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

This is VAERS ID 1240234



Case Details

VAERS ID: 1240234 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-04-21
Onset:2021-04-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8731 / 2 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cold sweat, Disorientation, Head injury, Heart rate decreased, Loss of consciousness, Nausea
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), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: He felt nauseous, got up to go to kitchen sink and passed out for a few seconds. When I got to him, he was on the ground, eyes open, but seriously disoriented. He got up to the couch. He was very, very clammy and his heart rate was 44 bpm. I held three fingers for him to identify, he correctly answered. He has a small gash on his forehead. His heart rate came up to 70, 20 minutes after episode. Refused to go to urgent care.


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