| VAERS ID: |
486747 (history) |
| Form: |
Version .0 |
| Age: |
0.3 |
| Gender: |
Male |
| Location: |
New York |
| Vaccinated: | 2013-02-05 |
| Onset: | 2013-03-07 |
| Days after vaccination: | 30 |
| Submitted: |
2013-03-12 |
| Days after onset: | 4 |
| Entered: |
2013-03-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B396B / 1 |
RL / IM |
| HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. |
H017030 / 1 |
LL / IM |
| PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
F18876 / 1 |
LL / IM |
| ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FB322A / 1 |
- / PO |
Administered by: Private Purchased by: Private
Symptoms: Barium enema,
Haematochezia,
Intestinal operation,
Intussusception,
Ultrasound scan normal
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal haemorrhage (narrow), Ischaemic colitis (broad)
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, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: 3/7/13 - developed bloody stool, U/S negative, bloody stool increased, air enema diagnosis of intussusception but not successfully reduced. 3/8/13 - Brought to OR for reduction. |
