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

This is VAERS ID 907330



Case Details

VAERS ID: 907330 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Arizona  
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 011J20A / 1 LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal discomfort, Abdominal pain, Dizziness, Dyspnoea, Headache, Hyperhidrosis, Hyperventilation, Rash macular, Tremor, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Parkinson-like events (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Flexeril, Advil, Protonix, Estrace, Vivelle DOT Norco PRN
Current Illness: No
Preexisting Conditions: Mild Osteopenia, GERD, Anemia,
Allergies: Reglan - anaphylaxis
Diagnostic Lab Data: 12/22 ED administrated PEPCID, ZOFRAN, Prednisone 60 mg, and Ativan 1mg IV.
CDC Split Type:

Write-up: Employee presented to COVID Clinic for Moderna COVID 19 vaccination 1st dose. Given to left arm. Left clinic prior to completing 15 minute observation time and told an MA in waiting area that she felt ill ot her stomach and having trouble taking deep breaths. Employee found in nearby Bathroom sitting on the floor, she had vomited, reported she was lightheaded, couldn''t breath, shaking, abdominal discomfort sweating, attempted to move employee to wheelchair, did respond well to transfer to Wheelchair, She reported symptoms worsening: HA, abdominal pain and developed blotchy skin, hyperventilating, and dizzy. CODE Blue called, patient given Epinephrine injection 0.5mg patient sent to ER


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=907330

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