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From the 10/15/2021 release of VAERS data:

This is VAERS ID 933686



Case Details

VAERS ID: 933686 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-23
Onset:2020-12-29
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J2OA / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Dyspnoea, Musculoskeletal chest pain, Pneumonia viral, Pulmonary embolism, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: rib pain/shortness breath/Pulmonary Embolus and viral pneumonia Narrative: Development of symptoms beyond the 48-72 window. Tested at time of ER visit Negative for Covid. Repeated Covid NP swab on 01/05/2021. Was not hospitalized overnight discharge home on oral anticoagulant medications.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=933686

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