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From the 1/14/2022 release of VAERS data:

This is VAERS ID 924410

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Case Details

VAERS ID: 924410 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2020-12-28
Onset:2021-01-05
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Adult failure to thrive, Asthenia, Respiratory failure
SMQs:, Anaphylactic reaction (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), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (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: AMLODIPINE BESYLATE 5MG TAB ASPIRIN 81MG EC TAB LEVOTHYROXINE (SYNTHROID) 88MCG TAB TAMSULOSIN HCL 0.4MG CAP FLUTICASONE 500MCG/SALMETEROL 50MCG INHL DISK 60 ROSUVASTATIN CA 20MG TAB CHOLECALCIFEROL 25MCG (1,000UNIT) TIOTROPIUM 2.5MCG
Current Illness:
Preexisting Conditions: Hypertension, COPD with oxygen dependence, hypothyroidism, osteoporosis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Adult failure to thrive; Chronic hypoxemic respiratory failure; Generalized weakness


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