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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1696972

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Case Details

VAERS ID: 1696972 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Virginia  
Submitted: 0000-00-00
Entered: 2021-09-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 RA / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arthralgia, Dyspnoea, Electrocardiogram, Headache, Magnetic resonance imaging abnormal, Myalgia, Nausea, Thrombosis
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Arthritis (broad), Tendinopathies and ligament disorders (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: I was taking prescribed medication.
Current Illness: None.
Preexisting Conditions: None.
Allergies: I am allergic to tetracycline.
Diagnostic Lab Data: I had a EKG test done and a MRI.
CDC Split Type: vsafe

Write-up: After the vaccine every joint in my body was aching, my muscles were aching. I was also nausea and I had a very headache. I went to my doctor on April 13, 2021. My doctor sent me to the emergency room because I had shortness of breath. When I got to the ER I was placed on oxygen. I had a MRI test done and this is when the doctor told me I had blood clots.

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