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From the 6/4/2021 release of VAERS data:

This is VAERS ID 1268087



Case Details

VAERS ID: 1268087 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-04-10
Onset:2021-04-19
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Anticoagulant therapy, Arthralgia, Blood test, Chest X-ray abnormal, Chills, Computerised tomogram thorax abnormal, Dizziness, Dyspnoea, Fatigue, Headache, Heart injury, Hypoaesthesia, Injection site hypoaesthesia, Injection site pain, Injection site paraesthesia, Musculoskeletal chest pain, Pain in extremity, Pulmonary embolism, Pyrexia, Traumatic lung injury
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Triamterene/HCTZ, Sildanifil.
Current Illness: None.
Preexisting Conditions: Hypertension.
Allergies: Paba sunscreen, pabamine.
Diagnostic Lab Data: In the hospital, CT chest showing pulmonary embolism.
CDC Split Type:

Write-up: He received the vaccine, had very painful going in and tingling going down his left arm and to the elbow which was numb, and the left little finger was numb, and a dizzy spell afterward which was typical for him. He then on the 9th day had extreme intercostal pain in the ribs on the right side and his right shoulder extremely painful, low grade fever, chills, fatigue and inability to draw a full breath. He called the doctor and they were on the way to the clinic they told him to go to the ER based on his symptoms. He went to the ER and they admitted him and did blood work, and then did a chest x-ray, then a chest CT scan and it was positive for pulmonary embolism. He was treated with an anti-inflammatory through the IV and a blood thinner to the stomach. He was hospitalized for 1 full day, and discharged home with Eliquis double dose for 14 days and then a single dose until further notice. He is still having fatigue and aches on the right side of his brain and aches in his feet, but is to see a pulmonologist for his lungs, as it will take up to 6 months for it to resolve. He also has damage to the right side of the heart and lung. Is waiting to get a CT of the brain.


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