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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1025497

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Case Details

VAERS ID: 1025497 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-19
Onset:2021-01-27
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Activated partial thromboplastin time prolonged, Anaemia, Coagulopathy, Disseminated intravascular coagulation, Fibrin D dimer increased, Haematocrit decreased, Haemoglobin decreased, Hepatic enzyme increased, International normalised ratio increased, Platelet count decreased, Prothrombin time prolonged, Tachycardia, White blood cell count increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

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: ASA 81 mg, Atenolol, Lasix, Terozosin, Lovastatin, Amlodipine, Bacitracin oint
Current Illness: None
Preexisting Conditions: Afib, T2DM, Hyperlipidemia, BPH, CKD stage 3, Peripheral Edema, Pulm HTN,
Allergies: None
Diagnostic Lab Data: WBC 17.4 Hgb decreased 10.3 HcT 31.8 Plts 19 LFT all elevated ddimer 2.48 (0-0.5) PT 16.3 PTT 41.4 INR 1.3
CDC Split Type:

Write-up: Disseminated Intravascular Coagulation Platelets = 19 Elevated Liver Enzymes. Bleeding coagulopathy Anemia Tachycardia Elevated white blood count


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