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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1376008



Case Details

VAERS ID: 1376008 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033B21A / 7+ LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Pruritus, Swelling face
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: Demerol and food allergies unknown and bees
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received moderna vac covid 19 at 4:38p in left arm. Pt was instructed to wait for 15 minutes as she answered "no" to any allergies. After the 15 minutes were up, patient continued to shop. She came back to the pharmacy around 5:08pm, complaining of feeling itching without any visible symptoms. Patient was provided with benadryl (diphenhydramin) 50mg (approx 5:10pm) as she stated her weight was over 100 Ibs. I observed pt and started to discuss with patient signs of generalized anaphylaxis, at which time patient informed me that she did have food allergies but did not think it was important to put on the form as she is not even sure what she is allergic to. Approx 5:16pm , pt stated she felt face swelling. Associate was instructed to call 911 immediately and inform mgmt of code white and location. One dose of epinephrine 0.3mg was administered intramuscularly in patient''s left thigh. Patient was observed and around 5:21pm, pt stated she had no more anaphylaxis reactions occurring. Approx 5:25pm, EMS arrived at which time patient was stable. Patient''s vitals were stable, and EMS recommended for pt to be seen in the ER for further evaluation. Pt was placed on stretcher and wheeled out by EMS at aprox 5:40pm.


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