Test results are negative.
CDC 'Split Type':

Write-up: He has had the following symptoms from the 4/12/2021 till present time: constant headache and fatigue. Intermittent low fever (99F). On 4/21/2021, his primary care doctor recommended that we take him to Emergency Room because she was concerned about thrombosis as side effects from the vaccine. His legs had some red patches on the back of the ankles area. At ER, doctor did blood test for blood clot and result was negative. He got an IV injection less headache.


Changed on 5/7/2021

VAERS ID: 1258608 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Washington
Vaccinated:2021-04-11
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / SYR

Administered by: Other      Purchased by: ??
Symptoms: Blood creatine phosphokinase normal, Blood magnesium normal, Differential white blood cell count normal, Erythema, Fatigue, Fibrin D dimer normal, Full blood count normal, Headache, Blood test normal, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? No
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: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a n/a
Diagnostic Lab Data: Blood test for blood clots - negative result on 4/21/2021 These test were normal: CBC w/ auto diff, CPK, Comprehensive Metabolic Panel, D DIMER, Mg. D DIMER, QUANTITATIVE Magnesium Test results are negative.
CDC 'Split Type':

Write-up: He has had the following symptoms from the 4/12/2021 till present time: constant headache and fatigue. Intermittent low fever (99F). On 4/21/2021, his primary care doctor recommended that we take him to Emergency Room because she was concerned about thrombosis as side effects from the vaccine. His legs had some red patches on the back of the ankles area. At ER, doctor did blood test for blood clot and result was negative. He got an IV injection less headache.


Changed on 5/14/2021

VAERS ID: 1258608 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Washington
Vaccinated:2021-04-11
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / SYR

Administered by: Other      Purchased by: ??
Symptoms: Blood creatine phosphokinase normal, Blood magnesium normal, Differential white blood cell count normal, Erythema, Fatigue, Fibrin D dimer normal, Full blood count normal, Headache, Blood test normal, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? No
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: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a n/a
Diagnostic Lab Data: Blood test for blood clots - negative result on 4/21/2021 These test were normal: CBC w/ auto diff, CPK, Comprehensive Metabolic Panel, D DIMER, Mg. D DIMER, QUANTITATIVE Magnesium Test results are negative.
CDC 'Split Type':

Write-up: He has had the following symptoms from the 4/12/2021 till present time: constant headache and fatigue. Intermittent low fever (99F). On 4/21/2021, his primary care doctor recommended that we take him to Emergency Room because she was concerned about thrombosis as side effects from the vaccine. His legs had some red patches on the back of the ankles area. At ER, doctor did blood test for blood clot and result was negative. He got an IV injection less headache.

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