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

This is VAERS ID 1466536



Case Details

VAERS ID: 1466536 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-04-07
Onset:2021-07-03
   Days after vaccination:87
Submitted: 0000-00-00
Entered: 2021-07-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030B21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen, Biotin, bupropion, calcium carb-cholecalciferol, capsaicin 0.025% cream, ferrous sulfate, fexofenadine, fluticasone, gabapentin, lactobacillus rhamnousus, levothyroxine, lidocaine foot cream, multivitamin, nicotine gum, olanz
Current Illness:
Preexisting Conditions: Heart failure with preserved ejection fraction, hx of adenocarcinoma of colon, anemia, B-12 deficiency, depression, hx of DVT, factor V deficiency, fibromyalgia, hyperlipidemia, hypothyroidism, neuropathy/peripheral neuropathy, hx of PE.
Allergies: Sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received both doses of the Moderna COVID-19 vaccine (on 3/1/2021 and 4/7/2021). She subsequently developed COVID, testing positive via PCR on 7/3/2021 and was admitted to our hospital on 7/3/2021. She was never ill enough to be in the ICU, instead staying in the general med/surg COVID unit until she was discharged on 7/7/2021. Her primary discharge diagnosis was "COVID-19 pneumonia with mild hypoxemic respiratory failure".


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