| VAERS ID: |
478201 (history) |
| Form: |
Version .0 |
| Age: |
0.2 |
| Gender: |
Male |
| Location: |
California |
| Vaccinated: | 2012-11-30 |
| Onset: | 2012-12-06 |
| Days after vaccination: | 6 |
| Submitted: |
2012-12-15 |
| Days after onset: | 9 |
| Entered: |
2012-12-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B344DA / 0 |
LL / IM |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UH681AA / 0 |
LL / IM |
| PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
F95942 / 0 |
RL / IM |
| RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FB304A / 0 |
- / PO |
Administered by: Private Purchased by: Other
Symptoms: Barium enema normal,
Intussusception,
Ultrasound scan abnormal,
Vomiting
SMQs:, Acute pancreatitis (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal obstruction (narrow), 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, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound positive at Medical Center, Barium Enema at Med Ctr negative
CDC Split Type:
Write-up: Vomiting, later presented to outside facility, ultrasound showed intussusception. Transferred to Med Ctr, barium enema done and negative, assumed intussusception self-resolved. |
