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

This is VAERS ID 1470395



Case Details

VAERS ID: 1470395 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Female  
Location: New York  
Vaccinated:2021-07-13
Onset:2021-07-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Foaming at mouth, Gaze palsy, Loss of consciousness, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), 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: Unknown
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Blood pressure 100/58
CDC Split Type:

Write-up: Patient lost consciousness for approximately 30 seconds immediately after receiving the vaccination. Her eyes and head rolled back, and there was a small amount of foam coming from the mouth. The patient did not enter anaphylaxis or stop breathing at any point. A pharmacy technician called 911 while the pharmacist moved the patient to the ground to lay down and monitor for further reaction. The patient was provided with food and water. EMS arrived on the scene approximately 10 minutes later. They took the patient''s pulse and blood pressure, which was slightly low (100/58 - I believe). The paramedics determined that the patient experienced syncope and there was no need for further evaluation at the facility. The patient remained in the pharmacy for about an hour until she felt strong enough to go home.


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