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This is VAERS ID 483887

History of Changes from the VAERS Wayback Machine

First Appeared on 2/13/2013

VAERS ID: 483887
VAERS Form:
Age:0.2
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 0 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 5/13/2013

VAERS ID: 483887 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 0 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 6/12/2013

VAERS ID: 483887 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 0 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: (blank) 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 9/17/2013

VAERS ID: 483887 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 0 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Anion gap increased, Barium enema abnormal, Blood potassium increased, Gastrointestinal disorder, Haematochezia, Intussusception, Irritability, Laparotomy, Small intestinal resection, Somnolence, Vomiting, Vomiting projectile, White blood cell count normal, X-ray abnormal, Enema administration, Urine leukocyte esterase positive, Ultrasound abdomen abnormal, Neutrophil percentage decreased, Monocyte percentage increased, Lymphocyte percentage increased, Gastrointestinal tube insertion, Urine ketone body present, Laparoscopic surgery, Urine output decreased, Abdominal X-ray, Hypophagia

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis The following information was obtained through follow-up and/or provided by the government. 5/2/2013 hospital records received for DOS 2/10-14/2013. Abdominal X-ray: multiple dilated loops small bowel compatible w/ small bowel obstruction. Abdominal US: intussusception causing small bowel obstruction. Blood: WBC 9.8 K/uL (N), neutros 46% (L), lymphs 42% (H), monos 11% (H), K 5.6 mEq/L (H), agap 21 (H). UA: leukocyte esterase (+), ketones (+). Barium enema: abnormal.
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception. The following information was obtained through follow-up and/or provided by the government. 2/15/2013 PCP records received for DOS 2/8/2013. No information abstracted. 5/2/2013 hospital records received for DOS 2/10-14/2013. D/c Dx''s: 1) intestinal intussusception; 2) intestine duplication. Pt presented w/ 1 day hx projectile emesis, poor PO intake, fussiness, decreased wet diapers, abdominal distension. On admission pt had BM w/ streak of blood. Tx''t: enema administration, laparoscopic & mini laparotomy reduction w/ resection of small bowel duplication cyst, NG tube, pain control. Pt d/c''d home in stable condition w/ care & f/u instructions.

Changed on 3/14/2015

VAERS ID: 483887 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 0 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Anion gap increased, Barium enema abnormal, Blood potassium increased, Gastrointestinal disorder, Haematochezia, Intussusception, Irritability, Laparotomy, Small intestinal resection, Somnolence, Vomiting, Vomiting projectile, White blood cell count normal, X-ray abnormal, Enema administration, Urine leukocyte esterase positive, Ultrasound abdomen abnormal, Neutrophil percentage decreased, Monocyte percentage increased, Lymphocyte percentage increased, Gastrointestinal tube insertion, Urine ketone body present, Laparoscopic surgery, Urine output decreased, Abdominal X-ray, Hypophagia

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis The following information was obtained through follow-up and/or provided by the government. 5/2/2013 hospital records received for DOS 2/10-14/2013. Abdominal X-ray: multiple dilated loops small bowel compatible w/ small bowel obstruction. Abdominal US: intussusception causing small bowel obstruction. Blood: WBC 9.8 K/uL (N), neutros 46% (L), lymphs 42% (H), monos 11% (H), K 5.6 mEq/L (H), agap 21 (H). UA: leukocyte esterase (+), ketones (+). Barium enema: abnormal.
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception. The following information was obtained through follow-up and/or provided by the government. 2/15/2013 PCP records received for DOS 2/8/2013. No information abstracted. 5/2/2013 hospital records received for DOS 2/10-14/2013. D/c Dx''s: 1) intestinal intussusception; 2) intestine duplication. Pt presented w/ 1 day hx projectile emesis, poor PO intake, fussiness, decreased wet diapers, abdominal distension. On admission pt had BM w/ streak of blood. Tx''t: enema administration, laparoscopic & mini laparotomy reduction w/ resection of small bowel duplication cyst, NG tube, pain control. Pt d/c''d home in stable condition w/ care & f/u instructions.

Changed on 2/14/2017

VAERS ID: 483887 Before After
VAERS Form:
Age:0.2 0.16
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 0 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 9/14/2017

VAERS ID: 483887 Before After
VAERS Form:(blank) 1
Age:0.16
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 0 1 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 0 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 0 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / - UNK - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 2/14/2018

VAERS ID: 483887 Before After
VAERS Form:1
Age:0.16
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 1 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 6/14/2018

VAERS ID: 483887 Before After
VAERS Form:1
Age:0.16
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 1 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 8/14/2018

VAERS ID: 483887 Before After
VAERS Form:1
Age:0.16
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 1 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

Changed on 9/14/2018

VAERS ID: 483887 Before After
VAERS Form:1
Age:0.16
Gender:Female
Location:California
Vaccinated:2013-02-08
Onset:2013-02-08
Submitted:2013-02-10
Entered:2013-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B377AA / 1 LL / IM
HIBV: HIB (PROHIBIT) / SANOFI PASTEUR UH691AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G10784 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB314A / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Intussusception, Irritability, Somnolence, Vomiting, Ultrasound abdomen abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None known
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Ultrasound confirming diagnosis
CDC 'Split Type':

Write-up: Pt with sleepiness, fussy, abd distention and vomiting. Diagnosed 2/9/13 with intussuception.

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