| VAERS ID: |
380180 (history) |
| Form: |
Version .0 |
| Age: |
0.4 |
| Gender: |
Male |
| Location: |
Arkansas |
| Vaccinated: | 2009-08-19 |
| Onset: | 2009-09-18 |
| Days after vaccination: | 30 |
| Submitted: |
0000-00-00 |
| Entered: |
2010-02-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B213 / 1 |
LL / IM |
| HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. |
UF596AA / 1 |
RL / IM |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
D74257 / 1 |
RL / IM |
| ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FA859 / 1 |
- / PO |
Administered by: Private Purchased by: Private
Symptoms: Abdominal X-ray,
Barium enema,
Dehydration,
Intussusception,
Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (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, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Flat plate Abd; Barium enema ultrasound, had exploratory surgery for intussusception 09/19/09
CDC Split Type:
Write-up: Vomiting-$gdehydration-$gintussusception. |
