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From the 6/4/2021 release of VAERS data:

This is VAERS ID 1228882



Case Details

VAERS ID: 1228882 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-04-10
Onset:2021-04-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Dizziness, Heart rate decreased, Loss of consciousness, Pallor, Presyncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (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? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: per patient: see last box (additional items) Prescriptions taken at time of vaccine as per patient: 1) pantoprazole 40mg 2) fluoxetine 10mg 3) atorvastatin 20mg 4) aspirin 81mg 5) mometasone nasal spray 6) fluoxetine 10mg 7) mvi 8) calcium
Current Illness: endoscopy 3/31/21 which she reported"fungus growing in throat"
Preexisting Conditions: chronic cough, acid reflux
Allergies: Scallops
Diagnostic Lab Data: need to obtain from patient.
CDC Split Type:

Write-up: This is a spouse. Medical Center do not have this patient''s medical record and is reporting the reaction on her behalf based on available information. Patient reported she was having brunch 4/11/21 am and started feeling very dizzy (was dining outside) and her son informed her that she was very pale. Her stomach started to rumble and threw up. Son called the ambulance due to "low pulse" and "loss of consciousness". She was treated at ER with iv fluids and anti-nausea medicine and was discharged that day (4/11/21) around 1pm with diagnosis of "Vagal Response". She recalled being in the ambulance around 4/11@11:10am.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1228882


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