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This is VAERS ID 107005

(NOTE: This result is from the 12/31/2003 version of the VAERS database)

Case Details

VAERS ID: 107005 (history)  
Form: Version .0  
Age: 12.1  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1998-01-13
Onset:1998-01-13
   Days after vaccination:0
Submitted: 1998-01-20
   Days after onset:7
Entered: 1998-01-28
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: TRIPEDIA / CONNAUGHT LABS 6F81441 / 3 LA / IM
MMR: MMR II / MSD 1238D / 1 RA / SC
PPV: PNU-IMUNE(R)23 / LEDERLE 441228 / 3 - / PO

Administered by: Private       Purchased by: Unknown
Symptoms: SYNCOPE
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: pt reportedly collapsed @ home suddenly


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20031231&IDNUMBER=107005


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