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

This is VAERS ID 1181417

Case Details

VAERS ID: 1181417 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Female  
Location: West Virginia  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 LA / IM

Administered by: School       Purchased by: ?
Symptoms: Dizziness, Hypoaesthesia oral, Metamorphopsia, Nausea, Palpitations, Paraesthesia oral, Vital signs measurement
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Retinal disorders (narrow), Vestibular disorders (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:
Current Illness:
Preexisting Conditions:
Allergies: Amoxicillin, Diflucan
Diagnostic Lab Data: Patient transferred to ED via EMS.
CDC Split Type:

Write-up: Patient approached this RN stating that she felt lightheaded and nausous. Assisted patient to floor, lying flat with feet elevated. Pt began complaining of "dark vision," swelling sensation and tingling in tongue, numbness and tingling in bilateral upper extremities and heart racing. Alerted physician. EMS notified for transport. Vitals obtained 1212- BP 90/48; HR 139; o2 98%; RR 22. Epipen 0.3mg LOT 0FM400 EXP 12/31/21 administered to R thigh at 1215 per physician order. 20g IV inserted into R-AC. 125mg Solumedrol LOT DA6800 EXP 6/2022 (administered 1217) and 25mg Diphenhydramine LOT 049343 EXP 4/2021 (administered 1220) administered IV push per order. Vitals obtained 1220- BP 122/50; HR 123; o2 99%. EMS arrived at 1225 to transport patient to ED.

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