| Days after vaccination:||0
|Vaccination / Manufacturer
||Lot / Dose
||Site / Route|
|COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN
||202A21A / 1
||RA / IM
Administered by: Pharmacy Purchased by: ?
Immediate post-injection reaction,
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Hearing impairment (narrow), Vestibular disorders (broad), Hypersensitivity (narrow), Dehydration (broad), Hypokalaemia (broad)
Life Threatening? No
Birth Defect? No
Permanent Disability? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Other Medications: NONE REPORTED
Current Illness: NONE REPORTED
Preexisting Conditions: NONE REPORTED
Diagnostic Lab Data: On day of event (6/3/2021), patient blood pressure, pulse oximetry, heart rate, and respirations monitored by pharmacy staff until EMS arrived. Patient was hypotensive, oxygen saturation of $g95% on room air, Patient was provided water and evaluated by EMS. EMS confirmed no life-threatening event associated with vaccination. Patient was encouraged to follow-up with medical provider as soon as leaving the facility by both EMS and pharmacy staff.
CDC Split Type:
Write-up: Immediately following administration of the vaccine, the patient reported lightheadedness, tinnitus, and paresthesia of extremities. Patient experienced these symptoms within 15 seconds of vaccine administration. Symptoms persisted for approximately 15 minutes.