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This is VAERS ID 276038

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 276038
VAERS Form:
Age:0.2
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 0 RL / IM
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES B08684H / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Gastrointestinal necrosis, Haematochezia, Explorative laparotomy, Decreased appetite

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/0"7-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surg


Changed on 12/8/2009

VAERS ID: 276038 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 0 RL / IM
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES B08684H / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Gastrointestinal necrosis, Haematochezia, Intussusception, Purulent discharge, Surgery, Vomiting, Ultrasound abdomen abnormal, Explorative laparotomy, Decreased appetite

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/0"7-1/25/07. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surg surgically reduced.


Changed on 3/2/2010

VAERS ID: 276038 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 0 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / LEDERLE LABORATORIES B08684H / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Gastrointestinal necrosis, Haematochezia, Intussusception, Purulent discharge, Surgery, Vomiting, Ultrasound abdomen abnormal, Explorative laparotomy, Decreased appetite

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 4/7/2010

VAERS ID: 276038 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 0 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / LEDERLE LABORATORIES B08684H / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Gastrointestinal necrosis, Haematochezia, Intussusception, Purulent discharge, Surgery, Vomiting, Ultrasound abdomen abnormal, Explorative laparotomy, Decreased appetite

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 5/13/2013

VAERS ID: 276038 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 0 RL / IM
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES B08684H / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Gastrointestinal necrosis, Haematochezia, Intussusception, Purulent discharge, Surgery, Vomiting, Ultrasound abdomen abnormal, Explorative laparotomy, Decreased appetite

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 2/14/2017

VAERS ID: 276038 Before After
VAERS Form:
Age:0.2 0.17
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 0 RL / IM
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES PFIZER/WYETH B08684H / 0 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Gastrointestinal necrosis, Haematochezia, Intussusception, Purulent discharge, Surgery, Vomiting, Ultrasound abdomen abnormal, Explorative laparotomy, Decreased appetite

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 9/14/2017

VAERS ID: 276038 Before After
VAERS Form:(blank) 1
Age:0.17
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 0 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 0 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08684H / 0 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 0 1 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 2/14/2018

VAERS ID: 276038 Before After
VAERS Form:1
Age:0.17
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08684H / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 1 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 6/14/2018

VAERS ID: 276038 Before After
VAERS Form:1
Age:0.17
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08684H / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 1 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 8/14/2018

VAERS ID: 276038 Before After
VAERS Form:1
Age:0.17
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08684H / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 1 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.


Changed on 9/14/2018

VAERS ID: 276038 Before After
VAERS Form:1
Age:0.17
Gender:Male
Location:Pennsylvania
Vaccinated:2007-01-15
Onset:2007-01-21
Submitted:2007-04-11
Entered:2007-04-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B059DA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0719R / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08684H / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0726F / 1 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery

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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x ray etc. LABS: Abdominal US revealed IS. Air contrast barium enema failed x 4.
CDC 'Split Type':

Write-up: intussusception diagnosed & operated 6 days later. 4/24/07 Received medical records from hospital which reveal patient experienced a 1 day hx of bloody stools & emesis with decreased appetite. Had been transferred from outlying hospital. Admitted1/21/07-1/25/07. Surg consult done & taken to OR for exp lap & ileocecectomy w/primary anastomosis. During surgery there was diffuse purulent fluid found in peritoneum w/necrotic IS. Patient progressed well & was d/c to home FINAL DX: Intussusception, surgically reduced.

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