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

This is VAERS ID 1193757

Case Details

VAERS ID: 1193757 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: New York  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Back pain, Deep vein thrombosis, Fatigue, Muscle spasms, Pain in extremity, Peripheral swelling, Weight bearing difficulty
SMQs:, Cardiac failure (broad), Angioedema (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, venous (narrow), Dystonia (broad), Thrombophlebitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Phenytoin, Clonazepam, Vitamin D3, Jardiance, Pantrapazole, Vitamin C, B12, Folic Acid,
Current Illness: None
Preexisting Conditions: No chronic or long standing health conditions prior to being vaccinated with the Johnson & Johnson Vaccine.
Allergies: Allergic to Botox, Sumatriptan, Halcion, Imatrex, and Metformin
Diagnostic Lab Data: I ended up going to the emergency room through the local VA Hospital where I was diagnosed with a substantial DVT, Deep Vein Thrombosis in my right leg, I was advised that the DVT is substantial and that I needed to follow up with the Anticoagulation Clinic once I was discharged. I was started on Lovonox injections @ 100ML twice a day and I was started on Warfarin 5 mg. daily. I am currently receiving treatment for the DVT from the Anticoagulation Clinic with labs twice a week and a Clinic as needed at least once a month I was advised. I was advised by the Anticoagulation Clinic to enroll through the VAERS System in regards to my adverse reaction to the J&J Vaccine and the Deep Vein Thrombosis (DVT),
CDC Split Type:

Write-up: Shortly after receiving the vaccination I started to experience chronic exhaustion, leg cramping and pain in my lower back right side, upper right thigh, behind my right knee and down into my right calf. I figured that the pain would go away but the pain increased and my leg started swelling and the pain increased making it very difficult for me to put my leg down on the ground and put pressure on my right leg.

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