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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 969618

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Case Details

VAERS ID: 969618 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Illinois  
Vaccinated:2020-12-30
Onset:2021-01-04
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0011JZ0A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Pericarditis
SMQs:, Systemic lupus erythematosus (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Pericarditis; Severe chest pain; A spontaneous report was received from a 56 year-old, female consumer, who was also the patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced pericarditis and severe chest pain. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. On 30 Dec 2020, approximately five days prior to the onset of symptoms, the patient received their first of two planned doses of mRNA-1273 (Lot number: 0011JZ0A) intramuscularly for prophylaxis of COVID-19 infection. On 04 Jan 2021, the patient went to the emergency room due to severe chest pain. On 05 Jan 2021, the patient went to see the cardiologist and was diagnosed with pericarditis. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not provided. The outcome of the events, pericarditis and severe chest pain, was unknown.; Reporter''s Comments: This case concerns a 56 year old, female patient. The patient''s medical history was not provided. The patient experienced a serious, unexpected event of pericarditis and severe chest pain. The event of severe chest pain occurred 5 days and the event of pericarditis occurred after 6 days after first dose of mRNA-1273 (Lot number: 0011JZ0A). Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the mRNA-1273 and the start date of the event, a causal relationship cannot be excluded.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=969618


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