VAERS ID: |
107005 (history) |
Form: |
Version 1.0 |
Age: |
12.0 |
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: |
1998-01-27 |
Days after submission: | 7 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES |
6F81441 / 4 |
LA / IM |
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
1238D / 2 |
RA / SC |
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH |
441228 / 4 |
MO / PO |
Administered by: Private Purchased by: Public Symptoms: Syncope SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
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: ~ ()~~~In patient 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 |