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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1331130



Case Details

VAERS ID: 1331130 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: New York  
Vaccinated:2021-05-19
Onset:2021-05-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Eye pruritus, Eye swelling, Muscle spasms
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Dystonia (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: FLU SHOT
Other Medications: CLONIDINE, LABETALOL, DOXAZOSIN, XOLAIR
Current Illness:
Preexisting Conditions: HYPERTENSION, INTERMITTENT ASHTMA, MAST CELL ACTIVATION SYNDROME, IDIOPATHIC ANAPHYLAXIS, CHRONIC IDIOPATHIC URTICARIA, HISTORY OF ALLERGIC REACTIONS, MASTOCYTOSIS
Allergies: PREDNISONE, PEANUTS, FLU VACCINE, ATROVENT, IODINE, ASPIRIN, VANCOMYCIN, MORPHINE, TOMATOES, PINEAPPLE, LATE, POTASSIUM CHLORIDE, SANDIMMUNE, CYCLOSPORINE, CARDIZEM, SHELLFISH, BARIUM, CONTRAST DYES, METOPROLOL, AMLODIPINE, HYDRALAZINE
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT RECEIVED VACCINE, AFTER ABOUT 25MINUTES SHE STARTED DEVELOPING SYMPTOMS SUCH AS LEG CRAMPING, EYE SWELLING AND EYE ITCHING SIMILAR TO MAST CELL ACTIVATION FLARES SHE HAS HAD IN THE PAST. SHE DENIED ANY LIP, TONGUE OR THROAT SWELLING AND DENIES ANY WHEEZING OR TROUBLE BREATHING, SHE ALSO DENIES ANY ABDOMINAL PAIN, VOMITING OR DIARRHEA.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1331130


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