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This is VAERS ID 303025

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2008

VAERS ID: 303025
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER UF193AB / 1 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007F / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: Dermoid Cyst over r eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast"barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/


Changed on 12/8/2009

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER UF193AB / 1 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007F / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: Dermoid Cyst over r eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast"barium contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/ C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 3/2/2010

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER UF193AB / 1 LL / UN
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B54007F / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: Dermoid Cyst over r eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 4/7/2010

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER UF193AB / 1 LL / UN
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007F / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: Dermoid Cyst over r eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 8/31/2010

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER UF193AB / 1 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B54007F / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: Dermoid Cyst over r eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 5/12/2012

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (NO BRAND NAME) HIB (ACTHIB) / UNKNOWN MANUFACTURER SANOFI PASTEUR UF193AB / 1 LL / UN IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none None
Current Illness: none None
Preexisting Conditions: Dermoid Cyst over r R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 5/13/2013

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 6/14/2014

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 2/14/2017

VAERS ID: 303025 Before After
VAERS Form:
Age:0.3 0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 4/14/2017

VAERS ID: 303025 Before After
VAERS Form:
Age:0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Diarrhoea, Haematochezia, Intussusception, Laparotomy, Mucous stools, Vomiting, Enema administration, Ultrasound abdomen 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 9/14/2017

VAERS ID: 303025 Before After
VAERS Form:(blank) 1
Age:0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 1 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 1 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 1 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 1 2 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Diarrhoea, Intussusception, Vomiting, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 2/14/2018

VAERS ID: 303025 Before After
VAERS Form:1
Age:0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 2 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Diarrhoea, Intussusception, Vomiting, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 6/14/2018

VAERS ID: 303025 Before After
VAERS Form:1
Age:0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 2 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Diarrhoea, Intussusception, Vomiting, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 8/14/2018

VAERS ID: 303025 Before After
VAERS Form:1
Age:0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 2 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Diarrhoea, Intussusception, Vomiting, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 9/14/2018

VAERS ID: 303025 Before After
VAERS Form:1
Age:0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 2 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Diarrhoea, Intussusception, Vomiting, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.


Changed on 10/14/2018

VAERS ID: 303025 Before After
VAERS Form:1
Age:0.34
Gender:Male
Location:Texas
Vaccinated:2007-11-13
Onset:2007-11-27
Submitted:2008-01-18
Entered:2008-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B125BB / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF193AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007F / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1168U / 2 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Abdominal pain, Diarrhoea, Intussusception, Vomiting, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Dermoid Cyst over R eye
Allergies:
Diagnostic Lab Data: Air contrast enema 2/5/08-records received-Incomplete reduction with air contrast enema. US positive for intussusception.
CDC 'Split Type':

Write-up: Infant on 11/27/07 began having small amount of diarrhea (non bloody)and vomiting. Later that evening there were no stools passed and worsening colicy abdominal pain and bilious vomiting. Discovered to have an intussuseption unreducible via air contrast barium enema. Infant taken to OR immediately and intussuseption reduced surgically. 02/05/08-records received for DOS 11/27-11/28/07-DC DX: Intussusception, status post appendectomy and laparotomy with reduction of intussusception. Presented to ED with C/O abdominal pain and vomiting. PE: bloody mucous stool.

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