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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1330104



Case Details

VAERS ID: 1330104 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-05-04
Onset:2021-05-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Deep vein thrombosis, Pain in extremity, Peripheral swelling, Ultrasound Doppler abnormal
SMQs:, Cardiac failure (broad), Angioedema (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: albuterol inhaler, amitriptyline, flexeril, voltaren gel, flonase, ibuprofen, sildenafil, cialis, b vitamin, vitamin d, testosterone topical solution
Current Illness: unknown
Preexisting Conditions: hypogonadism, knee pain, erectile dysfunction
Allergies: no known allergies
Diagnostic Lab Data: right lower extremity venous ultrasound on 5/10 which showed DVT in the right common femoral, femoral, popliteal, and peroneal veins.
CDC Split Type:

Write-up: Patient had onset of right calf pain and swelling several hours after receiving vaccine. Was seen on 5/10 and diagnosed with right lower extremity DVT.


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