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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1403397

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Case Details

VAERS ID: 1403397 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-05-05
Onset:2021-05-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood test, Chest pain, Dyspnoea, Injection site pain, Myocarditis, Pain
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: blood test
CDC Split Type:

Write-up: Myocarditis. Chest pain, shortness of breath, pain when leaning over or increasing heart rate, referred pain in left shoulder


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