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From the 9/17/2021 release of VAERS data:

This is VAERS ID 921465



Case Details

VAERS ID: 921465 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Rhode Island  
Vaccinated:2020-12-27
Onset:2020-12-30
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Arthralgia, Back pain, Chest X-ray normal, Chills, Computerised tomogram normal, Computerised tomogram spine, Ear pain, Headache, Laboratory test, Myalgia, Nausea, Pain, Pain in extremity, Photophobia, Purpura, Pyrexia, Rash, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Noninfectious meningitis (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Corneal disorders (broad), Eosinophilic pneumonia (broad), Retinal disorders (broad), Hypersensitivity (narrow), Arthritis (broad), Tendinopathies and ligament disorders (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? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 51-year-old female with history of intermittent asthma presented to the ED with 1 week of intermittent fevers, myalgias, arthralgias and headache. Patient reports receiving first dose of moderna vaccine last week. She initially developed arm soreness followed by chills and body aches. Subsequently developed frontal headache, photophobia, back pain, nausea and vomiting. She was seen in the ER on 1/1/21, when her work-up including labs, CT spine, chest x-ray were negative therefore she was discharged home. She continued to have symptoms and also developed bilateral intermittent ear pain. She also developed rash in her extremities and torso. Rash is pruritic but not painful. reports ongoing history of neck pain for which she sees PT. Denies sore throat, cough, chest pain or shortness of breath.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=921465


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