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

This is VAERS ID 1420397



Case Details

VAERS ID: 1420397 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-04-28
Onset:2021-06-20
   Days after vaccination:53
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Malaise
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: TN, paroxysmal AFib, HFpEF borderline, nonobstructive CAD, recurrent falls
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt hospitalized for COVID19 on 6/20/21. Sick for about 1 week prior to hospitalization. Exposure to family member that was positive.


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