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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1147356



Case Details

VAERS ID: 1147356 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-13
Onset:2021-03-29
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Bradykinesia, COVID-19, Cough, Mental status changes, Pneumonia, Pyrexia, SARS-CoV-2 test positive, Tachycardia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Parkinson-like events (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin, glipizide, metformin
Current Illness:
Preexisting Conditions: Diabetic retinopathy of both eyes, hyperlipidemia, leukopenia, kaposi sarcoma, hemorrhoids, diabetes "1.5", managed as type 2, depression, carotid artery disease, AVM (congenital), allergic rhinitis.
Allergies: Shellfish (anaphylaxis), adhesive tape, aluminum, horse derived products (positive during allergy testing), latex
Diagnostic Lab Data: 3/29/2021: Positive SARS-CoV-2 PCR NP
CDC Split Type:

Write-up: Pt received dose of J&J vaccine (Janssen) on 3/13/2021. Symptoms began around 3/27 similar to COVID-19. Pt presented to ED at another local hospital 3/29/2021, tested positive for COVID-19 and was transferred to be admitted to our hospital for treatment of COVID-19. Notes from hospital admission H&P: Patient is a 59 y.o. male with history DM, Who presented to Urgent care then hospital ER with covid positive, PNA, Fever and a cough. Real tachycardic there to 117, temp to 103, confused, moving slow. Altered mental status (slow cognition), 94% on 2L"


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1147356


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