| VAERS ID: |
298203 (history) |
| Form: |
Version 1.0 |
| Age: |
0.4 |
| Gender: |
Female |
| Location: |
Florida |
| Vaccinated: | 2007-09-26 |
| Onset: | 2007-11-24 |
| Days after vaccination: | 59 |
| Submitted: |
2007-11-28 |
| Days after onset: | 4 |
| Entered: |
2007-11-29 |
| Days after submission: | 1 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC14B046AA / 2 |
UN / IM |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UF163AA / 2 |
UN / IM |
| IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
Z0872 / UNK |
UN / IM |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0509U / 2 |
MO / PO |
Administered by: Public Purchased by: Public
Symptoms: Haematochezia,
Intussusception,
Ultrasound abdomen abnormal,
Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None PMH: congestion, rhinnorhea, cough & ear infection 3 wks prior tx w/antibiotics last dose 11/23.
Allergies:
Diagnostic Lab Data: Ultrasound showed telescoping of bowel segments. LABS: US revealed IS in right periumbilical region. Air contrast enema reduced IS.
CDC Split Type:
Write-up: Intussusception diagnosed by ultrasound after patient presented with vomiting and bloody stools. 12/04/07 Reviewed vax record which confirms RO dose/lot as reported. Faxed to CDC. 12/18/07 Reviewed hospital medical records which reveal patient experienced irritability, reduced oral intake, vomiting, abdominal pain & bloody stools. Taken to ER 11/24/07. Admitted for observation overnight. Progressed well & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC. |
