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

This is VAERS ID 1470563



Case Details

VAERS ID: 1470563 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: Maryland  
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 (MODERNA)) / MODERNA 047C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure decreased, Cold sweat, Dizziness, Dyskinesia, Electrocardiogram normal, Fall, Full blood count normal, Head injury, Headache, Loss of consciousness, Metabolic function test, Musculoskeletal stiffness, Pallor, Troponin I normal
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), Dyskinesia (narrow), Dystonia (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Arthritis (broad), Hypoglycaemia (broad), Dehydration (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: Denies taking any medications
Current Illness: None reported
Preexisting Conditions: After incident occurred pt stated he had a seizure about 10 years ago and has also fainted in the past.
Allergies: NKA
Diagnostic Lab Data: While at hospital pt had an EKG which was normal. CBC, CMP and Troponin I was drawn - all normal.
CDC Split Type:

Write-up: Pt received 2nd Moderna vaccine at 10:07am. Within 2 minutes of injection pt stated he felt dizzy and put his head down and then he jerked to his right, fell out of his chair and hit the right side of his head on the floor; his head bounced hard off the floor and he was lying face down unconcious. Attempted to break pt''s fall but this nurse ended up falling too. Was able to turn pt over onto his back being very careful with his head and neck. At that point pt''s entire body went stiff and he "woke up" and gasped and had a "post-icteric" stare. Placed pt on his back in an attempt to wake him up more. 10:10am: BP: 118/70, Pulse 47, pulse ox 98%. He became more coherent. Stated the side of his head was hurting ("5-7" on pain scale). No active bleeding or swelling observed. PERLLA. Pt very pale and clammy. 911 called for eval and transport to Emergency Room. Vitals taken every few minutes which remained fairly stable (BP at it''s lowest was 94/62, and pulse ranged from 47-64. EMS arrived and transported pt to UMPC.


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