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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1686001

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Case Details

VAERS ID: 1686001 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Pennsylvania  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: School       Purchased by: ?
Symptoms: Dizziness, Fatigue, Loss of consciousness, Muscle rigidity, Nausea, Pallor, Staring, Tremor, Urinary incontinence
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: per patient none
Current Illness: per patient none
Preexisting Conditions: per patient no medical conditions
Allergies: per patient none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine within a minute of sitting down she became pale and had a blank stare. Her arms and legs became extremely rigid and she became to shake. This lasted for 15 seconds, patient regained consciousness she had voided herself, she complained of being tired and dizzy. She laid down and drank water for 20 minutes, she tried to stand up and quickly felt she needed to vomit. Patient stated she had not eaten or drank that morning. I used my professional judgement and at this time I called an ambulance. Student with the assistance of her boyfriend walked outside the clinic and refused to go into the ambulance. She stated she felt better as soon as he stepped outside. Patient was contact today 09/09/21 by the medical assistant and ensured she was feeling well without any other adverse reaction.

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