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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1371822

Case Details

VAERS ID: 1371822 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: Alabama  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Gaze palsy, Hyperhidrosis, Loss of consciousness, Nausea, Pallor, Refusal of treatment by patient
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), Ocular motility disorders (narrow), 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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: Peanuts, Shellfish
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Approximately 5 minutes after receiving the vaccine, the patient passed out and his eyes rolled back (possible seizure activity). This activity lasted for approximately 1 minute. Patient also felt dizzy, sweaty, nauseous, and became pale. Patient was given a cold ice pack to lower his body temperature. Patient was also given crackers for nausea, and a bag just incase he had to vomit. Patient''s mother was also here to tend to the patient. The mother also gave him clear fluids (sprite) to help with the nausea. After approximately 10 minutes, the patient was able to stand without feeling dizzy. He left the store with his mother to be watched closely (His mother is a nurse.) They also refused emergency medical services.

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