VAERS ID: |
424301 (history) |
Form: |
Version .0 |
Age: |
0.2 |
Gender: |
Male |
Location: |
Connecticut |
Vaccinated: | 2011-05-17 |
Onset: | 2011-05-21 |
Days after vaccination: | 4 |
Submitted: |
2011-05-23 |
Days after onset: | 2 |
Entered: |
2011-05-31 |
Days after submission: | 8 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41CB157A / 0 |
- / PO |
Administered by: Private Purchased by: Public Symptoms: Intussusception,
Laparoscopic surgery,
Vomiting SMQs:, Acute pancreatitis (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, 4 days
Extended hospital stay? No
Previous Vaccinations: Other Medications: None Current Illness: None Preexisting Conditions: Nevus (R) shin; (+) Cafe au lait (L) thigh Allergies: Diagnostic Lab Data: Laparoscopic surgical reduction CDC Split Type:
Write-up: Started vomiting on 5/21/11 and went to hospital on 5/22/11 where diagnosed with intussusception which needed to be surgically reduced. |