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From the 1/7/2022 release of VAERS data:

This is VAERS ID 1034158

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Case Details

VAERS ID: 1034158 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-02-02
Onset:2021-02-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Abdominal pain, Blood test, Chest pain, Chills, Computerised tomogram thorax, Cough, Decreased appetite, Dizziness, Dyspnoea, Electrocardiogram, Feeling hot, Haematuria, Headache, Henoch-Schonlein purpura, Nasal congestion, Oedema, Oral discomfort, Pain, Petechiae, Proteinuria, Purpura, Rash, Rhinorrhoea
SMQs:, Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Vasculitis (narrow), Chronic kidney disease (broad), Hypersensitivity (narrow), Proteinuria (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

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? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Flonase, Metformin, losartan, flomax.
Current Illness: COVID-19 positive 01/07/2021.
Preexisting Conditions: Hypertention, irregular heart rate, diabetes.
Allergies: No known allergies.
Diagnostic Lab Data: Blood work, EKG, CT of the chest
CDC Split Type:

Write-up: Chills, headache, body aches, oral mucous membrane burning, runny and stuffy nose, feet "hot", cough, chest pain, difficulty breathing, crampy abdominal pain, rash - Henoch-Schonlien purpura purpura and petechiae, edema, proteinuria, hematuria, decreased appetite, dizziness


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