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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1190592

Case Details

VAERS ID: 1190592 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Rhode Island  
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Fibrin D dimer increased, Pulmonary embolism
SMQs:, Haemorrhage laboratory terms (broad), Embolic and thrombotic events, venous (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Sertraline 100 MG - 1/day LisinopriL 10 MG - 1/day Adderall XR 30 MG - 1/day Multi Vitamin
Current Illness: None
Preexisting Conditions: Asthma - mild
Allergies: None
Diagnostic Lab Data: D Dimer 3/31/2021 Value: 629
CDC Split Type:

Write-up: Bilateral Pulmonary Embolism

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