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From the 6/4/2021 release of VAERS data:

This is VAERS ID 1250896

Case Details

VAERS ID: 1250896 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New Jersey  
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain, Chest X-ray normal, Chest discomfort, Computerised tomogram head, Dizziness, Dyspnoea, Electrocardiogram normal, Fatigue, Headache, Lip swelling, Nausea, Peripheral swelling, Ultrasound Doppler
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

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? No
Previous Vaccinations: Flu
Other Medications: Atorvastatin, Exetimibe, Omeprazole, Flonase
Current Illness:
Preexisting Conditions: Gastritis, glaucoma, arthritis.
Allergies: Penicillin
Diagnostic Lab Data: Went to ER on 04/15 where they did US Doppler Venous Lower Extremity ; results negative. Also did EKG which was "normal". Headache continued so went back to ER on 04/17 where they did a EKG (normal), Chest X-ray (normal) and a CT Head without contrast (determined no clots). Was given Toradol and Reglan. Those drugs calmed my headache and I started to feel better. Slight headache ret 04/24.
CDC Split Type:

Write-up: Started 1 week after injection. Swelling in lower legs, felt like balloons. Feeling of swelling in lips. Headache started in left temple area of head; after a couple of days went across forehead and on back of head with intensity increasing but not extreme pain. Slight nausea; no vomiting. Some abdominal pain that would come and go. Periods of shortness of breath; tightness feeling in upper chest. Loss of energy and some light headed feeling.

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