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

This is VAERS ID 1331147



Case Details

VAERS ID: 1331147 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-05-19
Onset:2021-05-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 043A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Disorientation, Dizziness, Loss of consciousness, Muscle twitching
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Dyskinesia (broad), Dystonia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), 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? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: N?A
Preexisting Conditions: N/A
Allergies: NKDA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient started feeling lightheaded about 2- 3 mins of vaccine administration. Patient moved from the chair to the floor because he felt like he was going to pass out. Patient passed out for about 30 seconds, slight twitching during episode and then came through. He was a bit disoriented but alert, we had him stick around until his wife came and picked him up.


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