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

This is VAERS ID 1758835

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Case Details

VAERS ID: 1758835 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-07-14
Onset:2021-10-03
   Days after vaccination:81
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 204A21A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Chest X-ray normal, Cough, Dyspnoea, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol, ASA, duloxetine, empagliflozin, gabapentin, insulin degludec, insulin lispro, metformin, omeprazole, oxybutynin, roflumilast, sotalol, tamsulosin, tiotropium, zolpidem
Current Illness: no
Preexisting Conditions: anxiety, atrial fibrillation, back pain, bladder outlet obstruction, BPH, carotid stenosis, CAD, COPD, DM-2, depression, GERD, HTN, hyperlipidemia, neurogenic bladder, OSA, stroke and tobacco abuse
Allergies: oxycodone, PCN
Diagnostic Lab Data: PCR + 10/3/2021, CXR: unremarkable
CDC Split Type:

Write-up: breakthrough Covid + w/ cough/dyspnea


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