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This is VAERS ID 1330104

History of Changes from the VAERS Wayback Machine

First Appeared on 5/21/2021

VAERS ID: 1330104
VAERS Form:2
Age:61.0
Sex:Male
Location:Minnesota
Vaccinated:2021-05-04
Onset:2021-05-04
Submitted:0000-00-00
Entered:2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Pain in extremity, Ultrasound Doppler abnormal, Peripheral swelling, Deep vein thrombosis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: albuterol inhaler, amitriptyline, flexeril, voltaren gel, flonase, ibuprofen, sildenafil, cialis, b vitamin, vitamin d, testosterone topical solution
Current Illness: unknown
Preexisting Conditions: hypogonadism, knee pain, erectile dysfunction
Allergies: no known allergies
Diagnostic Lab Data: right lower extremity venous ultrasound on 5/10 which showed DVT in the right common femoral, femoral, popliteal, and peroneal veins.
CDC 'Split Type':

Write-up: Patient had onset of right calf pain and swelling several hours after receiving vaccine. Was seen on 5/10 and diagnosed with right lower extremity DVT.

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