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

This is VAERS ID 908401



Case Details

VAERS ID: 908401 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-23
Onset:2020-12-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: C-reactive protein increased, Chills, Dizziness, Electrocardiogram abnormal, Fibrin D dimer normal, Sinus tachycardia, Tremor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypoglycaemia (broad), Dehydration (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: Junel Birth Control
Current Illness: COVID-19 Positive with past 30 days, symptoms resolved
Preexisting Conditions: anxiety, heart murmur
Allergies: No known allergies
Diagnostic Lab Data: D-Dimer 0.64 C Reactive Protein 6.98 EKG- Sinus Tachycardia 146-160''s
CDC Split Type:

Write-up: Vaccine administered at 0730. Pt went home and went to bed. Woke up at 0930 with shaking, chills and feeling like she was going to pass out. Evaluated in ER and noted to have sinus tachycardia in 140-160''s. Given 5mg IV Lopressor which took heart rate down to 110''s. Admitted to hospital 12/23/2020.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=908401

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