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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1351207

Case Details

VAERS ID: 1351207 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Michigan  
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-05-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 - / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Absence of immediate treatment response, Anticoagulant therapy, Bilevel positive airway pressure, COVID-19, Death, Diarrhoea, Dyspnoea, Dyspnoea exertional, Endotracheal intubation, Gait disturbance, Hypoxia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Lack of efficacy/effect (narrow), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, Lipitor, bisoprolol, Plavix, dicyclomine, Aricept, Pepcid, Lasix, Norco, Isordil, Imdur, melatonin, Mexitil, Nitrostat, Protonix, Zoloft, Flomax, Urinozinc plus, verapamil ER, vitamin D
Current Illness:
Preexisting Conditions: AFib, acute MI (2020), arthritis, cigarette smoker, cluster headaches, colon polyps, elevated cholesterol, hypertension
Allergies: Dibucaine
Diagnostic Lab Data: SARS-CoV-2 (COVID-19), Point of Care: Positive (4/3/2021)
CDC Split Type:

Write-up: 73 year old male with PMHx of AFib, CAD, and HTN who presents with c/o dyspnea that started 4/6/21. Patient states it got to the point where he could not walk in his house without severe dyspnea. States he was diagnosed with COVID-19 one week prior. Per chart review he was in our ER 4/3/21 and diagnosed with COVID-19. At the time he was 95% on room air. His only other symptom has been diarrhea. He states he received the Johnson and Johnson vaccine one month ago. He denies any dizziness, chest pain, abdominal pain, n/v, weakness, or numbness. In ER patient was hypoxic and improved only with BiPAP. Per chart review patient had cardiac arrest on 11/2020 for 17 minutes. He has a significant cardiac history consisting of stemi, fem-pop bypass surgery, PVD, CABG x4, AFib post ablation 2017, V-tach. He was started on therapy with steroids, anticoagulation, and Remdesivir. He failed to improve and had increasing oxygen requirements. He was eventually intubated. Due to failure to improve patient was made DNR and eventually expired.

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