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

This is VAERS ID 1763952

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Case Details

VAERS ID: 1763952 (history)  
Form: Version 2.0  
Age: 22.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-10-04
Onset:2021-10-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30145BA / UNK LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Chest pain, Electrocardiogram normal, Heart rate increased, Presyncope
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (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: None
Current Illness: None
Preexisting Conditions: Hemorrhoids
Allergies: None
Diagnostic Lab Data: EKG 4 Oct 2021 - normal
CDC Split Type:

Write-up: 4:30 PM same day, sudden near syncope, rapid heartrate, chest pain


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