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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1375944



Case Details

VAERS ID: 1375944 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 049C21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood glucose normal, Dizziness, Nausea, Tremor
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient has no record with us, but patient mentioned that he suffers from thyroid.
Current Illness: None
Preexisting Conditions: None
Allergies: It is not allergic.
Diagnostic Lab Data: The doctor informed her that the reaction he had was due to the fright he had.
CDC Split Type:

Write-up: Patient arrives very nervous to get the vaccine, she was very scared. She was given the vaccine at 3:10PM and at 5 minutes (3:15PM) she begins to complain that she is dizzy, then says she feels nauseous and begins to shake. I proceed to take his blood pressure and he had 128/89 and a pulse at 126. He called 911 and when they arrived they checked his blood pressure and sugar levels and everything came out normal. Paramedics took her to the hospital. At 6:00PM, an Medical Staff came to inform us that she had contacted the patient and she informed her that she was fine and that the doctor told her that it was the fright that caused the reaction.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1375944


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