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From the 11/12/2021 release of VAERS data:

This is VAERS ID 921641

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Case Details

VAERS ID: 921641 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: New York  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Hypoxia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
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: acetaminophen 160 mg/5 mL (5 mL) oral solution albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization budesonide 0.5 mg/2 mL suspension for nebulization Certavite-Antioxidant 18 mg-400 mcg tablet ClearLax 17 gram/dose oral powder
Current Illness: Right lung atelectasis/infiltrate with right mediastinal shift on chest x-ray (12/25) that was treated with steroids and antibiotics
Preexisting Conditions: Chronic respiratory Failure Dependence on mechanical ventilation Seizure disorder Spastic quadriplegic cerebral palsy Encephalopathy
Allergies: NKA
Diagnostic Lab Data: 1/5/21 COVID PCR result: Positive
CDC Split Type:

Write-up: Administered first dose of COVID19 vaccine at 1:29pm on 1/4/21. At approximately 11:00pm resident exhibited acute respiratory decompensation with very limited air entry and hypoxemia. Patient received Benadryl, steroids, epinephrine, and Duoneb without improvement. Resident was referred to the emergency room and found to be COVID positive. No fever or rash were reported.

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