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This is VAERS ID 104094

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 104094
VAERS Form:
Age:80.7
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-11-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUVIRIN 1997-1998 / MEDEVA PHARMS LI E3337GB / 2 LA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: MALAISE, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type':

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 12/8/2009

VAERS ID: 104094 Before After
VAERS Form:
Age:80.7
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-11-04 1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUVIRIN 1997-1998 INFLUENZA (SEASONAL) (FLUVIRIN 97-98) / MEDEVA PHARMS LI MEDEVA PHARMA, LTD. E3337GB / 2 LA / IM

Administered by: Public      Purchased by: Unknown Public
Symptoms: Cardiac arrest, Malaise, MALAISE, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': (blank) CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 8/31/2010

VAERS ID: 104094 Before After
VAERS Form:
Age:80.7
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUVIRIN 97-98) INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 2 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 7/7/2013

VAERS ID: 104094 Before After
VAERS Form:
Age:80.7
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 2 LA / IM
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 2 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 2/14/2017

VAERS ID: 104094 Before After
VAERS Form:
Age:80.7 80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 2 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 5/14/2017

VAERS ID: 104094 Before After
VAERS Form:
Age:80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 2 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 9/14/2017

VAERS ID: 104094 Before After
VAERS Form:(blank) 1
Age:80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 2 3 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 2/14/2018

VAERS ID: 104094 Before After
VAERS Form:1
Age:80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 3 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 6/14/2018

VAERS ID: 104094 Before After
VAERS Form:1
Age:80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 3 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 8/14/2018

VAERS ID: 104094 Before After
VAERS Form:1
Age:80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 3 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 9/14/2018

VAERS ID: 104094 Before After
VAERS Form:1
Age:80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 3 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;


Changed on 10/14/2018

VAERS ID: 104094 Before After
VAERS Form:1
Age:80.0
Sex:Male
Location:Connecticut
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-10-30
Entered:1997-10-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3337GB / 3 LA / IM

Administered by: Public      Purchased by: Public
Symptoms: Cardiac arrest, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: diabetes, others not known
Allergies:
Diagnostic Lab Data: BP was taken @ clu clinic as a routine service offered to pt 130/66;
CDC 'Split Type': CT9711

Write-up: pt c/o not feeling well while in car w/wife;EMS was called when arrived pt was in cardiac arrest;attempts to revive failed was transported to hosp ER states COD listed on ER record as cardiac arrest;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=104094&WAYBACKHISTORY=ON


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