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This is VAERS ID 494301

(NOTE: This result is from the 9/17/2013 version of the VAERS database)

Case Details

VAERS ID: 494301 (history)  
Form: Version .0  
Age: 0.3  
Gender: Male  
Location: Alabama  
Vaccinated:2013-03-26
Onset:2013-04-13
   Days after vaccination:18
Submitted: 2013-06-14
   Days after onset:62
Entered: 2013-06-17
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4363AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH771AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR J1058 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH G73024 / 1 UN / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB315A / 1 - / PO

Administered by: Private       Purchased by: Private
Symptoms: Abdominal X-ray, Abdominal pain, Abdominal tenderness, Anxiety, Appendicectomy, Barium enema abnormal, Biopsy small intestine abnormal, Blood urine present, Condition aggravated, Culture stool negative, Diverticulectomy, Enema administration, Explorative laparotomy, Gastrointestinal tube insertion, Haematochezia, Hypophagia, Intussusception, Irritability, Large intestine perforation, Lethargy, Malaise, Occult blood positive, Pallor, Surgery, Ultrasound abdomen abnormal, Vitello-intestinal duct remnant, Vomiting, X-ray abnormal
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Retroperitoneal fibrosis (broad), Congenital, familial and genetic disorders (narrow), Pseudomembranous colitis (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal obstruction (narrow), Gastrointestinal perforation (narrow), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Ischaemic colitis (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (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, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: No The following information was obtained through follow-up and/or provided by the government. PMH: cough, GERD.
Allergies:
Diagnostic Lab Data: The following information was obtained through follow-up and/or provided by the government. 6/20 & 7/1/2013 lab/diagnostic records recieved for DOS 4/13/2013. Abdominal X-ray, US, contrast enema: intussusception. Occult blood (+). Stool cx (-). Small intestine, terminal ileum: Meckel diverticulum w/ heterotopic gastric mucosa. Appendix: intraluminal suppurative debris, reactive lymphoid hyperplasia w/ germinal center karyorrhexis.
CDC Split Type:

Write-up: 4/13/13 surgery for colonic perforation after intussusception. The following information was obtained through follow-up and/or provided by the government. 6/20/2013 after hours clinic records recieved for DOS 4/13/2013. Dx: intussusception. Pt c/o worsening cough, vomiting, blood in urine. PE: large grossly red current jelly stool, mild distress, abdomen diffusely tender, anxious. Transferred in stable condition for higher level care. 6/20 & 7/1/2013 hospital records recieved for DOS 4/13-17/2013. D/c Dx''s: 1) intussusception; 2) colonic perforation; 3) serosal injury; 4) Meckel diverticulum. Pt transferred as noted above. C/o 1 day hx vomiting, decreased oral intake, lethargy, fussiness, abdominal pain, bloody stools. PE: pale, ill appearing, generalized abdominal tenderness, grossly bloody stools. Admitted. NG tube placed. Air contrast enema partially reduced intussusception. On repeat enema free air noted c/w perforation. Tx''t: expl lap, repair of serosal injuries, repair of colonic perforation, appy, Meckel diverticulectomy, ABX, pain control. Condition improved, d/c''d home w/ care & f/u instructions. 6/20/2013 surgery consultant records recieved for DOS 5/6/2013. Assessment: s/p expl laparotomy for colonic perforation after intussusception reduction. Pt seen in f/u to surgery. No further issues. 6/20/2013 PCP records recieved for DOS 6/7/2013. Assessment: 1) well baby; 2) intussusception, recovered after surgery. WCC. No further issues. Given care & f/u instructions.


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