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This is VAERS ID 267839

History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2006

VAERS ID: 267839
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR, INC. UF016AA / - LL / IM
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATORIES B08646E / - RL / IM
ROTHB5: ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema.


Changed on 12/8/2009

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE AC21B071AA / - LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR, INC. SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO, 7-VALENT (PREVNAR) PNEUMO (PREVNAR) / LEDERLE LABORATORIES WYETH PHARMACEUTICALS, INC B08646E / - RL / IM
ROTHB5: ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT (ROTATEQ) ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Unknown Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 3/2/2010

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08646E / - RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 4/7/2010

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08646E / - RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 8/31/2010

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08646E / - RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 4/13/2011

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / - RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 5/13/2011

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / - RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 6/11/2011

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / - RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 5/13/2013

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / - RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 2/14/2017

VAERS ID: 267839 Before After
VAERS Form:
Age:0.4 0.36
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / - RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 5/14/2017

VAERS ID: 267839 Before After
VAERS Form:
Age:0.36
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / - RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - - / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 9/14/2017

VAERS ID: 267839 Before After
VAERS Form:(blank) 1
Age:0.36
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / - UNK LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / - UNK LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / - UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / - UNK - MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 2/14/2018

VAERS ID: 267839 Before After
VAERS Form:1
Age:0.36
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / UNK LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / UNK LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / UNK MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 6/14/2018

VAERS ID: 267839 Before After
VAERS Form:1
Age:0.36
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / UNK LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / UNK LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / UNK MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 8/14/2018

VAERS ID: 267839 Before After
VAERS Form:1
Age:0.36
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / UNK LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / UNK LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / UNK MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.


Changed on 9/14/2018

VAERS ID: 267839 Before After
VAERS Form:1
Age:0.36
Gender:Male
Location:Colorado
Vaccinated:2006-11-06
Onset:2006-11-06
Submitted:2006-11-07
Entered:2006-11-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B071AA / UNK LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF016AA / UNK LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08646E / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0941F / UNK MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Haematochezia, Intussusception, Lethargy, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None Birth HX: c section at term. Uncomplicated
Allergies:
Diagnostic Lab Data: Air enema, abdominal x-ray, CBC, chem profile LABS: WBC 19.7, H/H 11.9/35
CDC 'Split Type':

Write-up: Onset of vomiting and bloody stool 3-4 hours after administration of vaccines. Patient seen in emergency room and diagnosed with intussusception, reduced with air enema. 12/19/06 Received medical records from ER which reveal patient seen 11/06/06 s/p vomiting & bloody stool on day of vax. Afebrile. Lethargic. Hypoactive bowel sounds & palpable soft mass in RUQ with tenderness to palpation. Seen in ER at outlying hospital then transferred to facility which could provide air contrast enema. Kept in that ER for several hours s/p successful reduction for continued observation. Final DX: Intussusception, reduced by air enema.

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