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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1231977



Case Details

VAERS ID: 1231977 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-04-20
Onset:2021-04-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001C21A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Dyspnoea, Electrocardiogram, Fall, Lethargy, Miosis, Nausea, Pallor, Unresponsive to stimuli, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Plavix, warfarin, unknown others.
Current Illness: Patient denies
Preexisting Conditions: Prostate Cancer
Allergies: PCN
Diagnostic Lab Data: EKG by EMS 4/20/21
CDC Split Type:

Write-up: Lethargic, pale, glassy and pinpoint eyes to unresponsive, limp and falling to the right side. Client laid on ground due to unresponsiveness and unable to obtain vitals, client gasped when laid flat then reported nausea, rolled to side client started vomiting. EMS called, EKG ran, client refused services. Walked out of clinic.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1231977


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