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

This is VAERS ID 1470122

Case Details

VAERS ID: 1470122 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Idaho  
   Days after vaccination:52
Submitted: 0000-00-00
Entered: 2021-07-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cough, Dyspnoea, Oropharyngeal pain, Productive cough, Pyrexia, Respiratory tract congestion, Secretion discharge
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (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: Omeprozole, Gabapentin, Meloxicam
Current Illness: Hiatal Hernia, severe anemia, neuropathy in left leg, carpal tunnel syndrome both wrists, Gerd
Preexisting Conditions: Hiatal Hernia, Gerd
Allergies: Penicillin, sulfa drugs
Diagnostic Lab Data: Urgent care visits on 7/7/21 and 7/12/21. Received breathing treatment (steroid and Albuterol) and steroid shot on 7/12/22.
CDC Split Type:

Write-up: Developed upper respiratory infection On 7/2/2021. Low grade fever, cough, chest congestion, sore throat, yellow mucus, difficulty breathing, phlegm

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