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This is VAERS ID 332141

Case Details

VAERS ID: 332141 (history)  
Form: Version 1.0  
Age: 13.0  
Gender: Female  
Location: California  
Vaccinated:2008-10-28
Onset:2008-10-28
   Days after vaccination:0
Submitted: 2008-11-12
   Days after onset:15
Entered: 2008-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2757AA / UNK LA / IM
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1487U / 3 RA / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Fall, Immediate post-injection reaction, Mouth injury, Syncope, Tooth injury, X-ray
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Patient is in special classes.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was given Gardasil, Influenza Vac and PPD. Few minutes after the injections patient fainted and fell to the floor. Mother and the medical assistant were in room. Patient sustained a laceration to her left upper lip and her one incisor broke. Patient needed treatment for laceration at the emergency room after she was transported by paramedics. She also required dental treatment. Full dental treatment has not been done yet. She has seen the dentist, she had xrays. She needs a crown, a root canal in the affected tooth. 12/11/08-records received for DOS 10/28/08-immediately after receipt of vaccine fainted, fell and broke her upper lip and front left incisor. Fainting a second time. Seen in ED. 12/17/08-ER records received for DOS 10/28/08-syncope-lip laceration. loose teeth.


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