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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1397917



Case Details

VAERS ID: 1397917 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-05-03
Onset:2021-06-03
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Deep vein thrombosis, Ultrasound Doppler abnormal
SMQs:, 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? Yes
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: losartan, latanoprost, citalopram
Current Illness: Stage 3 Chronic Kidney Disease, Depression, Hypertension, Dyslipidemia, Impaired Glucose Tolerance, Glaucoma
Preexisting Conditions: As above
Allergies: NKDA
Diagnostic Lab Data: Venous Doppler, left leg
CDC Split Type:

Write-up: Deep Vein Thrombosis, left leg


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