| VAERS ID: |
274768 (history) |
| Form: |
Version 1.0 |
| Age: |
0.65 |
| Gender: |
Male |
| Location: |
Indiana |
| Vaccinated: | 2007-03-02 |
| Onset: | 2007-03-05 |
| Days after vaccination: | 3 |
| Submitted: |
2007-03-13 |
| Days after onset: | 7 |
| Entered: |
2007-03-26 |
| Days after submission: | 13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B092AA / 3 |
LL / - |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UF077AA / 3 |
RL / - |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
B36258C / 3 |
RL / - |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
1109F / 3 |
MO / PO |
Administered by: Private Purchased by: Private
Symptoms: Barium enema,
Intussusception,
Surgery
SMQs:, Gastrointestinal obstruction (narrow)
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, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Barium enema (+) for partially resolving ileocolic intussusception. Abdominal Survey:no free air is demonstrated. No gas can be seen on right side of abdomen. Findings may be due to mild constipation. Concern for intusssusception. Barium enema. ileocolic intussusception that reduced easily from distal transverse colon to ileoceal valve but was unable to completely reduce the intussusception despite several attempts.
CDC Split Type:
Write-up: Child developed an ileocolic intussusception 3/5/07. To surgery on 3/6/07. 04/03/07-records received from facility DC DX: Intussusception. Colicky abdominal pain. No bloody stool. Acute bilious vomiting. Surgical procedure:laparotomy, reduction of intussusception, appendectomy. Post operative diagnosis:ileocolic intussusception. | 