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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 907022

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Case Details

VAERS ID: 907022 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Ohio  
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: Anaphylactic reaction, Angioedema, Endotracheal intubation
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Oropharyngeal allergic conditions (narrow), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Calcium 600 mg with D daily; Women''s Multiple vitamin daily; Vitamin D3 5,000 units daily; Zyrtec 10 mg at bedtime PRN; Celebrex 200 mg daily; Gabapentin 300 mg (3 caps daily); Melatonin 9 mg daily PRN; Zanaflex 4 mg Daily
Current Illness: Not known
Preexisting Conditions: Anxiety; Depression; Chronic Back Pain
Allergies: Morphine; Tramadol; NSAIDs; Codeine; Oxycodone; Percocet
Diagnostic Lab Data: None at this time
CDC Split Type:

Write-up: Anaphylaxis/Angioedema Patient was given EpiPen 0.3 mg IM; Methylprednisolone 125 mg once; Diphenhydramine 25 mg IV push once; Famotidine 20 mg IV push once; Dexamethasone 10 mg IV push once Patient was intubated and put on propofol and midazolam drips for sedation


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=907022


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