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This is VAERS ID 331912

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2008

331912
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 wit"h Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce


Changed on 12/8/2009

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 wit"h with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 3/2/2010

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 4/7/2010

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 7/31/2010

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Enema administration, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 8/31/2010

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery, Urinary system X-ray, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 4/13/2011

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Enema administration, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 5/13/2011

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Enema administration, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 6/11/2011

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Enema administration, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 5/13/2013

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH UNKNOWN / 2 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Enema administration, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 6/14/2014

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH UNKNOWN / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Enema administration, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 2/14/2017

331912 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH UNKNOWN / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium double contrast, Barium enema abnormal, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Laparoscopy, Large intestinal obstruction reduction, Moaning, Pain, Surgery, Urinary system X-ray, Vomiting, X-ray abnormal, Enema administration, Platelet count increased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


Changed on 9/14/2017

331912 Before After
VAERS Form:(blank) 1
Age:0.5
Gender:Female
Location:Oregon
Vaccinated:2008-10-30
Onset:2008-11-05
Submitted:2008-11-10
Entered:2008-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B192CA / 2 3 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF505AB / 2 3 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH UNKNOWN / 2 3 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA692A / 0 1 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery, Urinary system X-ray, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none. PMH: none
Allergies:
Diagnostic Lab Data: KUB/contrast enemas. Labs and Diagnostics: Air contrast enema (+) for IS. Abd X-ray c/w IS. HCT 31.5. Hgb 10.4. Platelets 15.2K.
CDC 'Split Type':

Write-up:Intussusception - symptoms started 11/5/08; confirmed by x-ray on 11/6/08; unable to reduce by air contrast and barium contrast; required air transport to tertiary hospital and subsequent surgery. 11/18/2008 D/C Summary recieved for DOS 11/17-19/2008 with Final DX: Intussusception-ileocolic. Pt initially presented with pain, moaning, vomiting and blood streaked stool. Pt presented to hospital from another facility following failed reduction of IS via air contrast barium enema. Again, uanable to reduce so taken to OR for Laparoscopic reduction. Pt tolerated well, diet advance and d/c 11/9/08.


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