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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1700459

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Case Details

VAERS ID: 1700459 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-09-09
Onset:2021-09-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 206A21A / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Dyspnoea, Flushing, Headache, Pharyngeal swelling, Photophobia
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious meningitis (narrow), Glaucoma (broad), Cardiomyopathy (broad), Corneal disorders (broad), Retinal disorders (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? No
Previous Vaccinations:
Other Medications: Medications at the time of vaccination: loratadine 10mg PO daily
Current Illness:
Preexisting Conditions: Patient has no other known medical history.
Allergies: Pt w/ a hx of anaphylactic reaction to Amoxicillin, Penicillin G, and the Moderna Covid Vaccine.
Diagnostic Lab Data:
CDC Split Type:

Write-up: "Pt w/ a hx of anaphylactic reaction to Amoxicillin, Penicillin G, and the Moderna Covid Vaccine. Patient has no other known medical history. Medications at the time of vaccination: loratadine 10mg PO daily Pt presented to the vaccination clinic for Janssen vaccination to complete the Covid vaccination series after having an anaphylactic reaction to the first dose Moderna 3/5/21. Within 5mins of Janssen vaccination, pt c/o swelling in her throat and difficulty swallowing. The patient was noted to have some facial flushing around lips. Assessed by RN/PA: AOx4, VSS, BP 137/77, HR 87 Resp 18 SpO2 97% @1739. Per PA recommendation, PA administered 1 dose 0.3mg EpiPen @1733 to left leg. VSS, SpO2 97-100% on RA, GCS 15, lungs CTAB. @1739 Pt reported that she felt better after Epi injection but still symptomatic. Charge RN called 911 for transport to the hospital for additional evaluation and management. EMS arrival @1747, PA report for EMS transport. Patient left clinic via EMS transport to hospital at approx 1750. In the ED, pt was given another dose of Epi 0.3mg IM, Diphenhydramine 50mg IV x1, famotidine 20mg IV x1, methlprednisolone sod. succ 40mg IV x1, and ondansetron 4mg IV x1. Pt was discharged with a new presciption for EpiPen 0.3mg IM PRN anaphylaxis. 24hrs post vaccination pt developed a HA w/ light sensitivity. Pt returned to the ED 9/14 c/o HAx3 days. Pt was treated and discharged w/ new Rx for APAP 1000mg PO TID PRN HA. Per provider note after D/C, pt HA resolved."


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