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This is VAERS ID 494301

History of Changes from the VAERS Wayback Machine

First Appeared on 7/7/2013

VAERS ID: 494301
VAERS Form:
Age:0.3
Gender:Male
Location:Alabama
Vaccinated:2013-03-26
Onset:2013-04-13
Submitted:2013-06-14
Entered:2013-06-17
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: Intussusception, Large intestine perforation, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: No
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4/13/13 surgery for colonic perforation after intussusception.


Changed on 9/17/2013

VAERS ID: 494301 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Alabama
Vaccinated:2013-03-26
Onset:2013-04-13
Submitted:2013-06-14
Entered:2013-06-17
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 pain, Abdominal tenderness, Anxiety, Appendicectomy, Barium enema abnormal, Condition aggravated, Culture stool negative, Haematochezia, Blood urine present, Intussusception, Irritability, Large intestine perforation, Lethargy, Malaise, Pallor, Surgery, Vomiting, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal tube insertion, Biopsy small intestine abnormal, Explorative laparotomy, Abdominal X-ray, Occult blood positive, Hypophagia, Diverticulectomy, Vitello-intestinal duct remnant

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     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.


Changed on 10/13/2013

VAERS ID: 494301 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Alabama
Vaccinated:2013-03-26
Onset:2013-04-13
Submitted:2013-06-14
Entered:2013-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4363AA / 1 UN RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH771AA / 1 UN LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR J1058 / 1 UN RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH G73024 / 1 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G73024 / 1 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB315A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal pain, Abdominal tenderness, Anxiety, Appendicectomy, Barium enema abnormal, Condition aggravated, Culture stool negative, Haematochezia, Blood urine present, Intussusception, Irritability, Large intestine perforation, Lethargy, Malaise, Pallor, Surgery, Vomiting, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Gastrointestinal tube insertion, Biopsy small intestine abnormal, Explorative laparotomy, Abdominal X-ray, Occult blood positive, Hypophagia, Diverticulectomy, Vitello-intestinal duct remnant

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     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.


Changed on 2/14/2017

VAERS ID: 494301 Before After
VAERS Form:
Age:0.3 0.31
Gender:Male
Location:Alabama
Vaccinated:2013-03-26
Onset:2013-04-13
Submitted:2013-06-14
Entered:2013-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4363AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH771AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR J1058 / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G73024 / 1 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB315A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Large intestine perforation, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: No
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4/13/13 surgery for colonic perforation after intussusception.


Changed on 9/14/2017

VAERS ID: 494301 Before After
VAERS Form:(blank) 1
Age:0.31
Gender:Male
Location:Alabama
Vaccinated:2013-03-26
Onset:2013-04-13
Submitted:2013-06-14
Entered:2013-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4363AA / 1 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH771AA / 1 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR J1058 / 1 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G73024 / 1 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB315A / 1 2 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Large intestine perforation, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: No
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4/13/13 surgery for colonic perforation after intussusception.


Changed on 2/14/2018

VAERS ID: 494301 Before After
VAERS Form:1
Age:0.31
Gender:Male
Location:Alabama
Vaccinated:2013-03-26
Onset:2013-04-13
Submitted:2013-06-14
Entered:2013-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4363AA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH771AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR J1058 / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G73024 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB315A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Large intestine perforation, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: No
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4/13/13 surgery for colonic perforation after intussusception.


Changed on 6/14/2018

VAERS ID: 494301 Before After
VAERS Form:1
Age:0.31
Gender:Male
Location:Alabama
Vaccinated:2013-03-26
Onset:2013-04-13
Submitted:2013-06-14
Entered:2013-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4363AA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH771AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR J1058 / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH G73024 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB315A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Large intestine perforation, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: No
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4/13/13 surgery for colonic perforation after intussusception.

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