VAERS ID: |
457250 (history) |
Form: |
Version 1.0 |
Age: |
0.18 |
Gender: |
Female |
Location: |
Connecticut |
Vaccinated: | 2012-04-11 |
Onset: | 2012-06-01 |
Days after vaccination: | 51 |
Submitted: |
2012-06-05 |
Days after onset: | 4 |
Entered: |
2012-06-12 |
Days after submission: | 7 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR |
C4131AA / 1 |
RL / IM |
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS |
AHBVC090FA / 2 |
RL / IM |
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
917245 / 1 |
LL / IM |
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FB210A / 1 |
MO / PO |
Administered by: Other Purchased by: Other Symptoms: Barium enema,
Barium enema abnormal,
Intestinal obstruction,
Intussusception,
Surgery,
X-ray abnormal SMQs:, Pseudomembranous colitis (broad), Gastrointestinal obstruction (narrow), Ischaemic colitis (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
Extended hospital stay? Yes
Previous Vaccinations: Other Medications: None Current Illness: None Preexisting Conditions: None Allergies:
Diagnostic Lab Data: XRay barium enema confirming diagnosis CDC Split Type:
Write-up: Intestinal obstruction -$g intussusception. Required surgery. Pt admitted to hospital. |