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

This is VAERS ID 1421194



Case Details

VAERS ID: 1421194 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-06-16
Onset:2021-06-20
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Mental status changes, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Flu: adverse reaction
Other Medications: Multi vitamins Vitamin D 3 Coenzyme Q
Current Illness: none
Preexisting Conditions: Afib Heart failure Diabetes Millitis
Allergies: Ace Inhibitor
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Weakness, altered mental state, fever


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1421194


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