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

This is VAERS ID 1376028



Case Details

VAERS ID: 1376028 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: California  
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 044B21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest discomfort, Hypoaesthesia, Presyncope
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Sexual dysfunction (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: MMR
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: self reported seizure to first dose of MMR vaccine at 1 years old
Diagnostic Lab Data: BP of 151/97 and HR 94
CDC Split Type:

Write-up: patient started feeling numbness in their finger, toes, arms, and legs followed by chest pressure and near syncopal episode. Blood pressure was taken and was 151/97 with a heart rate of 94. Ambulance arrived, took vitals at pharmacy, after which patient was taken to the nearby hospital.


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