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

This is VAERS ID 1700750

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Case Details

VAERS ID: 1700750 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-03-11
Onset:2021-09-10
   Days after vaccination:183
Submitted: 0000-00-00
Entered: 2021-09-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 5318 / 1 AR / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP 6955 / 2 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cough, Dyspnoea, Malaise, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (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, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: Coronary artery disease, advanced dementia
Preexisting Conditions:
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: sxs onset 9/10 including fever, SOB, cough. admitted to hospital for 9/10 thru 9/11 for COVID symptoms.


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