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From the 5/7/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1214980

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Case Details

VAERS ID: 1214980 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Oklahoma  
Vaccinated:2021-04-12
Onset:2021-04-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Altered visual depth perception, Arthralgia, Aura, Blood test normal, Cardiac imaging procedure abnormal, Chest X-ray normal, Chest pain, Computerised tomogram abnormal, Dizziness, Dysgeusia, Electrocardiogram normal, Feeling abnormal, Heart rate irregular, Myocardial necrosis marker normal, Nausea, Pain in extremity, Paraesthesia, Parosmia, Pericarditis, Retching, Scan with contrast abnormal, Tremor
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Dementia (broad), Convulsions (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Vestibular disorders (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations: Tetanus hives, vomiting age 32
Other Medications: Synthroid, Xanax, Aspirin, Atenolol, Amlodipine, Omeprazole,
Current Illness: ear infection diagnosed and treated almost 4 weeks before Simvastatin, Diazepam, Cephalexin, Tetracycline. Latex. Contrast Dye (esp. iodine ones), vaccines. Cleaners, insect sprays Paint fumes, Shellfish.
Preexisting Conditions: paralyzed vocal cord, hypothyroidism, hypertension
Allergies: Penicillins, Erythromycin, Oxycodone Acetaminophen, Niacin, Gabapentine, Simvastatin, Fluticasone Propionate
Diagnostic Lab Data: 4/12-13/21 EKGs, chest X-rays and blood tests normal, cardiac enzyme tests showed no heart attack. 4/13/21 Heart CT showed inflammation of the pericardium. The Cardiologist said it m was caused by the Covid 19 immunization. I was placed on colchicine for 2 weeks. I was given follow-up appointments with my primary care physician and the cardiologist. These are results my husband and I were told during my hospital stay but I do not yet have the documentation in hand.
CDC Split Type:

Write-up: Strange odor a few minutes after injection, followed by bitter taste, then nausea and spaciness. Dizzyness, with vision looking 2D and flat by 15 minutes. Told Pharmacist, of spaciness who said stay as long as I wanted. Left at 30 minute point, still spacy and nauseous. Spaciness ended by an hour with nausea off and on. Chest pain - began around 7pm, continued to expand in area of chest, sharp stabbing pain later, pain from just above left elbow to hand and tingling of fingers, pain lower left leg and tingling of left foot. Irregular heart rate at different times. Checked into emergency room at 11:00. IV inserted, placed on continual heart and oxygen monitors, EKGs, chest X-rays (2), blood tests (3). Admitted to hospital sometime during the night. Given IV medications to counteract IV contrast allergy. These medications caused full body shakes, eyesight auras and extreme nausea with gagging. Heart CT taken with IV contrast. Discharged around 3:00 PM.


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