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This is VAERS ID 281104

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

281104
VAERS Form:
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
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) / WYETH PHARMACEUTICALS, INC B47442A / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac murmur, Colostomy, Culture negative, Echocardiogram abnormal, Colectomy

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Intussusception
CDC 'Split Type':

Write-up:Intussusception


Changed on 12/8/2009

281104 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
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) / WYETH PHARMACEUTICALS, INC B47442A / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Cardiac murmur, Colostomy, Haematochezia, Intussusception, Surgery, Ventricular septal defect, Vomiting, White blood cell count normal, Enema administration, Ultrasound abdomen abnormal, Laboratory test normal, Culture negative, Echocardiogram abnormal, Colectomy

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Intussusception 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 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.


Changed on 3/2/2010

281104 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
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) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B47442A / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Cardiac murmur, Colostomy, Haematochezia, Intussusception, Surgery, Ventricular septal defect, Vomiting, White blood cell count normal, Enema administration, Ultrasound abdomen abnormal, Laboratory test normal, Culture negative, Echocardiogram abnormal, Colectomy

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: 4     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.


Changed on 4/7/2010

281104 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
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 (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47442A / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Cardiac murmur, Colostomy, Haematochezia, Intussusception, Surgery, Ventricular septal defect, Vomiting, White blood cell count normal, Enema administration, Ultrasound abdomen abnormal, Laboratory test normal, Culture negative, Echocardiogram abnormal, Colectomy

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: 4     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.


Changed on 8/31/2010

281104 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
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) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B47442A / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Cardiac murmur, Colostomy, Haematochezia, Intussusception, Surgery, Ventricular septal defect, Vomiting, White blood cell count normal, Enema administration, Ultrasound abdomen abnormal, Laboratory test normal, Culture negative, Echocardiogram abnormal, Colectomy

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: 4     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.


Changed on 5/13/2013

281104 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
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
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Cardiac murmur, Colostomy, Haematochezia, Intussusception, Surgery, Ventricular septal defect, Vomiting, White blood cell count normal, Enema administration, Ultrasound abdomen abnormal, Laboratory test normal, Culture negative, Echocardiogram abnormal, Colectomy

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: 4     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.


Changed on 2/14/2017

281104 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
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, Colostomy, Haematochezia, Intussusception, Surgery, Ventricular septal defect, Vomiting, White blood cell count normal, Enema administration, Ultrasound abdomen abnormal, Laboratory test normal, Culture negative, Echocardiogram abnormal, Colectomy

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: 4     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 VSD & large amount of tissue transformation.
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.


Changed on 9/14/2017

281104 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Male
Location:Arizona
Vaccinated:2007-05-02
Onset:2007-06-03
Submitted:2007-06-07
Entered:2007-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 2 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. UE924AA / 1 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0018 / 1 2 UN / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47442A / 1 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 2 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception

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: 4     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 VSD & large amount of tissue transformation.
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.


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