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From the 5/14/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 906858

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Case Details

VAERS ID: 906858 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: Iowa  
Vaccinated:2020-12-22
Onset:2020-12-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Dyspnoea, Malaise, Pallor, Palpitations
SMQs:, Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: heart palpitations
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: At the 10 minute mark patient reported not feeling well. She was noted to be pale. Then she reported having slight breathing problems along with her heart racing. Call for ER staff to report to vaccinating area. Patient''s breathing concern resolved on its own by the time ER response team arrived within 2 minutes. Patient slowly gained her color back. Heart palpitations lessening but still reported by patient. Blood pressure / O2 Saturations / Respiratory rate monitored. No oxygen or treatment required at this time. Patient taken upstairs to be monitored by ER staff.


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