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This is VAERS ID 1700856

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First Appeared on 9/17/2021

VAERS ID: 1700856
VAERS Form:2
Age:62.0
Sex:Female
Location:Texas
Vaccinated:2021-05-22
Onset:2021-08-24
Submitted:0000-00-00
Entered:2021-09-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Diarrhoea, Dyspnoea, Intensive care, Nausea, Respiratory failure, Vomiting, Endotracheal intubation, Withdrawal of life support, COVID-19, SARS-CoV-2 test positive, COVID-19 pneumonia, Positive airway pressure therapy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-09-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol MDI PRN, Apixaban 5 mg QD, Bumetanide 2 mg QD,
Current Illness:
Preexisting Conditions: A-Fib, CHF, CAD, Type 2 DM, Hyperlipidemia, Hypertension, Rheumatoid arthritis, Obstructive sleep apnea
Allergies: Methylprednisolone (itching)
Diagnostic Lab Data: COVID-19 Positive Test on 9/5/2021 using PCR based methods
CDC 'Split Type':

Write-up: Janssen COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Janssen Vaccine on 5/22/2021. Patient was diagnosed with COVID-19 on 8/25/2021 with symptoms of nausea, vomiting, diarrhea starting on 8/24/2021. Per patient reoprt, she was admitted to a different facility for COVID-19 Pneumonia for two days. Patient did not require oxygen at that time. On 9/4/2021 patient presented to ED via EMS with complaints of shortness of breath. When EMS arrived patient was 55-70% on room air, was placed on a non-rebreather and came up to 88%, and was then placed on CPAP en route. Patient was admitted and started on dexamethasone and empiric ceftriaxone. On 9/10/2021, respiratory status

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