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This is VAERS ID 368114

(NOTE: This result is from the 9/14/2017 version of the VAERS database)

Case Details

VAERS ID: 368114 (history)  
Form: Version 1.0  
Age: 0.55  
Gender: Male  
Location: Iowa  
Vaccinated:2009-10-26
Onset:2009-10-31
   Days after vaccination:5
Submitted: 2009-11-09
   Days after onset:9
Entered: 2009-11-17
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B213AA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF729AA / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D90888 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CA943A / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Intussusception
SMQs:, Gastrointestinal obstruction (narrow)

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? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None. ED record and vaccination records received for date of service 10/31/09. PMH: None.
Allergies:
Diagnostic Lab Data: ED record and vaccination records received for date of service 10/31/09. Labs and diagnostics: UA. Labs: CBC, CMP Dx studies: air contrast barium enema
CDC Split Type:

Write-up: Intussusception resolved with Barium Enema after special Enema on 11/1/09. 11/18 & 11/19/09: ED record and vaccination records received for date of service 10/31/09. Dx: Intussusception Assessment: Presents with intussusception, admitted. 12/10/2009 ED record, Admission and consult notes for 10/31-11/1/2009, patient with c/o''s persistent vomiting x 2 days. Tx: IVF, NPO, barium enema + for intussusception


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