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This is VAERS ID 34628

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 34628
VAERS Form:
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP / CONNAUGHT LABS 0C21000 / 0 - / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M635FN / 0 - / IM
OPV: ORIMUNE / LEDERLE 297950 / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: BRADYCARDIA, APNEA, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type': prematurity, obstructive apnea

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 12/8/2009

VAERS ID: 34628 Before After
VAERS Form:
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-11 1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP DTP (NO BRAND NAME) / CONNAUGHT LABS CONNAUGHT LABORATORIES 0C21000 / 0 - / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M635FN / 0 - / IM
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 297950 / 0 - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest, BRADYCARDIA, APNEA, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type': prematurity, obstructive apnea (blank)

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 5/14/2017

VAERS ID: 34628 Before After
VAERS Form:
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 0 - / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M635FN / 0 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 297950 / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE NONE~ ()~~~In patient
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type':

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 9/14/2017

VAERS ID: 34628 Before After
VAERS Form:(blank) 1
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 0 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M635FN / 0 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297950 / 0 1 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE~ ()~~~In patient
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type':

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 2/14/2018

VAERS ID: 34628 Before After
VAERS Form:1
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M635FN / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297950 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE~ ()~~~In patient
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type':

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 6/14/2018

VAERS ID: 34628 Before After
VAERS Form:1
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M635FN / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297950 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE~ ()~~~In patient
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type':

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 8/14/2018

VAERS ID: 34628 Before After
VAERS Form:1
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M635FN / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297950 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE~ ()~~~In patient
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type':

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 9/14/2018

VAERS ID: 34628 Before After
VAERS Form:1
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M635FN / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297950 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE~ ()~~~In patient
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type':

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


Changed on 10/14/2018

VAERS ID: 34628 Before After
VAERS Form:1
Age:0.1
Sex:Male
Location:Pennsylvania
Vaccinated:1991-04-19
Onset:1991-04-20
Submitted:1991-07-15
Entered:1991-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M635FN / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297950 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-14
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: NONE~ ()~~~In patient
Other Medications: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC 'Split Type':

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=34628&WAYBACKHISTORY=ON


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