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This is VAERS ID 545049

History of Changes from the VAERS Wayback Machine

First Appeared on 10/14/2014

VAERS ID: 545049
VAERS Form:
Age:0.2
Gender:Male
Location:New York
Vaccinated:2014-08-26
Onset:2014-09-12
Submitted:2014-09-18
Entered:2014-09-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4724AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH H65735 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB434A / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Crying, Death, Disseminated intravascular coagulation, Dyspnoea, Haematochezia, Intussusception, Irritability, Lethargy, Shock, Enema administration, Ultrasound abdomen abnormal, Food intolerance

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2014-09-15
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Hyoscyamine sulfate prescribed 9/12/14
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal US 9/14/14 confirmed intussusception
CDC 'Split Type':

Write-up: Fussiness and crying onset 9/12/14 early AM, blood in stool that AM. More lethargic 9/13/14, not tolerating feeds. Seen in Emergency Room 9/13/14 - 9/14/14 - diagnosed with right upper quadrant intussusception reduced with air enema. Symptoms of shock, disseminated intravascular coagulation, third spacing of fluid, difficulty ventilating and ultimate death on 9/15/14.


Changed on 2/14/2017

VAERS ID: 545049 Before After
VAERS Form:
Age:0.2 0.17
Gender:Male
Location:New York
Vaccinated:2014-08-26
Onset:2014-09-12
Submitted:2014-09-18
Entered:2014-09-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4724AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH H65735 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB434A / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Crying, Death, Disseminated intravascular coagulation, Dyspnoea, Haematochezia, Intussusception, Irritability, Lethargy, Shock, Enema administration, Ultrasound abdomen abnormal, Food intolerance

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2014-09-15
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Hyoscyamine sulfate prescribed 9/12/14
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal US 9/14/14 confirmed intussusception
CDC 'Split Type':

Write-up: Fussiness and crying onset 9/12/14 early AM, blood in stool that AM. More lethargic 9/13/14, not tolerating feeds. Seen in Emergency Room 9/13/14 - 9/14/14 - diagnosed with right upper quadrant intussusception reduced with air enema. Symptoms of shock, disseminated intravascular coagulation, third spacing of fluid, difficulty ventilating and ultimate death on 9/15/14.


Changed on 9/14/2017

VAERS ID: 545049 Before After
VAERS Form:(blank) 1
Age:0.17
Gender:Male
Location:New York
Vaccinated:2014-08-26
Onset:2014-09-12
Submitted:2014-09-18
Entered:2014-09-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4724AA / 0 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH H65735 / 0 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB434A / 0 1 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Crying, Death, Disseminated intravascular coagulation, Dyspnoea, Haematochezia, Intussusception, Irritability, Lethargy, Shock, Enema administration, Ultrasound abdomen abnormal, Food intolerance

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2014-09-15
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Hyoscyamine sulfate prescribed 9/12/14
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal US 9/14/14 confirmed intussusception
CDC 'Split Type':

Write-up: Fussiness and crying onset 9/12/14 early AM, blood in stool that AM. More lethargic 9/13/14, not tolerating feeds. Seen in Emergency Room 9/13/14 - 9/14/14 - diagnosed with right upper quadrant intussusception reduced with air enema. Symptoms of shock, disseminated intravascular coagulation, third spacing of fluid, difficulty ventilating and ultimate death on 9/15/14.


Changed on 2/14/2018

VAERS ID: 545049 Before After
VAERS Form:1
Age:0.17
Gender:Male
Location:New York
Vaccinated:2014-08-26
Onset:2014-09-12
Submitted:2014-09-18
Entered:2014-09-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4724AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH H65735 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB434A / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Crying, Death, Disseminated intravascular coagulation, Dyspnoea, Haematochezia, Intussusception, Irritability, Lethargy, Shock, Enema administration, Ultrasound abdomen abnormal, Food intolerance

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2014-09-15
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Hyoscyamine sulfate prescribed 9/12/14
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal US 9/14/14 confirmed intussusception
CDC 'Split Type':

Write-up: Fussiness and crying onset 9/12/14 early AM, blood in stool that AM. More lethargic 9/13/14, not tolerating feeds. Seen in Emergency Room 9/13/14 - 9/14/14 - diagnosed with right upper quadrant intussusception reduced with air enema. Symptoms of shock, disseminated intravascular coagulation, third spacing of fluid, difficulty ventilating and ultimate death on 9/15/14.


Changed on 6/14/2018

VAERS ID: 545049 Before After
VAERS Form:1
Age:0.17
Gender:Male
Location:New York
Vaccinated:2014-08-26
Onset:2014-09-12
Submitted:2014-09-18
Entered:2014-09-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4724AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH H65735 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB434A / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Crying, Death, Disseminated intravascular coagulation, Dyspnoea, Haematochezia, Intussusception, Irritability, Lethargy, Shock, Enema administration, Ultrasound abdomen abnormal, Food intolerance

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2014-09-15
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Hyoscyamine sulfate prescribed 9/12/14
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal US 9/14/14 confirmed intussusception
CDC 'Split Type':

Write-up: Fussiness and crying onset 9/12/14 early AM, blood in stool that AM. More lethargic 9/13/14, not tolerating feeds. Seen in Emergency Room 9/13/14 - 9/14/14 - diagnosed with right upper quadrant intussusception reduced with air enema. Symptoms of shock, disseminated intravascular coagulation, third spacing of fluid, difficulty ventilating and ultimate death on 9/15/14.

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