| VAERS ID: |
380464 (history) |
| Form: |
Version .0 |
| Age: |
0.3 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2010-01-18 |
| Onset: | 2010-01-19 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2010-02-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR |
C3564AA / 1 |
UN / IM |
| PNC: PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC |
D67170 / 1 |
UN / IM |
| ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0574Y / 1 |
- / PO |
Administered by: Private Purchased by: Private
Symptoms: Barium enema,
Intussusception,
Ultrasound abdomen abnormal
SMQs:, Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (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, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Vomited twice day prior and once this morning
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: abd u/s positive with intussusception
CDC Split Type:
Write-up: Intussusception on 1-19-10. Had Barium enema and it resolved. |
