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

This is VAERS ID 988061

Case Details

VAERS ID: 988061 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Michigan  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, C-reactive protein, Chest X-ray abnormal, Chills, Computerised tomogram thorax abnormal, Fatigue, Fibrin D dimer increased, Intensive care, Lactic acidosis, Lung opacity, Procalcitonin, Pulmonary congestion, Pulmonary embolism, Pulmonary oedema, Pyrexia, Respiratory tract congestion, Troponin, White blood cell count
SMQs:, Cardiac failure (narrow), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, venous (narrow), Guillain-Barre syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Moduretic, ASA 81mg, glipizide, losartan, metformin, potassium chloride, potassium citrate
Current Illness: None
Preexisting Conditions: CKD stage 2, DM2, essential hypertension, hyperlipidemia, obesity (BMI 27.3)
Allergies: None
Diagnostic Lab Data: Labs- elevated d diner, troponin, procalcitonin, lactic acidosis, c reactive protein, white blood cells. chest X-rays- ground glass, pulmonary edema and congestion. ct scan- positive for pulmonary emboli and ground glass
CDC Split Type:

Write-up: Chills, fever, fatigue from day of onset. Currently in ICU for ARDS

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