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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1696399

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Case Details

VAERS ID: 1696399 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: New Jersey  
   Days after vaccination:129
Submitted: 0000-00-00
Entered: 2021-09-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Aspartate aminotransferase increased, COVID-19, Chest X-ray abnormal, Computerised tomogram thorax, Cough, Dyspnoea, Fibrin D dimer increased, International normalised ratio increased, Lung infiltration, Malaise, SARS-CoV-2 test positive, Tachycardia, Tachypnoea
SMQs:, Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), 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? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin (Aspirin Low Dose) 81 mg tablet,delayed release (DR/EC) Directions: 1 tablet oral daily (Active) ciprofloxacin HCl 500 mg Tablet Directions: 1 tablet oral twice a day Extended Instructions: Stop 9/14/21 (Active) foLIC Acid 1 m
Current Illness:
Preexisting Conditions: Asthma, HTN; Rheumatoid arthritis. Smoking Status Light Tobacco Smoker.
Allergies: Penicillin
Diagnostic Lab Data: SARS-CoV-2 Antigen (+) on 9/13/2021
CDC Split Type:

Write-up: 63-year-old male with a medical history of hypertension and rheumatoid arthritis reports to the ER today with complaints of shortness of breath. The patient reports that Friday he started not to feel well he was coughing and over the weekend he developed shortness of breath. This morning he went to see his primary physician who instructed the patient come in urgently to the ER. Here in the ER the patient retested for covid19 it was positive patient noted to have oxygenation of 96% and tachypnea into the 20''s as well as tachycardia 116. Chest x-ray completed shows bilateral infiltrates. Labs were significant for elevated D-dimer of 361, INR 1.21, elevated AST. The pt is vaccinated with Moderna. Patient received IV fluids and Lovenox in the ER, CT of the chest was done not yet resulted will follow-up. Admit to tele for covid management.

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