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From the 4/30/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 1262490

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Case Details

VAERS ID: 1262490 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Florida  
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood test, Cardiomegaly, Chest pain, Hiatus hernia, Hypokalaemia, Oesophageal stenosis, Pericardial effusion, Pericarditis, Pleural effusion, Pneumonia
SMQs:, Cardiac failure (broad), Systemic lupus erythematosus (narrow), Gastrointestinal obstruction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Taking Ventolin HFA 108 (90 Base) MCG/ACT Aerosol Solution 1 puff as needed Inhalation every 4 hrs, Taking Imipramine HCl 50 MG Tablet 1 tablet Orally Once a day, Taking Triamcinolone Acetonide 0.1 % Cream apply small amount with q tip to e
Current Illness: Patient is a stable type 2 diabetic other than that no illnesses prior.
Preexisting Conditions: Patient had no other long standing chronic health condition.
Allergies: Allergies: Codeine Phosphate, Losartan Potassium, ACE Inhibitor, Milk, Caffeine.
Diagnostic Lab Data: testing and bloodwork was performed in hospital.
CDC Split Type:

Write-up: 03/28/2021 to 03/30/2021- Admitted Ip via E/R , Dx: Pneumonia, Cardiomegaly, Small pericardial effusion, Esophageal stenosis (s/p dilation), Small hiatal hernia. F/U with PCP for Hopital F/u on 04/01/2021. Visit ER on 04/03/2021- 04/05/21 04/14/21-ReAdmitted IP via E/R. -Dx: Dx: Chest pain, Pericarditis w/ mod-large Pericardial effusion (s/p pericardiocentesis), Hypokalemia, Pleural Effusion (s/p thoracentesis)

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