| 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 | 