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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 1177803

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Case Details

VAERS ID: 1177803 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Arizona  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Blood albumin decreased, Blood creatine phosphokinase MB, Blood creatine phosphokinase increased, Blood lactic acid, Blood magnesium normal, Blood sodium decreased, Blood urea nitrogen/creatinine ratio, Brain natriuretic peptide increased, Cardiac failure congestive, Drug screen negative, Dyspnoea, Haematocrit decreased, Haemoglobin decreased, Headache, Hepatic enzyme abnormal, Immature granulocyte percentage increased, Insomnia, International normalised ratio increased, Lymphocyte percentage decreased, Metabolic function test normal, Myocarditis, Nausea, Neutrophil percentage increased, Pain, Peripheral swelling, Protein urine present, Prothrombin level normal, Red blood cell count decreased, SARS-CoV-2 test negative, Troponin increased, Urine analysis normal, Vomiting, Walking aid user
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (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 5mg tab qday Fenasteride 5mg tab qday Insulin Aspart Flexpen 15 UNITS with meals Insulin Glargine 30 UNITS bid Losartan 100 mg tab qday Metformin 1000 mg tab bid Simvastatin 10 mg qday Amlodipine 5 mg qday Finasteride 5 mg tab q
Current Illness:
Preexisting Conditions: Diabetes Type II Essential hypertension Hyperlipidemia Hx of abnormal LFTs Hx of microalbuminuria Hx of COVID19 (11/2020)
Allergies: Lisinopril
Diagnostic Lab Data: Urine: normal, trace protein UDS: negative CMP: BUN/CREAT 23.70, Sodium 131, Albumin 3.0, Elevated Liver Enzymes BMP: RBC 4.38, Hemoglobin 12.9, Hematocrit 38.4, NE% 76.1, LY% 14, IG% 0.5 *TROPONIN: 31.860 CK MB: 14.5 CK:716 Lactic Acid normal Magnesium normal *BNP: 2441.5 PT: 12.1, INR 1.15 COVID19: NEGATIVE
CDC Split Type:

Write-up: Per triage note of 4/7/2021: "Chief Complaint: pt presents with Nausea & vomitting, ha, body ache, unable to sleep, swollen feet. Symptoms started 3/25 after he recieved his 1st covid vaccine. has had to use a walker and gets SOB. pt had COVID 11/2020" Assessment reveals mild CHF, positive troponin, myocarditis per physician''s notes of 4/7/2021 Patient treated with Zofran 4 mg IV and given 500 ml NS IV then Lasix 40 mg IV. Patient transferred to Medical Center 4/7

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