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From the 6/11/2021 release of VAERS data:

This is VAERS ID 904385



Case Details

VAERS ID: 904385 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Texas  
Vaccinated:2020-12-16
Onset:2020-12-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Comminuted fracture, Epistaxis, Facial bones fracture, Haemorrhage, Loss of consciousness, Subcutaneous haematoma, Tenderness
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amLODIPine, 7.5 mg, oral, Nightly ? cevimeline, 30 mg, oral, TID ? cholecalciferol (vitamin D3), 2,000 Units, oral, Daily ? irbesartan-hydrochlorothiazide, 1 tablet, oral, QAM ? levothyroxine, 50 mcg, oral, Daily at 0600 ? metoprolol s
Current Illness: None
Preexisting Conditions: Sjogrens Syndrome, Hypertension, Hypothyroidism
Allergies: Quinilones, Sulfa
Diagnostic Lab Data: There is a comminuted fracture of the nasal bones bilaterally with Left orbital floor blowout fracture with hemorrhagic opacification of the left maxillary sinus and slight inferior displacement with slight extraconal fat protrusion. There is associated left orbital preseptal and postseptal emphysema. Comminuted fracture involving the anterior and posterior wall of the left maxillary sinus with hemorrhagic opacification of the sinus and left malar subcutaneous hematoma
CDC Split Type:

Write-up: Patient is a pleasant 83 y.o. female pediatrician with history of Sjogren''s, hypothyroidism, hyperlipidemia, hypertension who had been at Hospital to get her Covid vaccine. 30 minutes after doing so she reports being in the lobby and about to walk upstairs and feeling fine. The next thing she knows she wakes up on the stairs with her nose and face bleeding surrounded by healthcare team. She denies any precipitating symptoms such as chest pain, shortness of breath, fevers dizziness, headache. She reports feeling well otherwise in the last few days. I did a thorough bony palpation exam including spine and he only point of tenderness besides on her face was the area above her right ankle. She does not have a history of syncope or collapse


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