VAERS ID: |
413829 (history) |
Form: |
Version .0 |
Age: |
0.4 |
Gender: |
Male |
Location: |
New York |
Vaccinated: | 2010-12-17 |
Onset: | 2010-12-21 |
Days after vaccination: | 4 |
Submitted: |
2010-12-30 |
Days after onset: | 9 |
Entered: |
2010-12-31 |
Days after submission: | 1 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B256BA / 1 |
RL / IM |
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FB109A / 1 |
- / PO |
Administered by: Private Purchased by: Private Symptoms: Abdominal X-ray,
Enema administration,
Intussusception,
Vomiting projectile,
X-ray abnormal SMQs:, Acute pancreatitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad)
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, 3 days
Extended hospital stay? No
Previous Vaccinations: Other Medications: Denies Current Illness: None Preexisting Conditions: None Allergies: Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat. CDC Split Type:
Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.). |