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This is VAERS ID 1271243

History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1271243
VAERS Form:2
Age:77.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-18
Onset:2021-03-27
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Chills, Confusional state, Death, Dizziness, Intensive care, Nausea, Pyrexia, Endotracheal intubation, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-18
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? Yes, days: 23     Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin (HALFPRIN) 81 MG tablet carvedilol (COREG) 25 MG tablet cilostazol (PLETAL) 100 MG tablet clopidogrel (PLAVIX) 75 MG tablet doxazosin (CARDURA) 2 MG tablet ferrous sulfate (FEOSOL, 65 FE,) 325 (65 FE) MG tablet Glucosamine 500 MG ca
Current Illness: None known
Preexisting Conditions: Hypertension associated with stage 3 chronic kidney disease due to type 2 diabetes mellitus (HCC) Stage 3b chronic kidney disease Proteinuria Non-insulin dependent type 2 diabetes mellitus (HCC) Multiple pulmonary nodules PAD (peripheral artery disease) (HCC) Hypertriglyceridemia Thrombocytopenia (HCC) Acute on chronic anemia Anemia in stage 3 chronic kidney disease Secondary hyperparathyroidism (HCC) Hyperkalemia Atherosclerosis of native artery of both lower extremities with intermittent claudication (HCC) Acute respiratory failure with hypoxia (HCC) Pneumonia due to COVID-19 virus Acute kidney injury superimposed on CKD (HCC) Essential hypertension Elevated liver enzymes Sepsis due to COVID-19 (HCC) Metabolic acidosis NSVT (nonsustained ventricular tachycardia) (HCC) Positive occult stool blood test
Allergies: None known
Diagnostic Lab Data: COVID-19 test positive on 3/27/21
CDC 'Split Type':

Write-up: Symptoms of fever, nausea, and weakness started 3 days following vaccination. Denies any exposure to COVID positive person. Presented to local emergency department on 3/27/21 with nausea, fever, chills, dizziness, and confusion. Due to patient''s condition, he was transferred to larger facility for further management. Patient was admitted to hospital and subsequently transferred to ICU on 4/17/21. He was intubated at that time. Patient went into multisystem organ failure and died on 4/18/21.


Changed on 5/7/2021

VAERS ID: 1271243 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-18
Onset:2021-03-27
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Chills, Confusional state, Death, Dizziness, Intensive care, Nausea, Pyrexia, Endotracheal intubation, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-18
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? Yes, days: 23     Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin (HALFPRIN) 81 MG tablet carvedilol (COREG) 25 MG tablet cilostazol (PLETAL) 100 MG tablet clopidogrel (PLAVIX) 75 MG tablet doxazosin (CARDURA) 2 MG tablet ferrous sulfate (FEOSOL, 65 FE,) 325 (65 FE) MG tablet Glucosamine 500 MG ca
Current Illness: None known
Preexisting Conditions: Hypertension associated with stage 3 chronic kidney disease due to type 2 diabetes mellitus (HCC) Stage 3b chronic kidney disease Proteinuria Non-insulin dependent type 2 diabetes mellitus (HCC) Multiple pulmonary nodules PAD (peripheral artery disease) (HCC) Hypertriglyceridemia Thrombocytopenia (HCC) Acute on chronic anemia Anemia in stage 3 chronic kidney disease Secondary hyperparathyroidism (HCC) Hyperkalemia Atherosclerosis of native artery of both lower extremities with intermittent claudication (HCC) Acute respiratory failure with hypoxia (HCC) Pneumonia due to COVID-19 virus Acute kidney injury superimposed on CKD (HCC) Essential hypertension Elevated liver enzymes Sepsis due to COVID-19 (HCC) Metabolic acidosis NSVT (nonsustained ventricular tachycardia) (HCC) Positive occult stool blood test
Allergies: None known known
Diagnostic Lab Data: COVID-19 test positive on 3/27/21
CDC 'Split Type':

Write-up: Symptoms of fever, nausea, and weakness started 3 days following vaccination. Denies any exposure to COVID positive person. Presented to local emergency department on 3/27/21 with nausea, fever, chills, dizziness, and confusion. Due to patient''s condition, he was transferred to larger facility for further management. Patient was admitted to hospital and subsequently transferred to ICU on 4/17/21. He was intubated at that time. Patient went into multisystem organ failure and died on 4/18/21.


Changed on 5/14/2021

VAERS ID: 1271243 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-18
Onset:2021-03-27
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Chills, Confusional state, Death, Dizziness, Intensive care, Nausea, Pyrexia, Endotracheal intubation, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-18
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? Yes, days: 23     Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin (HALFPRIN) 81 MG tablet carvedilol (COREG) 25 MG tablet cilostazol (PLETAL) 100 MG tablet clopidogrel (PLAVIX) 75 MG tablet doxazosin (CARDURA) 2 MG tablet ferrous sulfate (FEOSOL, 65 FE,) 325 (65 FE) MG tablet Glucosamine 500 MG ca
Current Illness: None known
Preexisting Conditions: Hypertension associated with stage 3 chronic kidney disease due to type 2 diabetes mellitus (HCC) Stage 3b chronic kidney disease Proteinuria Non-insulin dependent type 2 diabetes mellitus (HCC) Multiple pulmonary nodules PAD (peripheral artery disease) (HCC) Hypertriglyceridemia Thrombocytopenia (HCC) Acute on chronic anemia Anemia in stage 3 chronic kidney disease Secondary hyperparathyroidism (HCC) Hyperkalemia Atherosclerosis of native artery of both lower extremities with intermittent claudication (HCC) Acute respiratory failure with hypoxia (HCC) Pneumonia due to COVID-19 virus Acute kidney injury superimposed on CKD (HCC) Essential hypertension Elevated liver enzymes Sepsis due to COVID-19 (HCC) Metabolic acidosis NSVT (nonsustained ventricular tachycardia) (HCC) Positive occult stool blood test
Allergies: None known known
Diagnostic Lab Data: COVID-19 test positive on 3/27/21
CDC 'Split Type':

Write-up: Symptoms of fever, nausea, and weakness started 3 days following vaccination. Denies any exposure to COVID positive person. Presented to local emergency department on 3/27/21 with nausea, fever, chills, dizziness, and confusion. Due to patient''s condition, he was transferred to larger facility for further management. Patient was admitted to hospital and subsequently transferred to ICU on 4/17/21. He was intubated at that time. Patient went into multisystem organ failure and died on 4/18/21.

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