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

This is VAERS ID 1258374



Case Details

VAERS ID: 1258374 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-08
Onset:2021-04-12
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / UNK LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Chest X-ray, Chills, Computerised tomogram head, Confusional state, Fracture, Laboratory test, Magnetic resonance imaging abnormal, Pain, Retching, Seizure, Venous thrombosis, Vomiting, X-ray
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Convulsions (narrow), Embolic and thrombotic events, venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Osteoporosis/osteopenia (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (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:
Other Medications: Flomax 0.4mg, lipitor 40mg, lisinopril 20mg, melatonin 5mg, red rice yeast 600mg, CoQ10 30mg
Current Illness: none
Preexisting Conditions: controlled hypertension
Allergies: none
Diagnostic Lab Data: 4/12, labs, chest x-ray, shoulder x-ray, 4/13 CT head, and Adomnal MRI with contrast. 4/ 15 Head MRI with contrast
CDC Split Type:

Write-up: 4/9 thru 4/12, body aches, chills. 4/12 0400 throwing up stomach pain from dry heaving throughout the day, confusion starting at 6pm on 4/12. Seizure on 4/12 at 8 pm. 911, ambulance. to Hospital Seizure so severe caused a Fracture in the Right Scapula. MRI on 4/15 showed a venous thrombosis partial occlusion in the brain.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1258374


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