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

This is VAERS ID 1075246



Case Details

VAERS ID: 1075246 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-03-04
Onset:2021-03-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chest pain, Electrocardiogram normal, Fall, Flank pain, Head injury, Hypotension, Laboratory test normal, Neck injury, Renal function test normal, Syncope, Troponin I normal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tramadol, Diltiazem, Potassium, Magnesium, Protonix, Dorzolamide, Tamsulosin, Atorvastatin, Xarelto, Metoprolol, Oxycontin, Oxycodone, Prazosin
Current Illness: Unknown
Preexisting Conditions: Hepatits C, Anxiety, A-Fib, A-Flutter, Kidney Disease, Diabetes, GERD, Hypotension, Cardiac Stent
Allergies: Januvia, Lyrica
Diagnostic Lab Data: 3/4/21, Emergency Department: Vital Signs: Noted to be hypotensive EKG: Paced, Heart Rate 84, confirmed pacer functioning normally Labs: Within Normal Limits, Troponin Negative, Renal Function = baseline Blood pressure improved with IV Fluids
CDC Split Type:

Write-up: (3) syncopal episodes following vaccination, one of which resulted in a fall with direct injury to the base of neck, head, and right flank. Pt reported chest pain prior to syncope.


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