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From the 1/7/2022 release of VAERS data:

This is VAERS ID 908119

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Case Details

VAERS ID: 908119 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Missouri  
Vaccinated:2020-12-22
Onset:2020-12-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Mental status changes, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, Atorvastatin, Bisacodyl, Calcium Acetate, Clopidogrel Bisulfate, diphenhydramine, Docusate, Levothyroxine, Midodrine, Morphine Sulfate, Oxycodone, Omeprazole, Pregabalin, Salicyic Acid gel, Senna, Simethicone, Vitamin B, Vitamin D,
Current Illness: Polyneuropathy, Sleep Apnea, Reflux, End Stage Renal disease, Anemia, Thrombocytopenia, Hypothyroidism, Type 2 Diabetes, Hyperlipidemia, Retinopathy, Hypotension, Cellulitis, Peripheral Vascular Disease, Acquired absence of kidney, Dependence on renal dialysis, Acquired absence of leg below knee. Recent mrsa infected wound, finished vancomycin on 12/18
Preexisting Conditions: See above.
Allergies: None
Diagnostic Lab Data: Started on Vancomycin in case it''s related to infected wound which is a reoccurring problem with this individual. Also started on Phenergan.
CDC Split Type:

Write-up: Fever 101.8, vomiting, mental status change


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