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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1328747

Case Details

VAERS ID: 1328747 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Male  
Location: California  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: Hypoaesthesia, Lethargy, Loss of consciousness, Nausea, Pallor, Palpitations, Paraesthesia, Presyncope, Staring, Tremor, Unresponsive to stimuli, Vision blurred, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Cardiomyopathy (broad), Lens disorders (broad), Retinal 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? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness:
Preexisting Conditions: history of asthma, resolved
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client complained of palpitations 20mins after receiving vaccine. First vitals at 1637: pulse 147, blood pressure 124/78, oxygen 99%. Alert and oriented x4. Client denied chest pain, shortness of breath, headache, or blurry vision. Per Father client had asthma that resolved years ago, no current medications or allergies. Pulse at 1638: 127. Vitals at 1640: blood pressure 118/70, pulse 124, oxygen 100%. Per client palpitations improving. Alert and oriented. 1644: client hands shaking, client stated only had breakfast. RN brought client juice and snack. Client began to eat. Father denied client having diabetes. 1648 vitals: blood pressure 122/80, pulse fluctuating from 110-low 120s, oxygen 97%. Symptoms the same with new onset o blurry vision, per client could not focus image. PHN offered Father to call paramedics for further assessment and he declined. PHN advised for client to follow up with provider. Per Father client''s sugar lowers when he skips meals. PHN asked Father is he has followed up with provider or checks client''s sugar at home, Father denied. Per Father he knows his son and "he needs to eat or sugar goes low". At 1656 client stated he wanted to vomit, emesis bag given. 1658 client pale, PHN asked client how to was feeling. Per client feeling like he "was going to pass out". At 1700 client stated he could not feel legs, RN assessed for sensory and motor. Per client felt like legs "were asleep". PHN assessed for level of consciousness, client unable to answer, client lethargic. 1701 client lost consciousness. PHN and RN lowered client to floor from chair. EMT called 911 at 1703. RN did sternal rub, client unresponsive, breathing normal, pupils reactive. 1704 client woke up with urge to vomit. PHN and RN turned client on side. EMT able to place emesis bag near. Client had 1 small vomit episode. Client''s eyes open, blank stare, not answering questions. At 1707 client went unresponsive again. Paramedics arrived at 1709 and assumed care. Client transported to hospital at 1717

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