| VAERS ID: |
44528 (history) |
| Form: |
Version 1.0 |
| Age: |
0.4 |
| Sex: |
Male |
| Location: |
Kansas |
| Vaccinated: | 1992-07-24 |
| Onset: | 1992-07-24 |
| Days after vaccination: | 0 |
| Submitted: |
1992-08-18 |
| Days after onset: | 25 |
| Entered: |
1992-08-25 |
| Days after submission: | 7 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES |
2H31068 / 2 |
LL / IM |
| HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM |
1002A2 / 1 |
RL / IM |
| HIBV: HIB (HIBTITER) / PFIZER/WYETH |
M700AE / 2 |
LL / IM |
| OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH |
0648L / 2 |
MO / PO |
Administered by: Private Purchased by: Private
Symptoms: Cyanosis,
Pallor,
Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NA
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NA
CDC Split Type:
Write-up: circumoral pallor & cyanosis, passed out lasting few seconds; pt hospitalized; |
