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From the 10/15/2021 release of VAERS data:

This is VAERS ID 907075



Case Details

VAERS ID: 907075 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Female  
Location: Ohio  
Vaccinated:2020-12-22
Onset:2020-12-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bronchospasm, Cough, Tongue pruritus
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations: Influenza - other information unknown
Other Medications: Prescription: atenolol, omeprazole, simvastatin, primidone, levothyroxine, escitalopram, albuterol inhaler
Current Illness: no
Preexisting Conditions: Hypothyroidism, asthma, high cholesterol, palpitations, essential tremor, anxiety, depression, hiatal hernia
Allergies: Medication allergies: morphine - anaphylaxis, flexeril - mood and behavior disturbances, zolpidem- shortness of breath, lamotrigine - shortness of breath Patient had a previous reaction to influenza vaccination with shortness of breath
Diagnostic Lab Data: BMP, CBC w/diff, trop/myoglobin x2, TSH, Free T4, Chest X-ray (all ordered 12/22/20)
CDC Split Type:

Write-up: Patient experienced bronchospasm with coughing and tongue itching approximately 10 minutes after the injection.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=907075

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