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

This is VAERS ID 930611

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Case Details

VAERS ID: 930611 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-01-06
Onset:2021-01-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Cardiac failure congestive, Condition aggravated, Intensive care, Respiratory failure
SMQs:, Cardiac failure (narrow), 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), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? Yes
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: Albuterol, metoprolol, fish oil, apixiban, insulin
Current Illness: Advanced diastolic heart failure and CKD. Returned from hospitalization one week prior for CHF exacerbation treated with BIPAP, IV diuresis
Preexisting Conditions: oxygen dependent COPD, type II DM, diastolic CHF, stage IV renal failure, personality disorder
Allergies: statin, PCN
Diagnostic Lab Data: unknonw
CDC Split Type:

Write-up: Developed hypercapnic respiratory failure, CHF exacerbation - readmitted to Hospital. In ICU with BIPAP


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