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This is VAERS ID 275814

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

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

Administered by: Public      Purchased by: Unknown
Symptoms: Anxiety, Fall, Loss of consciousness, Syncope

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) 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.


Changed on 12/8/2009

275814 Before After
VAERS Form:
Age:11.0
Gender:Female
Location:Oklahoma
Vaccinated:2007-04-09
Onset:2007-04-09
Submitted:2007-04-09
Entered:2007-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1208F / 0 LA / IM
MNQ: MENINGOCOCCAL (MENACTRA) / AVENTIS PASTEUR 12142AA / 0 LA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B015A / 0 RA / IM

Administered by: Public      Purchased by: Unknown Public
Symptoms: Anxiety, Fall, Loss of consciousness, Syncope

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) 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, 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.


Changed on 4/7/2010

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

Administered by: Public      Purchased by: Public
Symptoms: Anxiety, Fall, Loss of consciousness, Syncope

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) 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.


Changed on 5/14/2017

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

Administered by: Public      Purchased by: Public
Symptoms: Anxiety, Fall, Loss of consciousness, Syncope

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) 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.


Changed on 9/14/2017

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

Administered by: Public      Purchased by: Public
Symptoms: Anxiety, Fall, Loss of consciousness, Syncope

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) 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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