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This is VAERS ID 281912

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 281912
VAERS Form:
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 RL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08692D / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Blood potassium increased, Blood sodium decreased, Blood urea normal, Explorative laparotomy, 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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center.


Changed on 12/8/2009

VAERS ID: 281912 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 RL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08692D / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Blood potassium increased, Blood sodium decreased, Blood urea normal, Intussusception, Lethargy, Nausea, Pyrexia, Small intestinal anastomosis, Small intestinal resection, Surgery, Urinary system X-ray, Vomiting, White blood cell count, Explorative laparotomy, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 3/2/2010

VAERS ID: 281912 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 RL / UN
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08692D / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood potassium increased, Blood sodium decreased, Blood urea normal, Intussusception, Lethargy, Nausea, Pyrexia, Small intestinal anastomosis, Small intestinal resection, Surgery, Urinary system X-ray, Vomiting, White blood cell count, Explorative laparotomy, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 4/7/2010

VAERS ID: 281912 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 RL / UN
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08692D / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood potassium increased, Blood sodium decreased, Blood urea normal, Intussusception, Lethargy, Nausea, Pyrexia, Small intestinal anastomosis, Small intestinal resection, Surgery, Urinary system X-ray, Vomiting, White blood cell count, Explorative laparotomy, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 8/31/2010

VAERS ID: 281912 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 RL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08692D / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood potassium increased, Blood sodium decreased, Blood urea normal, Intussusception, Lethargy, Nausea, Pyrexia, Small intestinal anastomosis, Small intestinal resection, Surgery, Urinary system X-ray, Vomiting, White blood cell count, Explorative laparotomy, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 5/13/2013

VAERS ID: 281912 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood potassium increased, Blood sodium decreased, Blood urea normal, Intussusception, Lethargy, Nausea, Pyrexia, Small intestinal anastomosis, Small intestinal resection, Surgery, Urinary system X-ray, Vomiting, White blood cell count, Explorative laparotomy, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 5/14/2017

VAERS ID: 281912 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 0 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood potassium increased, Blood sodium decreased, Blood urea normal, Intussusception, Lethargy, Nausea, Pyrexia, Small intestinal anastomosis, Small intestinal resection, Surgery, Urinary system X-ray, Vomiting, White blood cell count, Explorative laparotomy, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 9/14/2017

VAERS ID: 281912 Before After
VAERS Form:(blank) 1
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 0 1 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 0 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 0 1 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Pyrexia, Small intestinal resection, Vomiting, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 2/14/2018

VAERS ID: 281912 Before After
VAERS Form:1
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 1 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Pyrexia, Small intestinal resection, Vomiting, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 6/14/2018

VAERS ID: 281912 Before After
VAERS Form:1
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 1 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Pyrexia, Small intestinal resection, Vomiting, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 8/14/2018

VAERS ID: 281912 Before After
VAERS Form:1
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 1 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Pyrexia, Small intestinal resection, Vomiting, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 9/14/2018

VAERS ID: 281912 Before After
VAERS Form:1
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 1 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Pyrexia, Small intestinal resection, Vomiting, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.


Changed on 10/14/2018

VAERS ID: 281912 Before After
VAERS Form:1
Age:0.2
Gender:Female
Location:Texas
Vaccinated:2007-05-07
Onset:2007-05-30
Submitted:2007-06-12
Entered:2007-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF018AA / 1 RL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692D / 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0235U / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Pyrexia, Small intestinal resection, Vomiting, Abdominal X-ray, Obstruction

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: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None PMH: Noted to have birth defects of grossly deformed right ear & spot on kidney
Allergies:
Diagnostic Lab Data: Abdominal xray-$gobstruction LABS: WBC 13, Na 133, K 5.6, BUN 10. KUB c/w SBO.
CDC 'Split Type':

Write-up: This patient developed fever/vomiting and then had small bowel resection for intussusception at medical center. 6/19/07 Received vax record from PCP which confirms RO lot & dose as reported. 7/26/07 Received medical records from hospital via fax from CDC. Records are primarily for ENT but IS mentioned on clinic note having been perfomed 6/1/07 w/resection of 5cm of bowel resected. 7/27/07 Received hospital medical records which reveal patient experienced nausea, bilious vomiting, fever & lethargy x 4 days. Admitted 5/30-6/3/07. Tx w/IV antibiotics & taken to OR. Small bowel IS found at proximal mid ileum. Did well post op w/o complications. FINAL DX: Intussusception; s/p exp lap & small bowel resection w/reanastomosis. Records faxed to CDC.

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