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This is VAERS ID 289405

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 289405
VAERS Form:
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47492K / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Enema administration, Gastrointestinal sounds abnormal

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain


Changed on 12/8/2009

VAERS ID: 289405 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47492K / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Pallor, Vomiting, X-ray, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal sounds abnormal

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


Changed on 3/2/2010

VAERS ID: 289405 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B47492K / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Pallor, Vomiting, X-ray, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal sounds abnormal

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


Changed on 4/7/2010

VAERS ID: 289405 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47492K / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Pallor, Vomiting, X-ray, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal sounds abnormal

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


Changed on 8/31/2010

VAERS ID: 289405 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B47492K / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Pallor, Vomiting, X-ray, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal sounds abnormal

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


Changed on 5/13/2013

VAERS ID: 289405 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47492K / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Pallor, Vomiting, X-ray, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal sounds abnormal

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


Changed on 2/14/2017

VAERS ID: 289405 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 RA / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47492K / 1 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Pallor, Vomiting, X-ray, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal sounds abnormal

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


Changed on 9/14/2017

VAERS ID: 289405 Before After
VAERS Form:(blank) 1
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 2 3 RA / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47492K / 1 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 2 3 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Vomiting, X-ray, Enema administration

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


Changed on 2/14/2018

VAERS ID: 289405 Before After
VAERS Form:1
Age:0.5
Gender:Male
Location:Kansas
Vaccinated:2007-08-03
Onset:2007-08-18
Submitted:2007-08-30
Entered:2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 3 RA / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47492K / 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 3 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Haematochezia, Intussusception, Pain, Vomiting, X-ray, Enema administration

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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC 'Split Type':

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


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