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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1134642

Case Details

VAERS ID: 1134642 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Male  
Location: California  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805025 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Confusional state, Dry skin, Head injury, Loss of consciousness, Musculoskeletal stiffness, Pallor, Skin warm, Vital signs measurement
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Dystonia (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Arthritis (broad), Hypoglycaemia (broad), Dehydration (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: None per patient
Current Illness: None per patient
Preexisting Conditions: None per patient
Allergies: None per patient
Diagnostic Lab Data: Unknown. Patient transported by EMS to hospital.
CDC Split Type:

Write-up: Patient received Janssen COVID-19 vaccine at 123pm on 3/25/2021. Patient directed to observation area and fell backwards out of chair at 127pm on 3/25/2021. After falling backwards out of chair patient had a full body stiffening episode and was noted to be bleeding from his head. Bleeding controlled with gauze held by an RN. Patient initially GCS 13 and unable to answer questions appropriately, manual blood pressure 118/60 HR 50 SpO2 89% on room air, patient pale and dry. Patients legs raised by RN and pressure to laceration on top of forehead continued to be held by RN. After 5-7 minutes patient GCS increased to 15 and he was alert and oriented x 4, manual blood pressure 114/60 HR 62 SpO2 97% on room air, patient pink warm and dry. Fire arrived on scene at 147pm and Ambulance shortly after. Fire and Ambulance given report by RN on site while other RN on site continued holding pressure to laceration on forehead with gauze.

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