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From the 5/14/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 1208205

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Case Details

VAERS ID: 1208205 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Georgia  
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain lower, Deep vein thrombosis, Erythema, Pain in extremity, Skin warm, Swelling, Thrombophlebitis
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Tendinopathies and ligament disorders (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Advil, losartan potassium
Current Illness:
Preexisting Conditions: High blood pressure. herpes simplex
Allergies: hazelnut, penicillins, amoxicillin, sulfamethoxazole, Vitamin - B
Diagnostic Lab Data: urgent care medical examination (April 14, 2021) waiting primary cared physician exam on April 15, 2021
CDC Split Type:

Write-up: deep vein thrombosis, swelling, pain in both legs and lower abdomen. warm and red skin. red swollen veins.

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