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

This is VAERS ID 1376410



Case Details

VAERS ID: 1376410 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0176 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Confusional state, Dizziness, Fatigue, Flushing, Hyperhidrosis, Hypophagia, Hypotension, Lethargy, Loss of consciousness, Syncope, Tremor, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Confusion-Mild, Systemic: Dizziness / Lightheadness-Mild, Systemic: Exhaustion / Lethargy-Mild, Systemic: Fainting / Unresponsive-Mild, Systemic: Flushed / Sweating-Medium, Systemic: Hypotension-Medium, Systemic: Shakiness-Mild, Additional Details: No immediate reaction after vaccine administration. He was sweating profusely and momentarily lost consciousness/not responsive. He came around after a minute or two. He was shaking, so we got him down onto the floor & had him roll to his left side. We called the paramedics to check him out. He was responsive & was answering all questions. He said that he was tired. We questioned him about his medication schedule & he said he takes his blood pressure meds in the pm. He had not eaten.


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