| VAERS ID: |
432001 (history) |
| Form: |
Version 1.0 |
| Age: |
0.34 |
| Gender: |
Female |
| Location: |
Wisconsin |
| Vaccinated: | 2011-08-09 |
| Onset: | 2011-08-21 |
| Days after vaccination: | 12 |
| Submitted: |
2011-08-23 |
| Days after onset: | 2 |
| Entered: |
2011-08-30 |
| Days after submission: | 7 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B300CA / 2 |
RL / UN |
| HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. |
0487AA / 2 |
LL / UN |
| PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
915347 / 2 |
LL / UN |
| RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41CB203A / 2 |
MO / PO |
Administered by: Private Purchased by: Private
Symptoms: Abdominal pain,
Enema administration,
Haematochezia,
Intussusception,
Lethargy,
Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Hypoglycaemia (broad)
Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Contrast enema dx''d intussusception
CDC Split Type:
Write-up: ROTARIX #2 given 8/9/11. 1 currant jelly stool, severe lethargy, crampy abd pain, bile emesis. Intussusception occurred 8/21/11. Radiology reduced partially 8/21. Radiology reduced fully 8/22. |
