| VAERS ID: |
281104 (history) |
| Form: |
Version .0 |
| Age: |
0.3 |
| Gender: |
Male |
| Location: |
Arizona |
| Vaccinated: | 2007-05-02 |
| Onset: | 2007-06-03 |
| Days after vaccination: | 32 |
| Submitted: |
2007-06-07 |
| Days after onset: | 4 |
| Entered: |
2007-06-11 |
| Days after submission: | 4 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR |
C2553AA / 1 |
UN / IM |
| HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. |
UE924AA / 1 |
UN / IM |
| IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
Z0018 / 1 |
UN / SC |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
B47442A / 1 |
UN / IM |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
1112F / 1 |
- / PO |
Administered by: Private Purchased by: Private
Symptoms: Cardiac murmur,
Colectomy,
Colostomy,
Culture negative,
Echocardiogram abnormal,
Enema administration,
Haematochezia,
Intussusception,
Laboratory test normal,
Surgery,
Ultrasound abdomen abnormal,
Ventricular septal defect,
Vomiting,
White blood cell count normal
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Congenital, familial and genetic disorders (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Cardiomyopathy (broad)
Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Intussusception. LABS: No lab reports were included w/records. Following was noted in D/C summary: US of abd showed IS. Air contrast unable to reduce. WBC 14.7. Chemistry WNL. Cultures neg. Echocardiogram revealed moderate membranous
CDC Split Type:
Write-up: Intussusception. 6/12/07 Received vax record which confirms RO lot & dose # as correct. 7/31/07 Received hospital medical records which reveal patient experienced emesis & bloody stools. Admitted 6/3-6/7/07. Surgical consult & taken to OR for reduction of IS & right hemicolectomy w/ileocolostomy. Cardio consult done for heart murmur. Recovery uneventful. Surg & cardio f/u on d/c. FINAL DX: Intussusception, s/p right hemicolectomy & ileocolostomy; VSD. |
