National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 290330

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 290330
VAERS Form:
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08674E / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Faeces discoloured, Intussusception, Enema administration

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continu"ed w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; app


Changed on 12/8/2009

VAERS ID: 290330 Before After
VAERS Form:
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08674E / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal pain, Appendicectomy, Faeces discoloured, Intussusception, Surgery, Vomiting, Enema administration

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continu"ed Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; app appendectomy.


Changed on 3/2/2010

VAERS ID: 290330 Before After
VAERS Form:
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08674E / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Appendicectomy, Faeces discoloured, Intussusception, Surgery, Vomiting, Enema administration

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.


Changed on 4/7/2010

VAERS ID: 290330 Before After
VAERS Form:
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08674E / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Appendicectomy, Faeces discoloured, Intussusception, Surgery, Vomiting, Enema administration

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.


Changed on 8/31/2010

VAERS ID: 290330 Before After
VAERS Form:
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08674E / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Appendicectomy, Faeces discoloured, Intussusception, Surgery, Vomiting, Enema administration

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.


Changed on 5/13/2013

VAERS ID: 290330 Before After
VAERS Form:
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08674E / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Appendicectomy, Faeces discoloured, Intussusception, Surgery, Vomiting, Enema administration

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.


Changed on 4/14/2017

VAERS ID: 290330 Before After
VAERS Form:
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08674E / 0 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Appendicectomy, Faeces discoloured, Intussusception, Surgery, Vomiting, Enema administration

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.


Changed on 9/14/2017

VAERS ID: 290330 Before After
VAERS Form:(blank) 1
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 0 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 0 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08674E / 0 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 0 1 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.


Changed on 2/14/2018

VAERS ID: 290330 Before After
VAERS Form:1
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08674E / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.


Changed on 6/14/2018

VAERS ID: 290330 Before After
VAERS Form:1
Age:0.1
Gender:Male
Location:California
Vaccinated:2007-05-26
Onset:2007-07-15
Submitted:2007-09-05
Entered:2007-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B074AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF022AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08674E / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1231F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: Enema unsuccessful x several attempts.
CDC 'Split Type':

Write-up: July 2007, intussusception S/P repair. 9/18/07 Reviewed vax record from provider which confirms RO dose & lot # as reported. 9/17/07 Reviewed hospital medical records which reveal patient experienced vomiting. Seen in ER 7/15/07 & d/c to home. Continued w/vomiting, abdominal pain & developed dark stools. Admitted 7/16-7/19/2007. Failed hydrostatic reduction & taken to OR for reduction & appy. Progressed well & d/c to home. FINAL DX: Ileocecal intussusception w/lead point in midtransverse colon; appendectomy.

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=290330&WAYBACKHISTORY=ON


Copyright © 2018 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166