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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1385404



Case Details

VAERS ID: 1385404 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-05-29
Onset:2021-06-04
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain, Blood test, Chills, Diarrhoea, Fatigue, Haematochezia, Nausea, Occult blood
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 325mg Bayer Aspirin, Basaglar, Amlodipine Besylate, Lisinopril, Carvedilol, Leflunomide, Folic Acid, Chlorthalidon, Fish Oil, Red Yeast Rice, Calc/Mag/Zinc, Centrum Silver, Probiotic, Vitamin D. As needed: Alprazolam, Clobetasol Propionat
Current Illness:
Preexisting Conditions: Diabetes, Lupus, High Blood Pressure
Allergies: beans
Diagnostic Lab Data: awaiting results of blood tests and stool sample test
CDC Split Type:

Write-up: June 4 onset of diarrhea around 1pm. Took OTC Kaeopectate to stop diarrhea. Stools turned to nothing but blood. Fatigue, abdominal pain, nausea. Same symptoms as my daughter (she has filed a report). Saw Dr. at PCP office on Monday, June 7th. Blood tests requested. Stool Sample requested. Awaiting results. Since my daughter and myself both came down with same symptoms within 24 hours of each other we were instructed to complete this form and we have been discussing possibility of food poisoning with our PCPs. Still have nausea, chills, abdominal pain. Bloody stools have stopped for me.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1385404


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