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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1440816



Case Details

VAERS ID: 1440816 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-03-24
Onset:2021-06-29
   Days after vaccination:97
Submitted: 0000-00-00
Entered: 2021-07-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back injury, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Dyspnoea, Fall, Fibrin D dimer, Hypoxia, Malaise, SARS-CoV-2 test negative, SARS-CoV-2 test positive, Serum ferritin increased
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Asthma, COPD, DM, HTN, HLD, hypothyroidism
Allergies:
Diagnostic Lab Data: 6/29/21: SARS-CoV-2 PCR: Positive CXR (6/28/21): Reported as consistent with COVID-19 in notes D-dimer(6/29/21): 1.64 mcg/mL Ferritin 6/29/21: 402 ng/mL
CDC Split Type:

Write-up: Presented to ED with 2 weeks of SOB, not feeling well. Had fallen 2 weeks prior to admission and landed on her back. Was hypoxic on admission and required 10 L of supplemental oxygen to maintain saturations $g 90%. Was transferred to this facility for further care. SARS-CoV-2 test was positive at OSH (PCR + but antigen test negative) and PCR test + here. CXR suspicious for multifocal PNA consistent with COVID-19. Currently admitted.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1440816


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