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From the 11/26/2021 release of VAERS data:

This is VAERS ID 919376

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Case Details

VAERS ID: 919376 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Montana  
Vaccinated:2020-12-30
Onset:2021-01-02
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Limb discomfort, Limb mass, Pain of skin, Skin warm, Thrombosis, Ultrasound scan abnormal
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dasetta 1/35, Bile salts OTC, Proair Inhaler PRN
Current Illness: N/a
Preexisting Conditions: Asthma
Allergies: Penicillin
Diagnostic Lab Data: 1/4/2021 confirmed with ultrasound of lower extremity.
CDC Split Type:

Write-up: Patient received Moderna vaccine, Wednesday 12/30. On Saturday 1/3/2021 patient felt pressure/tightness in lower extremity. When patient touched area, a noticeable ball was felt under the skin, tender to the touch and warm. Patient went into urgent care on Monday 1/4/2021 with a confirmed dx of a superficial blood clot. Unknown etiology of whether this is from current birth control or the COVID19 Moderna vaccine.


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