Page breadcrumb nav

VAERS Report 2115967

Case Report Section

Vaer Report Details

Age: 46 years old

Gender: Male

State: Ohio

Patient Died?
Vaccine information


Type: Coronavirus 2019 vaccine

Manufacturer: JANSSEN

Lot: 204a21a

Date report was received
Date form completed
Date Vaccinated
Date of Onset
Number of days (onset date – vaccination date)
Adverse Event Description

1/9/22 pt presented to ed w/ symptoms for a week. patient is a 47 y.o. male of md with history of recent dvt, pe on eliquis presented with shortness of breath, nonproductive cough and fatigue in context of covid-19 pneumonia. acute respiratory failure with hypoxia covid-19 virus infection date of onset of symptoms: approximate 1 week pta symptoms present on admission: fever fatigue, mental cloudiness, shortness of breath, hypoxia date of covid positive test: 1/9/2022 vaccination status: vaccinated (johnson & johnson in june 2021) imaging: cxr with no infiltrate or effusion noted, slight bilateral perihilar bronchitis oxygen requirements on admission: 2 l nc medical therapy: steroids patient work of breathing normal. he reports only becoming short of breath when going up and down a flight of stairs. no shortness of breath with activities of daily living. while ambulating here, spo2 dropped to 89%. he will be sent home with supplemental o2. if his breathing were to worsen, or his oxygen requirement were to increase he is counseled to return to the er. patient will be given referral for advanced home services (ahs) telemedicine visits. patient was weaned off o2 at home on 1/12/22 chronic kidney disease stage ii baseline scr 1.3, presenting scr 1.4 recent history of venous thromboembolism patient is self prescribing reduced dose of eliquis. he should be on 5 mg twice daily

Lab Data
1/9/22 nasal swab positive sars-cov-2. negative influenza a/b normal electrolytes and cbc. bun 24 cr 1.38, ast 53, alt 51 cxr impression: 1. slight bilateral perihilar bronchitis suggested. 2. no infiltrate or effusion noted
List of symptoms
blood urea increased fatigue feeling abnormal alanine aminotransferase increased blood creatinine increased hypoxia cough dyspnoea aspartate aminotransferase increased pyrexia bronchitis chest x-ray abnormal influenza a virus test negative covid-19 sars-cov-2 test positive influenza b virus test dyspnoea exertional full blood count normal blood electrolytes normal covid-19 pneumonia acute respiratory failure
Patient Died?
Date Died
Birth defect
Vaccine Administered By:
Vaccine Purchased By:
Patient visit ER?
Patient Hospitalized?
Stay in hospital
Days in hospital
Permanent disability?
Current Illness