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

This is VAERS ID 916473

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Case Details

VAERS ID: 916473 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Arizona  
Vaccinated:2020-12-31
Onset:2020-12-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac assistance device user, Dyspnoea, Headache, Loss of consciousness, Seizure, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), 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? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: COPD, depression, pace-maker, diabetes, obesity, osteoarthritis, plantar fasciitis, localized edema, moderate persistent asthma, sleep apnea, and ovarian cyst.
Allergies: Penicillin and Blueberries
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient complained of a headache, then patient was losing consciousness and gasp for air. EpiPen was utilized due to being unresponsive then began to seizing. Patient started to flatline and an AED was used while a paramedic came. Patient was put on her side then facility gave something for seizures. Lastly, ,ambulance took her to the hospital.


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