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From the 10/8/2021 release of VAERS data:

This is VAERS ID 923791

Case Details

VAERS ID: 923791 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Tennessee  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: Anxiety, Blood test, Chills, Diarrhoea, Hallucination, visual, Headache, Insomnia, Nausea, Parosmia, Thinking abnormal, Urine analysis, Vomiting
SMQs:, Acute pancreatitis (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Theophylline, Acyclovir, Gabapentin, Sertraline HCL, Lorazepam, Azithromycin, Famotidine , Zinc, Vitamin C
Current Illness: None
Preexisting Conditions: Legally blind, lung cancer in remission in 5 years, colon cancer in remission for 4 years, diverticulosis, COPD, emphysema
Allergies: None
Diagnostic Lab Data: Urine and bloodwork done at emergency room on 1/4/21. Patient unsure of what tests were ran.
CDC Split Type:

Write-up: 12/30/2020 around 2:00 nausea, vomitting, diarrhea, and chills started. Insomnia x3 days. Patient states she felt "wired and worked up". Noises made her anxious. Patient states "everything smelled bad". Patient had hallucinations seeing the devil and satanic thoughts 12/31/2020 to 1/4/2021 when patient finally fell asleep. 1/5/21 patient woke up with a headache and took ibuprofen and used a heating pad with relief. Patient took melatonin 1/5/21 before bed to go to sleep. Diarrhea stopped 12/31/20. Nausea stopped 1/5/21.Vomitting stopped 12/31/2020. Chills stopped 1/5/21. Patient has been eating bananas and chicken noodle soup and drinking sweet tea. Patient not as nervous 1/6/21 when she woke up.

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