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

This is VAERS ID 1084058



Case Details

VAERS ID: 1084058 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: Connecticut  
Vaccinated:2021-03-06
Onset:2021-03-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Dyspnoea, Fall, Post vaccination syndrome, Syncope, Tonic clonic movements, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (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: Insulin
Current Illness:
Preexisting Conditions: Diabetes
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Post vaccination feeling of breath doom, walking to door to get fresh air. Syncope, fell to floor. No head injury. Post vaccination syncope, brief generalized tonic-clonic movement followed by emesis. Blood glucose 114, BP 120/80, HR90, O2 Sat 96%.


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