| VAERS ID: |
266161 (history) |
| Form: |
Version .0 |
| Age: |
0.2 |
| Gender: |
Female |
| Location: |
New Jersey |
| Vaccinated: | 2006-10-02 |
| Onset: | 2006-10-08 |
| Days after vaccination: | 6 |
| Submitted: |
2006-11-07 |
| Days after onset: | 30 |
| Entered: |
2006-11-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE |
AC21B056AA / 0 |
LL / - |
| HIBV: HIB (ACTHIB) / AVENTIS PASTEUR, INC. |
UE965AA / 0 |
RL / - |
| PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATORIES |
B08642E / 0 |
RL / - |
| ROTHB5: ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT (ROTATEQ) / MERCK & CO. INC. |
0726F / 0 |
- / PO |
Administered by: Private Purchased by: Unknown
Symptoms: Haematochezia,
Ileus,
Intussusception,
Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad)
Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed dilated loops & + fluid levels. US of abd revealed right mid abdomen telescoping./ss
CDC Split Type:
Write-up: Pt given Rotateq vaccine PO 10/02/06. Pt diagnosed with intussusception 10/08/06 and had surgical reduction 10/09/2006. |
