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

This is VAERS ID 1759072

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Case Details

VAERS ID: 1759072 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Michigan  
   Days after vaccination:234
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Cough, Dyspnoea, Pyrexia, SARS-CoV-2 test positive
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), Infective pneumonia (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, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received Pfizer vaccine with 1st dose on 01/20/2021 and 2nd dose on 02/12/2021. Covid + on 10/04/2021 and hospitalized Per ED Note: Patient is a pleasant 77year old male presented today to emergency department for evaluation of shortness of breath. He has been feeling this way for the past 2 days. He does admit to fevers and cough at home. He took Tylenol prior to coming in. Patient denies any chest pain, abdominal pain, vomiting, focal paresthesias or weakness, headache, change in bowel or bladder habits, dizziness, leg pain or edema or history of blood clots, or changes in medications. He denies any other modifying precipitating or relieving factors.

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