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

This is VAERS ID 1181410



Case Details

VAERS ID: 1181410 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-04-08
Onset:2021-04-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 043A21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Hypopnoea, Hypotension, Pallor, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: Blood pressure was taken after the epipen was administered it was 110/52 on 4/8/2021
CDC Split Type:

Write-up: The patient received the vaccine, proceeded to the observation chair to wait for 15 minutes. The wife informed us: "He is having a reaction" we immediately went over to assess the situation. The patient was shallow breathing, unresponsive, low blood pressure, and very pale. The patient was slumped in the chair and then brought to the ground. An EpiPen was administered and 911 was called. The EMTs then came and did an assessment as the patient was able to then sit up. They took him to the hospital for further observation.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1181410

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