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From the 4/1/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1104152



Case Details

VAERS ID: 1104152 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-10
Onset:2021-03-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / UNK - / IM

Administered by: Public       Purchased by: ?
Symptoms: Deep vein thrombosis, Erythema, Pain, Swelling, Ultrasound Doppler
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Doppler performed
CDC Split Type:

Write-up: Developed 3 small blood clots in his left lower leg on Saturday, 3/10/2021 - swelling and slight redness along with pain


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210401&IDNUMBER=1104152

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