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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1076306



Case Details

VAERS ID: 1076306 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-04
Onset:2021-03-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (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:
Allergies: latex = rash, gluten=unspecified, bupropion=dysphoria,
Diagnostic Lab Data:
CDC Split Type:

Write-up: 65m received J&J vaccine, 10 minutes after admit c/o a gripping pain mid sternum, a 2 on scale of 1-10. Pt brought ot observation area, pain non changing after 15 minutes, eval''d by on site EMS. Transferred to ED for eval. Pt notified his daughter prior to leaving vaccine clinic. He had no complaints of other symptoms. Per electronic health records, pt drove himself to ED.


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