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This is VAERS ID 267943

History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2006

VAERS ID: 267943
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE AC21B059DA / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 - / IM
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATORIES B08657K / 1 - / IM
ROTHB5: ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Intussusception, Laboratory test abnormal, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema.


Changed on 12/8/2009

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE AC21B059DA / 1 - / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 - / IM
PNC: PNEUMO, 7-VALENT (PREVNAR) PNEUMO (PREVNAR) / LEDERLE LABORATORIES WYETH PHARMACEUTICALS, INC B08657K / 1 - / IM
ROTHB5: ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT (ROTATEQ) ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Unknown Public
Symptoms: Intussusception, Laboratory test abnormal, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 1/5/2010

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 - UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 - UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08657K / 1 - UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 3/2/2010

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 4/7/2010

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 8/31/2010

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 1/4/2011

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 4/13/2011

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 5/13/2011

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 6/11/2011

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 5/13/2013

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 6/14/2014

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 2/14/2017

VAERS ID: 267943 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting, Enema administration, Abdominal X-ray

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 9/14/2017

VAERS ID: 267943 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 2 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 1 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 1 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 1 2 - MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 2/14/2018

VAERS ID: 267943 Before After
VAERS Form:1
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 2 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 6/14/2018

VAERS ID: 267943 Before After
VAERS Form:1
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 2 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 8/14/2018

VAERS ID: 267943 Before After
VAERS Form:1
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 2 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.


Changed on 9/14/2018

VAERS ID: 267943 Before After
VAERS Form:1
Age:0.3
Gender:Female
Location:New York
Vaccinated:2006-09-18
Onset:2006-11-05
Submitted:2006-11-29
Entered:2006-11-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 2 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0085 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08657K / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0146F / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Intussusception, Lethargy, Vomiting

Life Threatening? Yes
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zantac
Current Illness:
Preexisting Conditions: GERD; SC trait: SGA Birth HX: full term, normal vag delivery, no complications. PMH: GERD, small for gestational age.
Allergies:
Diagnostic Lab Data: LABS: abdominal films revealed IS.
CDC 'Split Type':

Write-up: Intussusception 11/5/06 - 11/09/06 reduced with Ba enema. 12/8/06 Received medical records from hospital which reveal patient experienced a week of vomiting prior to admit. No fever & no sick contacts. Lethargic on admission 11/3/06 & anterior fontanelle was depressed & mucous membranes dry. Abdomen was soft with no masses or distention. Surgical consult done. Air enema relieved the IS. No further vomiting & patient d/c to home on 11/8/06.

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