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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1024665

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Case Details

VAERS ID: 1024665 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: New York  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M2OA / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Computerised tomogram thorax abnormal, Deep vein thrombosis, Fibrin D dimer increased, Lung consolidation, Pleuritic pain, Pulmonary embolism, Ultrasound Doppler abnormal
SMQs:, Haemorrhage laboratory terms (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: As above: D Dimer +/- 4800 CT Ang. 2/5/2021 Bilateral Pulm. Emboli segmental and sub segmental with corresponding basal infarcts and consolidation U/S Legs 2/9/2021 Thrombus Left Femoral Vein
CDC Split Type:

Write-up: Developed severe pleuritic chest pain x 5 days, went to ER on 2/5/2021, D Dimer over 4000, CT chest showed bilateral segmental and sub segmental Pulmonary Emboli. Initial Ultrasound of legs was negative for DVT, follow-up U/S on 2/9/2021 was positive for large Femoral vein DVT. All family history, medical history and other risk factors for coagulation disorder was negative. I was initiated on anticoagulation therapy. (Enoxaparin)

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