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This is VAERS ID 277955

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

277955
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08683D / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and d"iagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced


Changed on 12/8/2009

277955 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08683D / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Blood creatinine decreased, Blood sodium increased, Crying, Decreased activity, Diarrhoea, Eye discharge, Fatigue, Haematochezia, Intussusception, Irritability, Lethargy, Lymphocyte count abnormal, Lymphocyte count decreased, Nasopharyngitis, Nausea, Neutrophil count increased, Otitis media acute, Pallor, Pyrexia, Vomiting, White blood cell count decreased, Enema administration, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and d"iagnosed diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to Missoula where peds surgeon Dr. Manktelow reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema


Changed on 3/2/2010

277955 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08683D / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Blood creatinine decreased, Blood sodium increased, Crying, Decreased activity, Diarrhoea, Eye discharge, Fatigue, Haematochezia, Intussusception, Irritability, Lethargy, Lymphocyte count abnormal, Lymphocyte count decreased, Nasopharyngitis, Nausea, Neutrophil count increased, Otitis media acute, Pallor, Pyrexia, Vomiting, White blood cell count decreased, Enema administration, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to Missoula where peds surgeon Dr. Manktelow reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema


Changed on 4/7/2010

277955 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08683D / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Blood creatinine decreased, Blood sodium increased, Crying, Decreased activity, Diarrhoea, Eye discharge, Fatigue, Haematochezia, Intussusception, Irritability, Lethargy, Lymphocyte count abnormal, Lymphocyte count decreased, Nasopharyngitis, Nausea, Neutrophil count increased, Otitis media acute, Pallor, Pyrexia, Vomiting, White blood cell count decreased, Enema administration, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to Missoula where peds surgeon Dr. Manktelow reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema


Changed on 8/31/2010

277955 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08683D / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Blood creatinine decreased, Blood sodium increased, Crying, Decreased activity, Diarrhoea, Eye discharge, Fatigue, Haematochezia, Intussusception, Irritability, Lethargy, Lymphocyte count abnormal, Lymphocyte count decreased, Nasopharyngitis, Nausea, Neutrophil count increased, Otitis media acute, Pallor, Pyrexia, Vomiting, White blood cell count decreased, Enema administration, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to Missoula where peds surgeon Dr. Manktelow reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema


Changed on 1/7/2013

277955 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08683D / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Blood creatinine decreased, Blood sodium increased, Crying, Decreased activity, Diarrhoea, Eye discharge, Fatigue, Haematochezia, Intussusception, Irritability, Lethargy, Lymphocyte count abnormal, Lymphocyte count decreased, Nasopharyngitis, Nausea, Neutrophil count increased, Otitis media acute, Pallor, Pyrexia, Vomiting, White blood cell count decreased, Enema administration, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to Missoula hospital where peds surgeon Dr. Manktelow reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema was repeated successfully. Had a bloody stool & vomiting s/p enema. Kept overnight for observation & d/c home next am. FINAL DX: ileocolonic intussusception, reduced by air enema.


Changed on 5/13/2013

277955 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08683D / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Blood creatinine decreased, Blood sodium increased, Crying, Decreased activity, Diarrhoea, Eye discharge, Fatigue, Haematochezia, Intussusception, Irritability, Lethargy, Lymphocyte count abnormal, Lymphocyte count decreased, Nasopharyngitis, Nausea, Neutrophil count increased, Otitis media acute, Pallor, Pyrexia, Vomiting, White blood cell count decreased, Enema administration, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to hospital where peds surgeon reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema was repeated successfully. Had a bloody stool & vomiting s/p enema. Kept overnight for observation & d/c home next am. FINAL DX: ileocolonic intussusception, reduced by air enema.


Changed on 5/14/2017

277955 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08683D / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal mass, Abdominal pain, Blood creatinine decreased, Blood sodium increased, Crying, Decreased activity, Diarrhoea, Eye discharge, Fatigue, Haematochezia, Intussusception, Irritability, Lethargy, Lymphocyte count abnormal, Lymphocyte count decreased, Nasopharyngitis, Nausea, Neutrophil count increased, Otitis media acute, Pallor, Pyrexia, Vomiting, White blood cell count decreased, Enema administration, Band neutrophil count increased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to hospital where peds surgeon reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema was repeated successfully. Had a bloody stool & vomiting s/p enema. Kept overnight for observation & d/c home next am. FINAL DX: ileocolonic intussusception, reduced by air enema.


Changed on 9/14/2017

277955 Before After
VAERS Form:(blank) 1
Age:0.4
Gender:Male
Location:Montana
Vaccinated:2006-11-29
Onset:2007-04-21
Submitted:2007-05-04
Entered:2007-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR 0278F / 1 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08683D / 1 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0278F / 0 1 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Diarrhoea, Fatigue, Intussusception, Irritability, Nasopharyngitis, Otitis media acute, Pallor, Pyrexia, Vomiting, Abnormal behaviour

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: unknown
Preexisting Conditions: extensive port wine stain on lower extremities with resultant leg assymetry PMH: Klippel-Trenaunay syndrome. Fever & otitis media dx 6 days prior & on antibiotics. Extensive port wine stain over lower back down to feet.
Allergies:
Diagnostic Lab Data: LABS: WBC low at 5.2, neutros elevated at 38, bandss elevated at 15, lymphs low at 39 w/markedly reactive lymphs noted. Creatinine low at 0.33. Na elevated at 145.
CDC 'Split Type':

Write-up:Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to hospital where peds surgeon reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema was repeated successfully. Had a bloody stool & vomiting s/p enema. Kept overnight for observation & d/c home next am. FINAL DX: ileocolonic intussusception, reduced by air enema.


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