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From the 5/7/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 908471

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Case Details

VAERS ID: 908471 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Missouri  
Vaccinated:2020-12-22
Onset:2020-12-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Blood pressure orthostatic abnormal, Body temperature increased, Bradycardia, Chills, Decreased appetite, Disturbance in attention, Dizziness, Electrocardiogram, Fatigue, Feeling abnormal, Headache, Hypotension, Laboratory test, Nausea, Pain, Sluggishness
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (broad), Depression (excl suicide and self injury) (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Lab work and EKG was performed at the hospital . I am unsure as to what test at the time of reporting
CDC Split Type:

Write-up: I was very tired at 18:30 after receiving the vaccine at 14:29. I went to bed at 18:30 that night awoke at 3 am for work and was still very tired and body aches. I was driving to work and notice that I was having a delayed reaction to such things as I was looking at Christmas lights and had to remind myself I was driving. The drive to work otherwise I do not remember. I felt as if I was just not processing things around me correctly. At work the symptoms were intermittent. The thought process or lack of continued. I began to have stomach pain felt like diarrhea coming on however I never had it. Then nauseated and thought I was going to throw up and felt like I was going to pass out. The passing out feeling continued until I had my coworker call a rapid because I knew my blood pressure was dropping and my hear rate became slow and I was passing out. I was then taken to the emergency room to where I continued to experience orthostatic blood pressure changes and bradycardia and hypotension. I was given fluids and potassium IV and was feeling slightly better. I went home and slept for the next 18 hours. When I did briefly awaken through the evening I had an elevated temperature 102, chills and an extreme headache and body aches. Today I awoke at 6 am and still sluggish with a slight headache and absolutely no appetite.


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