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

This is VAERS ID 1265993



Case Details

VAERS ID: 1265993 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-04-05
Onset:2021-04-11
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac stress test, Chronic obstructive pulmonary disease, Dyspnoea, Headache, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), COVID-19 (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, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: VITAMINS [ASCORBIC ACID;ERGOCALCIFEROL;NICOTINAMIDE;RETINOL;RIBOFLAVIN;THIAMINE HYDROCHLORIDE]; ELDERBERRY [SAMBUCUS NIGRA]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure high; COPD; Diabetes
Allergies:
Diagnostic Lab Data: Test Name: stress test; Result Unstructured Data: Test Result:Results Not Provided; Test Date: 20210408; Test Name: Nasal Swab; Result Unstructured Data: Test Result:Negative
CDC Split Type: USPFIZER INC2021409963

Write-up: 6 days later I had breathing problems , I have copd. But I had severe headaches n breathing problems increased.; 6 days later I had breathing problems , I have copd. But I had severe headaches n breathing problems increased.; 6 days later I had breathing problems , I have copd. But I had severe headaches n breathing problems increased.; This is a spontaneous report from a contactable consumer (patient). A 55 years old non pregnant female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE) via an unspecified route of administration, administered in Arm Left on 05Apr2021 at 16:00 (Batch/Lot number was not reported) as SINGLE DOSE for Covid19 immunization. Medical history included diabetes mellitus, chronic obstructive pulmonary disease, hypertension. Concomitant medications included high blood pressure medication (details not provided); ascorbic acid, ergocalciferol, nicotinamide, retinol, riboflavin, thiamine hydrochloride (VITAMINS [ASCORBIC ACID;ERGOCALCIFEROL;NICOTINAMIDE;RETINOL;RIBOFLAVIN;THIAMINE HYDROCHLORIDE]); elderberry [Sambucus nigra] (ELDERBERRY [SAMBUCUS NIGRA]). The patient previously took hydrocodone and experienced drug hypersensitivity. Historical Vaccine includes Flu Shot on 11Feb2021 at the age of 55 years old (Flu vaccine given within 4weeks, other vaccine 4weeks vaccine location Left arm). On 11Apr2021 at 12:00, the patient experience ''6 days later I had breathing problems, I have COPD. But I had severe headaches and breathing problems increased''. The patient was hospitalized for 3 days. Treatment was given included ''High blood pressure meds, rest, stress tests''. The patient underwent lab tests and procedures which included Sars-cov-2 test Nasal Swab: results negative on 08Apr2021, stress test results not provided on an unspecified date. The clinical outcome of the events were recovering. Information about lot/batch number has been requested.


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