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This is VAERS ID 189239

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 189239
VAERS Form:
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (UNKNOWN MFR) / UNKNOWN MFR NOT REPORTED / 0 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: MYOCARDITIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis


Changed on 12/8/2009

VAERS ID: 189239 Before After
VAERS Form:
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (UNKNOWN MFR) MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MFR UNKNOWN MANUFACTURER NOT REPORTED / 0 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: Myocarditis, MYOCARDITIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis


Changed on 9/14/2017

VAERS ID: 189239 Before After
VAERS Form:(blank) 1
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER NOT REPORTED / 0 1 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis


Changed on 2/14/2018

VAERS ID: 189239 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER NOT REPORTED / 1 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis


Changed on 6/14/2018

VAERS ID: 189239 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER NOT REPORTED / 1 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis


Changed on 8/14/2018

VAERS ID: 189239 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER NOT REPORTED / 1 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis


Changed on 9/14/2018

VAERS ID: 189239 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER NOT REPORTED / 1 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis


Changed on 10/14/2018

VAERS ID: 189239 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:California
Vaccinated:2001-01-17
Onset:2002-03-07
Submitted:2002-08-21
Entered:2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER NOT REPORTED / 1 - / -

Administered by: Public      Purchased by: Unknown
Symptoms: Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-03-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC 'Split Type':

Write-up: myocarditis

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=189239&WAYBACKHISTORY=ON


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