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This is VAERS ID 289959

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 289959
VAERS Form:
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47300F / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Faeces discoloured, Haematochezia, Intussusception, Enema administration, Abdominal X-ray

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced pro"gressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussu


Changed on 12/8/2009

VAERS ID: 289959 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47300F / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO

Administered by: Private      Purchased by: Unknown Public
Symptoms: Faeces discoloured, Haematochezia, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, X-ray gastrointestinal tract normal, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced pro"gressively progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussu Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 3/2/2010

VAERS ID: 289959 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B47300F / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Haematochezia, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, X-ray gastrointestinal tract normal, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 4/7/2010

VAERS ID: 289959 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47300F / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Haematochezia, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, X-ray gastrointestinal tract normal, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 8/31/2010

VAERS ID: 289959 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B47300F / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Haematochezia, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, X-ray gastrointestinal tract normal, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 5/13/2013

VAERS ID: 289959 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47300F / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Haematochezia, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, X-ray gastrointestinal tract normal, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 5/14/2017

VAERS ID: 289959 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47300F / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Haematochezia, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, X-ray gastrointestinal tract normal, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 9/14/2017

VAERS ID: 289959 Before After
VAERS Form:(blank) 1
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 0 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 0 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47300F / 0 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 0 1 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 2/14/2018

VAERS ID: 289959 Before After
VAERS Form:1
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47300F / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


Changed on 6/14/2018

VAERS ID: 289959 Before After
VAERS Form:1
Age:0.2
Gender:Female
Location:Washington
Vaccinated:2007-08-24
Onset:2007-08-29
Submitted:2007-09-06
Entered:2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47300F / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Faeces discoloured, Intussusception, Irritability, Lethargy, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC 'Split Type':

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.

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