| VAERS ID: |
425901 (history) |
| Form: |
Version .0 |
| Age: |
0.2 |
| Gender: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2011-06-01 |
| Onset: | 2011-06-05 |
| Days after vaccination: | 4 |
| Submitted: |
2011-06-10 |
| Days after onset: | 5 |
| Entered: |
2011-06-22 |
| Days after submission: | 12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR |
C3807AA / 0 |
UN / IM |
| HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS |
AHBVB807DA / 1 |
UN / IM |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
915703 / 0 |
UN / IM |
| ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FB158A / 0 |
- / PO |
Administered by: Private Purchased by: Public
Symptoms: Intussusception,
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? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Transferred after birth to larger hosp. for r/o sepsis and breathing difficulty.
Allergies:
Diagnostic Lab Data: Had surgery for intussusception. In hospital for 10 days.
CDC Split Type:
Write-up: 6/6/11 acute vomiting. |
