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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1005180



Case Details

VAERS ID: 1005180 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-25
Onset:2021-01-29
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Blood test, Catheterisation cardiac, Chest X-ray, Computerised tomogram, Echocardiogram, Electrocardiogram, Myocarditis, Scan with contrast
SMQs:, Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Anxiety
Allergies: Latex
Diagnostic Lab Data: Cardiac catheterization, heart ultrasound, chest x ray, EKG, Cat Scan with IV, bloodwork
CDC Split Type:

Write-up: Diagnosed with myocarditis 4 days after injection. Hospitalized for 1 day.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1005180

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