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From the 12/31/2003 release of VAERS data (an older release, current is 1/7/2021):

This is VAERS ID 33136

Case Details

VAERS ID: 33136 (history)  
Form: Version .0  
Age: 0.2  
Sex: Male  
Location: Oklahoma  
Vaccinated:1969-12-18
Onset:1969-12-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 1991-08-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: UNK. DTP / UNCLASSIFIED - / - - / -

Administered by: Private       Purchased by: Unknown
Symptoms: CONVULS, CONVULS GRAND MAL, FEVER
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: Pt exp sz w/DTP
Other Medications:
Current Illness: NONE
Preexisting Conditions: seizure disorder
Allergies:
Diagnostic Lab Data: Not available
CDC Split Type: seizure disorder

Write-up: P/each DTP shot pt had extreme fever of 104; Taken to MD then administered PCN shot;noticed pt lay in bed in trance;no sound could disturb;did not realize pt had petit mal until p/ grand mal.


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