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From the 4/23/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1213180

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Case Details

VAERS ID: 1213180 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Laboratory test, Loss of consciousness, Pneumothorax traumatic, Rib fracture
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Patient visit to ED, no chart notes acquired by myself.
CDC Split Type:

Write-up: Possible vasovagal syncope. She "blacked out" in bathroom and fell. Broke ribs and had pneumothorax due to the fall. Had a couple other episodes of "blacking out" in the next 48 hours. Went to E.D. for injury. Work up was done, she mentioned she had just had the vaccine a few days prior and no VAERS was submitted by ED, they dismissed it. According to patient workup was done to detect embolism or hemorrhage and none was found.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210423&IDNUMBER=1213180


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