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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1753355

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Case Details

VAERS ID: 1753355 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: New York  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Erythema, Lethargy, Photophobia, Pruritus, Skin warm, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Glaucoma (broad), Corneal disorders (broad), Retinal disorders (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Colace 100 mg 1 tab daily at bedtime Atorvastatin 10 mg 1 tab at bedtime Levothyroxine 75 mcg 1 tab q am MONTELUKAST 10 mg 1 tab by mouth daily Albuterol sulfate 90 mcg 2 puffs every 4 hours as needed Triamterene/hydrochl 37.5-25 m
Current Illness: NA
Preexisting Conditions: Hypertension, history of kidney stones, bronchitis/asthma, cervical spine stenosis
Allergies: : Colophony Bacitracin Chlorhexidine adhesive tape pine nuts and cinnamon
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Left upper shoulder redness, warmth, swelling and itchiness. Complains of lethargy and sensitivity to light.

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