VAERS ID: |
110547 (history) |
Form: |
Version 1.0 |
Age: |
74.0 |
Sex: |
Male |
Location: |
Michigan |
Vaccinated: | 1998-04-07 |
Onset: | 1998-04-07 |
Days after vaccination: | 0 |
Submitted: |
1998-04-08 |
Days after onset: | 1 |
Entered: |
1998-05-04 |
Days after submission: | 26 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
TD: TD ADSORBED (NO BRAND NAME) / CONNAUGHT LABORATORIES |
0923910 / 3 |
LA / IM |
Administered by: Private Purchased by: Private Symptoms: Apnoea,
Cardiac arrest,
Coma,
Syncope,
Ventricular fibrillation SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-04-07
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: Azulfidine, HCTZ, Cardizem, Synthroid; Current Illness: NONE Preexisting Conditions: ulcerative colitis, asthma, CAD; Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: (null). The medical records state loss of consciousness and ventricular fibrillation. |