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

This is VAERS ID 907878

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Case Details

VAERS ID: 907878 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Missouri  
Vaccinated:2020-12-23
Onset:2020-12-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest discomfort, Dizziness, Dysphagia, Dyspnoea, Emotional distress, Headache, Limb discomfort, Oxygen saturation normal
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Vestibular disorders (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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received COVID vaccine at approximately 9AM this morning. Stayed 15 minutes after injection for monitoring, felt fine and returned to department. Employee returned at approximately 11:45AM with possible symptoms of reaction. Admitted to a headache that started approximately an hour after injection. Symptoms now include heaviness of arm, chest, feeling emotional, light headed. Vitals taken at 11:48 BP 150/86, P 79, R16 Pox 97. Oral Benadryl 25mg administered PO 11:50AM. EKG run. Patients symptoms progressed to include difficulty breathing and swallowing. Epi pen adult 0.3mg administered IM Left thigh at 12:13PM. Vitals checked at 12:13PM BP 188/90, pulse 97, pulse ox97. Called for emergency response for transport to ER. Pt remained stable until transport by EMS to ER. Employee health informed of patient transport. ER informed of patient transport.


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