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

This is VAERS ID 1078314

Case Details

VAERS ID: 1078314 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Ohio  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805020 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, Chills, Feeling cold, Hypotension, Nausea, Panic attack, Tremor
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (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? No
Previous Vaccinations:
Other Medications: Not known. Patient was not a customer of pharmacy at the time of admin.
Current Illness: Pt stated a cut on finger which he was taking antibiotics for; however, no other issues within last month.
Preexisting Conditions: Pharmacy unaware of health conditions. Pt has omitted that from intake form. No previous care given to pt at time of incident.
Allergies: NKDA
Diagnostic Lab Data: ER evaluation 3/6/2021. Follow-up from medical assistant at ER with pharmacist concluded pt was anxious and nervous of side effects of vaccine. This caused somewhat of a "panic attack" causing multitude of symptoms. Vaccine believed to cause nausea.
CDC Split Type:

Write-up: Pt was held for 15 minutes. Past 15 minutes, patient was ready to leave but complained of nausea. Asked pt to stick around. Took blood pressure. It was low ~90/55. Asked again how he was doing, stated okay but feeling chills/cold. Started to shake uncontrollably. Ask pt if he thought a hospital visit was necessary; he stated no at that time. Decision was made to call squad; BP was elevated now and still shaking. Transported at that time.

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