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From the 12/31/2003 release of VAERS data (an older release, current is 1/15/2021):

This is VAERS ID 26803

Case Details

VAERS ID: 26803 (history)  
Form: Version .0  
Age: 79.8  
Sex: Male  
Location: Massachusetts  
Vaccinated:1990-11-01
Onset:1990-11-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 1990-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUZONE 1990-1991 CONNAUGHT / CONNAUGHT LABS 0F11224 / - RA / SC

Administered by: Public       Purchased by: Unknown
Symptoms: COUGH INC, FEVER, FLUTTER ATR, HEART FAIL RIGHT, MYALGIA
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Isordil, Cardizem, Kerlone
Current Illness:
Preexisting Conditions: HBP, coronary ischemia
Allergies:
Diagnostic Lab Data: CSR & CBC - normal 6NOV90
CDC Split Type:

Write-up: Pt vaccinated with Influenza experienced low grade fever, cough, sx persist & atrial flutter fib, admitted to hosp w/pneumonia, CHF.


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