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

This is VAERS ID 1775511

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Case Details

VAERS ID: 1775511 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-05-19
Onset:2021-10-09
   Days after vaccination:143
Submitted: 0000-00-00
Entered: 2021-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0150 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0179 / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Chest X-ray normal, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, 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: albuterol, eliquis, ASA-dipyridamole, atorvastatin, biotin, symbicort, coreg, vit D, clonidine, flexeril, ferrour sulfate, glipizide, hydralazine, insulin glargine, omeprazole, valsartan
Current Illness: no
Preexisting Conditions: severe uncontrolled HTN, CKD4, T2DM, PAD, recurrent unprovoked DVTs, and COPD, DVT, chronic pain
Allergies: clopidogrel, codeine
Diagnostic Lab Data: CXR: clear, PCR + 10.9/2021
CDC Split Type:

Write-up: breakthrough covid +, no change in chronic O2 requirements


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