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

This is VAERS ID 1041500

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Case Details

VAERS ID: 1041500 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-01-30
Onset:2021-02-14
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA NOT AVAILABLE / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Angiogram, Angiogram abnormal, Anion gap, Blood creatinine normal, Blood glucose increased, Blood potassium decreased, Blood sodium decreased, Blood urea normal, COVID-19, Dizziness, Dyspnoea, Fall, Fibrin D dimer increased, Haematocrit normal, Haemoglobin normal, Neutrophil percentage, Platelet count normal, Pneumonia, Presyncope, Pulmonary embolism, Pulmonary infarction, SARS-CoV-2 test positive, Thrombectomy, Troponin increased, Urine analysis normal, Walking aid user, White blood cell count increased
SMQs:, Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Hypokalaemia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: calcium-vitamin D extended release, 2 Tab, PO, Daily Combigan ophth soln, 1 Drop, Eye, Left, Daily multivitamin, adult tab, PO, Daily Pred Forte 1% ophthalmic suspension, 1 Drop, Eye, Both, Daily Restasis 0.05% ophthalmic emulsion, 1 Dr
Current Illness: None
Preexisting Conditions: Cataracts
Allergies: No known allergies
Diagnostic Lab Data: CT Angio on 02/15/21 at 11:10 pm: 1. Acute bilateral pulmonary artery emboli with saddle embolus, mild right heart strain, and right upper lobe pulmonary infarct. Interventional radiology consultation may be considered for pulmonary embolectomy. 2. Mild multifocal pneumonia, high confidence features for COVID infection. Correlate clinically. Thrombectomy on 02/16/21
CDC Split Type:

Write-up: Patient presented to the ED 2/15/2021 for shortness of breath and lightheadedness with near syncopal event. The pt reported 2 episodes of SOB and lightheadedness, with the second one as the more severe. On her second episode, she felt severe shortness of breath, tried to walk quickly to her bed with her walker, and fell into her bed. CT angio demonstrated acute saddle PE, mild right heart strain, RUL pulmonary infarct, and mild multifocal pneumonia with suspicion of COVID; IR was consulted and suggested thrombectomy due to the severity of the embolism. In the ED, she was started on heparin drip and put on low-flow NC oxygen without distress. Upon arrival to the emergency department her vital signs were significant for T 36.4, SBP 120/81, HR 95 bpm, NSR, RR 18, FiO2 94% on room air. Her oxygen increased to 98% on 2 L nasal cannula. Her laboratory values revealed WBCs 15.1, Hb 14.4, HCT 43.4, PLT 321, neutrophils 68.8%, D-dimer 4642, NA 134, K3.4, anion gap 9, BUN 17, creatinine 1.00, glucose 163, troponin elevated 0.12, 0.25, and 0.41, urinalysis is unremarkable, COVID-19 swab is positive. A thrombectomy was performed 2/16/2021. She tested COVID positive on 2/16/2021 and her SpO2 remains in the high 90s with dips to mid 80s while talking, but she does not currently experience any SOB.


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