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

This is VAERS ID 1745926

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Case Details

VAERS ID: 1745926 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: New York  
Vaccinated:2021-09-29
Onset:2021-09-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30125BA / 3 RA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR UJ702AB / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dyspnoea, Flushing, Muscle spasms
SMQs:, Anaphylactic reaction (narrow), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad)

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? No
Previous Vaccinations:
Other Medications: fluoxetine 20mg metformin 1000mg glimepiride 4mg losartan/hctz 100-25
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was administered a booster Pfizer vaccine and a FluHD both in right arm due to a mastectomy on her left breast. The doses were administered 1 inch apart in her right deltoid muscle. The patient was fine initially but when she was out sitting for her 15 minute interval she began having low back spasms, was having difficulty breathing and was feeling flush. 911 was called as well as Code White. I sat with the patient and got her a bottle of water. By the time paramedics arrived her breathing had returned to normal and the flushing in her face went down and the back spasms subsided. The paramedics took her blood pressure and oxygen level. The patient did not want to go to the hospital and left the store on her own.


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