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This is VAERS ID 275814

Case Details

VAERS ID: 275814 (history)  
Form: Version 1.0  
Age: 11.0  
Gender: Female  
Location: Oklahoma  
Vaccinated:2007-04-09
Onset:2007-04-09
   Days after vaccination:0
Submitted: 2007-04-09
   Days after onset:0
Entered: 2007-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1208F / 1 LA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR 12142AA / 1 LA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B015A / 1 RA / IM

Administered by: Public       Purchased by: Public
Symptoms: Anxiety, Fall, Loss of consciousness, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Approx 2-3 min after vaccine admin, pt experienced syncope episode with 2-3 sec loss of consciousness and fall to ground from own height. Pt had not eaten that day and had expressed anxiety re: immuniz. prior to event vs immediately after event BP-110/70; P-130/min, R-24/min, O2 sat 98%. Placed pt in recumbent position and gave her mild to drink. Fs OS-109 mg/dl. Fully recovered w/in 10 min BP-100/70; P-88/mm; R-16/mn O2 Sat 99%. Recovered at 11:55 in stable condition.


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