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From the 6/4/2021 release of VAERS data:

This is VAERS ID 1261714



Case Details

VAERS ID: 1261714 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-04-10
Onset:2021-04-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK RA / -

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Haematemesis, Headache, Nausea, Pain in extremity, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Tendinopathies and ligament disorders (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? No
Previous Vaccinations:
Other Medications: FLUOXETINE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021399153

Write-up: with small amounts of blood in vomit; Pain in right arm; back and head ache; back and head ache; nausea; vomiting; This is a spontaneous report from a contactable consumer (patient). A 25-years-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration in the right arm on 10Apr2021 at 13:15 (lot number and expiration date: unknown) at a single dose for COVID-19 immunization. Medical history was not reported. Concomitant medication included fluoxetine (FLUOXETINE) taken for an unspecified indication, start and stop date were not reported. The patient had known allergies with Nyquil. The patient had no other vaccine in four weeks, had no COVID prior to vaccination and was not tested post vaccination. The patient experienced pain in right arm, back and head ache, nausea and vomiting, with small amounts of blood in the vomit on 11Apr2021 at 02:00. No treatment was administered for the events. The events were resolving at the time of the report. Information about lot/batch has been requested.


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