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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1758871

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Case Details

VAERS ID: 1758871 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-13
Onset:2021-10-03
   Days after vaccination:204
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001B21A / 2 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Confusional state, Eye movement disorder, Feeling abnormal, Headache, Loss of consciousness, Musculoskeletal stiffness, SARS-CoV-2 test positive, Seizure, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Convulsions (narrow), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Arthritis (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hypertension, hypercholesteremia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This pleasant 70-year-old female presents with feeling poorly headaches and momentary loss of consciousness with confusion and at with test seizure x1---more detailed history per attending physician, is verified and reproduced below Tested positive on 10/03/2021 Presents with 70 year old female with a history of hypertension, hypercholesteremia presents to emergency room complaining of not feeling good for the past few days. Patient reports that she has been having intermediate episodes of headache. Patient reports that this morning she did not feel well after getting up. Spoke with patient''s husband which reports that she was sitting down on the sofa and became stiff, eyes rolled back and unresponsive for few seconds. Patient came into the emergency slightly confused. The onset was just prior to arrival. The occurrence was single episode. Witnessed: yes. The location where the incident occurred was at home. The character of symptoms is Eyes rolled back and body tensed up. The Postictal symptoms is confusion. The exacerbating factor is none. Risk factors consist of. Therapy today: none. Pregnancy symptoms none. Associated symptoms: headache. Associated injury: none. [1]


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