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From the 12/31/2003 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 26639

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Case Details

VAERS ID: 26639 (history)  
Form: Version .0  
Age: 39.7  
Sex: Female  
Location: Washington  
Vaccinated:1990-11-09
Onset:1990-11-09
   Days after vaccination:0
Submitted: 1990-11-14
   Days after onset:5
Entered: 1990-11-20
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUOGEN 1990-1991 PARKE-DAVIS / PARKE-DAVIS 00280P / 0 A / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: ANXIETY, LARYNGISMUS, PAIN CHEST
SMQs:

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

Write-up: Pt vaccinated wih Influenza A/B throat constricting, tightness in chest, anxiety.


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