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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1172613



Case Details

VAERS ID: 1172613 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-04-06
Onset:2021-04-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure measurement, Cognitive disorder, Dizziness, Fall, Heart rate, Loss of consciousness
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), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Vestibular disorders (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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: 80/46 mmHg w/ 60bpm. Patient reports feeling "hot" and was visibly sweating. Skin was pale.
CDC Split Type:

Write-up: Patient reported feeling dizzy. Advised the patient to remain seated. Patient lost consciousness and fell to the ground. Sat patient upright and began screening for medical history. Cognition was low and speech was quiet. Measured blood pressure and pulse (80/46 mmHg pulse of 60bpm).


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1172613

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