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

This is VAERS ID 915480

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Case Details

VAERS ID: 915480 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray normal, Chills, Injection site erythema, Injection site induration, Laboratory test normal, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (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? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vitamin D3 4,000 units daily, famotidine 20 mg daily, ferrous sulfate 325 mg daily, gabapentin 400 mg BID, levothyroxine 100 mcg daily, melatonin 9 mg at hs, metoprolol tartrate 12.5 mg BID, nortriptyline 10 mg at HS, Norvasc 10 mg daily, S
Current Illness: Had a uti 12/8/2020 finished abx on 12/10/2020; prior to admitting had COVID with multiple complications spent along time in the hospital recovering.
Preexisting Conditions: Type 2 diabetes, morbid obesity, hypertension, sleep apnea, anemia, GERD, chronic pain
Allergies: Benzalkonium, lisinopril, Percocet, Adhesive Tape
Diagnostic Lab Data: Sent to ER admitted to hospital under observation. Per Hospital notes "There does not appear to be a cellulitis or abscess at this time. Labs and chest x-ray in the ED did not reveal any origin to where her fevers may be coming from".
CDC Split Type:

Write-up: Developed sudden onset of shaking chills and fevers as high as 103.0. She has developed a small circular 5 x 5 area of erythema and firmness at the injection site of her left upper arm.


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