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

This is VAERS ID 1258608



Case Details

VAERS ID: 1258608 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-04-11
Onset:2021-04-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Blood creatine phosphokinase normal, Blood magnesium normal, Blood test normal, Differential white blood cell count normal, Erythema, Fatigue, Fibrin D dimer normal, Full blood count normal, Headache, Metabolic function test
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: Blood test for blood clots - negative result on 4/21/2021 These test were normal: CBC w/ auto diff, CPK, Comprehensive Metabolic Panel, D DIMER, Mg. D DIMER, QUANTITATIVE Magnesium Test results are negative.
CDC Split Type:

Write-up: He has had the following symptoms from the 4/12/2021 till present time: constant headache and fatigue. Intermittent low fever (99F). On 4/21/2021, his primary care doctor recommended that we take him to Emergency Room because she was concerned about thrombosis as side effects from the vaccine. His legs had some red patches on the back of the ankles area. At ER, doctor did blood test for blood clot and result was negative. He got an IV injection less headache.


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