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This is VAERS ID 36657

(NOTE: This result is from the 12/8/2009 version of the VAERS database)

Case Details

VAERS ID: 36657 (history)  
Form: Version .0  
Age: 14.5  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1991-11-18
Onset:1991-11-18
   Days after vaccination:0
Submitted: 1991-11-22
   Days after onset:4
Entered: 1991-11-26
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUOGEN 91-92) / PARKE-DAVIS 04161P / 0 RA / IM

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cyanosis, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Slo bid, Ventolin, pred, allergy inject, vit B6, Beconase;
Current Illness: NONE
Preexisting Conditions: environmental allergies, asthma
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: minutes p/the inject pt was SOB progressing to cyanosis & respiratory arrest; mouth to mouth resucitation, epi given x 3, DPH & albuterol, 02;


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20091208&IDNUMBER=36657


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