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

This is VAERS ID 1376671



Case Details

VAERS ID: 1376671 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Female  
Location: Missouri  
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 (MODERNA)) / MODERNA 049C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Blood pressure decreased, Dizziness, Heart rate increased, Hypotension, Injection site pain, Syncope, Tachycardia, Tremor, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Site: Pain at Injection Site-Mild, Systemic: Dizziness / Lightheadness-Medium, Systemic: Fainting / Unresponsive-Medium, Systemic: syncope and tonic presentation for 5-10 seconds, increased pulse and decreased blood pressure-Severe, Systemic: Hypotension-Mild, Systemic: Shakiness-Medium, Systemic: Tachycardia-Mild, Systemic: Weakness-Medium, Additional Details: paramedics called and within 15 minutes patient was able to stand, sit and speak normally and her color had come back. BP and pulse normalized and after 30 minutes of observation by RPh and paramedic was walked out of store by paramedic.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1376671


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