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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1310558



Case Details

VAERS ID: 1310558 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: California  
Vaccinated:2021-04-30
Onset:2021-05-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-05-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain upper, Anaemia, Chills, Confusional state, Depressed level of consciousness, Discoloured vomit, Faeces discoloured, Gastrointestinal haemorrhage, Haematemesis, Melaena, Mental status changes, Metabolic encephalopathy, Nausea, Pain, Pyrexia, Restlessness, Upper gastrointestinal haemorrhage, Vomiting
SMQs:, Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (narrow), Dementia (broad), Akathisia (broad), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: presented with altered mental status and hematemesis and admitted for metabolic encephalopathy and severe anemia secondary to upper GI bleeding. Patient was in her usual state until 3 days prior to admission when she had her 2nd dose of COVID-19 vaccination that she started to experience generalized body aches accompanied by fever and chills a day later. She also developed epigastric pain accompanied by nausea and vomiting which was later noted to have dark colored vomitus. One day prior to admission, she went to Urgent Care and was given Famotidine. Yesterday, she was found to be obtunded with dark colored vomitus and black tarry stools and was sent to ER where she was noted to have severe anemia. GI consult called for further evaluation. Patient still confused and restless. History taken from chart and from nursing staff. Currently, no more hematemesis and no BM.


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