VAERS ID: |
274395 (history) |
Form: |
Version .0 |
Age: |
0.2 |
Gender: |
Female |
Location: |
California |
Vaccinated: | 2007-01-17 |
Onset: | 2007-03-15 |
Days after vaccination: | 57 |
Submitted: |
2007-03-20 |
Days after onset: | 5 |
Entered: |
2007-03-20 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B079BA / 0 |
LL / IM |
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. |
0784F / 0 |
RL / IM |
PNC: PNEUMO (PREVNAR7) / LEDERLE LABORATORIES |
836258A / 0 |
RL / IM |
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0779F / 0 |
- / PO |
Administered by: Other Purchased by: Unknown Symptoms: Barium double contrast,
Intussusception,
Ultrasound scan SMQs:, Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations: Other Medications: NONE Current Illness: NONE Preexisting Conditions: NONE Allergies: Diagnostic Lab Data: records received 3/28/07-Intussusception. Confirmed by ultrasound and successfully reduced with air contrast barium enema CDC Split Type:
Write-up: Patient developed intussusception 3/15/07 sent to hospital - reduced with barium air enema. 03/28/07-DC summary received. DC DX: Intussusception. Confirmed by ultrasound and successfully reduced with air contrast barium enema. |