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This is VAERS ID 414363

Case Details

VAERS ID: 414363 (history)  
Form: Version 1.0  
Age: 0.24  
Gender: Female  
Location: Maryland  
Vaccinated:2010-12-09
Onset:2010-12-26
   Days after vaccination:17
Submitted: 2011-01-06
   Days after onset:11
Entered: 2011-01-10
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 1 RL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH019AA / 1 LL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E804460 / 1 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB104A / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Food intolerance, Haematochezia, Intussusception, Ultrasound scan, X-ray
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Ischaemic colitis (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, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Was on Nutramifen before for milk intolerance
Allergies:
Diagnostic Lab Data: Diagnostic ultrasound and fluoroscopy
CDC Split Type:

Write-up: Pt. had bloody stools 17 days after receiving ROTARIX, dx with intussusception. Went to hospital 12/31/10. Dx with formula intolerance - on ELECORE.


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