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

This is VAERS ID 1490039

Case Details

VAERS ID: 1490039 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Pennsylvania  
   Days after vaccination:75
Submitted: 0000-00-00
Entered: 2021-07-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Chest X-ray, Condition aggravated, Dyspnoea, Productive cough
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), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), 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? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: acetaminophen (TYLENOL EXTRA STRENGTH) 500 mg tablet albuterol 2.5 mg /3 mL (0.083 %) nebulizer solution albuterol HFA (PROAIR HFA) 90 mcg/actuation inhaler allopurinoL (ZYLOPRIM) 100 mg tablet amLODIPine (NORVASC) 10 mg tablet aspirin 81 m
Current Illness: suspected liver cirrhosis.
Preexisting Conditions: Nervous Coronary artery disease involving native coronary artery of native heart with angina pectoris (CMS/HCC) Osteoarthritis of thoracic spine with myelopathy Benzodiazepine dependence, episodic (CMS/HCC) Precordial chest pain Respiratory Chronic obstructive pulmonary disease (CMS/HCC) Cough Multifocal pneumonia Acute respiratory failure with hypoxia (CMS/HCC) Circulatory Aortic stenosis Essential hypertension External hemorrhoids ACS (acute coronary syndrome) (CMS/HCC) Congestive heart failure, unspecified HF chronicity, unspecified heart failure type (CMS/HCC) Digestive Gastroesophageal reflux disease Vitamin D deficiency BMI 40.0-44.9, adult (CMS/HCC) Genitourinary Type 2 diabetes mellitus with stage 4 chronic kidney disease, with long-term current use of insulin (CMS/HCC) Chronic kidney disease (CKD), stage III (moderate) (CMS/HCC) Infective urethritis Renal dysfunction Urinary tract infection without hematuria, site unspecified Musculoskeletal Arthritis Cellulitis of finger of right hand Abscess of right ring finger Endocrine/Metabolic Mixed hyperlipidemia Hypothyroidism Infectious/Inflammatory COVID-19 Immune Sjogren''s syndrome (CMS/HCC)
Allergies: Hydrocodone-acetaminophenIndigestion / GI upset Iodinated Contrast MediaOther (document details in comments), Anaphylaxis IodineOther (document details in comments) Iodine Containing MultivitaminAnaphylaxis LisinoprilCoughing MeperidineNausea and Vomiting, Other (document details in comments) MorphineIndigestion / GI upset PenicillinsItching Propoxyphene N-acetaminophenNausea and Vomiting Sulfa (Sulfonamide Antibiotics)Itching PropoxypheneNausea And Vomiting Tramadol HydromorphoneOther (document details in comments)
Diagnostic Lab Data: Chest X-ray
CDC Split Type:

Write-up: Acute respiratory failure with hypoxia wet cough Shortness of breath

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