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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1242683



Case Details

VAERS ID: 1242683 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-09
Onset:2021-04-21
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Basal ganglia haemorrhage, Cerebrovascular accident, Deep vein thrombosis, Ultrasound Doppler abnormal
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nifedipine
Current Illness:
Preexisting Conditions: Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Deep Vein Thrombosis- occlusive and non-occlusive in R axial and R brachial veins at level of PICC line. Pt admitted to hospital on 4/18/21 with acute basal ganglia hemorrhagic CVA, with PICC line placement on admission. DVTs identified on 4/21 via ultrasound. Pt currently admitted to Hospital


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