VAERS ID: |
68431 (history) |
Form: |
Version 1.0 |
Age: |
1.4 |
Sex: |
Female |
Location: |
Illinois |
Vaccinated: | 1994-10-31 |
Onset: | 1994-11-01 |
Days after vaccination: | 1 |
Submitted: |
1994-11-04 |
Days after onset: | 3 |
Entered: |
1994-11-14 |
Days after submission: | 10 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES |
4H51123 / 4 |
RA / - |
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES |
4H51123 / UNK |
RA / - |
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0403A / 1 |
LA / - |
Administered by: Other Purchased by: Public Symptoms: Pneumonia SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1994-11-01
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient Other Medications: phenobarbital; Current Illness: sz dis,poss ?;poor growth;cerebral palsy Preexisting Conditions: h/o 32 wk premature, twin A: h/o apnea bradycardia, sz disorder; mixed cerebral palsy; Allergies:
Diagnostic Lab Data: unofficial result of autopsy is pneumonia; CDC Split Type:
Write-up: pt recvd vax on 31oct94 am; at 11:30am on 1nov94 laughing, playfull & took nap; at 1:15pm found in crib by pub hlth nurse cold & pulseness; to er, t 88.9 rectally; resucitation unsuccessful; pronounced dead at 2pm; |