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

This is VAERS ID 1762484

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Case Details

VAERS ID: 1762484 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-10-04
Onset:2021-10-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022C2114 / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Muscle tightness, Swollen tongue, Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Dystonia (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lamictal 200mg Avery morning Prilosec 30mg daily
Current Illness: None
Preexisting Conditions: None
Allergies: Seafood, strawberries, bactrim , bee stings
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Tightness in throat and jaw, tongue swelling, shortness of breath., chest pain Treatment at the ER with Benadryl and Pepcid


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1762484


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