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

This is VAERS ID 1172751



Case Details

VAERS ID: 1172751 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Missouri  
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 / N/A LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Hyperhidrosis, Hypotension, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), 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: COULD NOT GIVE ANY DETAIL
Other Medications: PATIENT REPORTED TAKING ONLY 2 MEDICATIONS FOR BACK PAIN AT TIME OF VACCINATION, BUT COULD NOT THINK OF WHAT IT WAS NAMED. THOUGHT ONE OF THE MEDICATIONS WAS MELOXICAM, WHICH HE HAD TAKEN THAT MORNING. ENTIRE HISTORY UNKNOWN.
Current Illness: PATIENT PUT NO ON ALL QUESTIONS ON VAR, BUT UPON QUESTIONING VERBALLY, PATIENT REPORTED ONLY HEALTH CONDITION AS BACK PAIN. DENIED ALL OTHER HEALTH CONDITIONS OR ILLNESSES.
Preexisting Conditions: BACK PAIN
Allergies: NKDA
Diagnostic Lab Data: BLOOD SUGAR 4/6/21, BLOOD PRESSURE 4/6/21, PULSE OX 4/6/21 TAKEN BY PARAMEDICS IN PHARMACY. FURTHER TREATMENT OR TESTS/LABS UNKNOWN.
CDC Split Type:

Write-up: PATIENT REPORTED STARTING TO FEEL FAINT AND BLACKED OUT FOR 30-45 SECONDS WITHIN 1-2 MINUTES AFTER RECEIVING VACCINE. HE EXPERIENCED DIAPHORESIS AND FELT HE WAS GOING TO PASS OUT. DENIED SOB, HIVES, SWELLING, STOMACH PAIN. REPORTED HE HAD NO HEALTH CONDITIONS BUT THAT THIS HAD HAPPENED TO HIM BEFORE BUT THIS WAS WORSE - SAID HE HAD NOT EATEN THAT DAY OR DRANK WATER. RPH GAVE PATIENT WATER AND LEMONADE ABOUT 2 MINUTES OR SO INTO REACTION AND PATIENT SAID HE STARTED TO FEEL BETTER AFTERWARD. 911 WAS CALLED AND PARAMEDICS RESPONDED WITH TAKING BLOOD PRESSURE AND BLOOD SUGAR - BP A LITTLE LOWER THAN AVERAGE BUT UNSURE WHAT PT TYPICALLY RAN AT. BLOOD SUGAR NORMAL AFTER DRINKING LEMONADE. PATIENT TAKEN TO ER FOR FURTHER CARE


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