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From the 1/14/2022 release of VAERS data:

This is VAERS ID 903014

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Case Details

VAERS ID: 903014 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: West Virginia  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2020-12-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram normal, Confusional state, Dyspnoea, Haematuria, Laboratory test normal, Loss of consciousness, Neurological examination normal, Syncope, Tonic clonic movements, Unresponsive to stimuli, Urinary assistance device user, Urinary tract infection
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Convulsions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), 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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Finasteride 5mg qd, Terazosin 10mg qd, pantoprazole 40mg qd, memantine er 7mg qd, tramadol 50mg q8PRN, Xarelto 15mg BID, Aricept 5mg qd, synthroid 100mcg qd, mirtazapine 15mg qhs, centrum silver qd, calcium + vitamin D BID, melatonin 3mg qh
Current Illness: Patient has recurrent DVTs. Patient had ORIF (held Xarelto for a week prior to procedure) and then patient had pneumonia and DVT with PE prior to admission at Nursing Facility on December 10, 2020. UTI diagnosed after transport to hospital on December 16, 2020.
Preexisting Conditions: Patient has recurrent DVTs. Alzheimer''s (nutritional deficiencies secondary to this diagnosis as well), urinary retention, hypertension, anemia, hypothyroidism, BPH, insomnia.
Allergies: No known allergies
Diagnostic Lab Data: Patient had a CT scan, which came back normal. He was diagnosed with a UTI and administered Ceftriaxone at the hospital and discharged back to Nursing Home on Omnicef the same day.
CDC Split Type:

Write-up: Patient reported to CNA that they felt like they soiled their pants. CNA confirmed that patient did not soil themself and transferred patient to the restroom. While the patient was on the toilet attempting to have a bowel movement the CNA reported patient had 10 seconds of tonic clonic behavior and then went unresponsive and then back to tonic clonic behavior. This happened 3 times prior to getting patient put back into his bed. Patient went unconscious after last episode while on bed for a more extended period of time while a STAT page was called. Physical Therapist and Aid sternal rubbed him and he had gasp and woke up. Prior to and immediately following the episode his vitals were within normal limits. Neuro exam was unremarkable after patient came to. When he woke up he knew his name, date, and day of the week. He was only confused to where he was. Patient was agreeable to be transported out. EMS was called and transported the patient to Hospital. Patient displayed no seizure activity or neurological deficits in ER. Patient had a CT scan, which came back normal. Virals remained within normal limits and laboratory values were noncontributory. He was diagnosed with a UTI due to the presence of hematuria associated with a syncopal episode. Patient had a Foley catheter upon admission to the nursing home. Patient was administered Ceftriaxone at the hospital and discharged back to Nursing Home on Omnicef the same day. Patient is back at nursing home facility and has not displayed any additional signs of seizure. He is stable and Foley catheter has been removed. Facility spoke to wife who reported that patient did not have a seizure history.

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