| VAERS ID: |
276539 (history) |
| Form: |
Version .0 |
| Age: |
0.3 |
| Gender: |
Male |
| Location: |
Vermont |
| Vaccinated: | 2007-02-01 |
| Onset: | 2007-04-08 |
| Days after vaccination: | 66 |
| Submitted: |
2007-04-10 |
| Days after onset: | 2 |
| Entered: |
2007-04-17 |
| Days after submission: | 7 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B097AB / 1 |
RL / IM |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UF014AA / 1 |
LL / IM |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
B08674 / 1 |
LL / IM |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0979F / 1 |
- / PO |
Administered by: Private Purchased by: Public
Symptoms: Abdominal pain,
Abnormal faeces,
Barium double contrast,
Explorative laparotomy,
Intussusception,
Surgery
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal obstruction (narrow), Biliary system related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Contrast enema in interventional radiology - intussusception record received 4/26/07-US positive for Intussusception.
CDC Split Type:
Write-up: Patient developed abd pain, current jelly stools and diagnosed with intussusception. Not able to reduce via gastrografin enema. Brought to OR for ex-lap. Ileo-cecal intussusception reduced manually. Records received 4/26/07-DC Summary for DOS 4/8-4/10/07 DX:Intussusception. HX of vomiting and bloody stool. Exploratory laparotomy and appendectomy |
