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

This is VAERS ID 1400178



Case Details

VAERS ID: 1400178 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-06-02
Onset:2021-06-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest X-ray, Differential white blood cell count, Dysphagia, Dyspnoea, Full blood count, Metabolic function test, Prothrombin time, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: ACCU-CHEK AVIVA PLUS strip TEST BLOOD SUGAR TWICE DAILY OR AS DIRECTED BY PROVIDER aspirin 81 MG tablet 1 QD atenolol (TENORMIN) 50 MG tablet Take 1 tablet by mouth daily. atorvastatin (LIPITOR) 40 MG tablet Take 1 tablet by mouth daily.
Current Illness: Diabetes Mellitus type 2
Preexisting Conditions: DM2
Allergies: Septra Sulfa
Diagnostic Lab Data: TELEMON BY PHILIPS Routine 06/03/2021 2:00 PM XR CHEST 1V PORTABLE ASAP 06/03/2021 1:30 PM CBC WITH AUTO DIFFERENTIAL, LAB GENERATED ORDER STAT 06/03/2021 1:17 PM PROTHROMBIN TIME Routine 06/03/2021 1:17 PM COMPREHENSIVE METABOLIC PANEL STAT 06/03/2021 1:17 PM SARS-COV-2 PCR (SIMPLEXA) Routine 06/03/2021 1:09 PM COVID-19 PCR
CDC Split Type:

Write-up: Patient was observed for 30 minutes post vaccination. It was determined he was at baseline and no reaction was occuring. The following day the patient contacted our on-call nurse advice service stating shortness of breath and difficulty swallowing. He was advised to go to the ED. Patient was treated in the ED. He remained under observation for 8 hours before they determined patient was back to baseline and okay to discharge home.


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