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This is VAERS ID 104095

Case Details

VAERS ID: 104095 (history)  
Form: Version 1.0  
Age: 68.0  
Sex: Male  
Location: Mississippi  
Vaccinated:1997-10-15
Onset:1997-10-15
   Days after vaccination:0
Submitted: 1997-10-16
   Days after onset:1
Entered: 1997-11-03
   Days after submission:18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 1 RA / IM

Administered by: Public       Purchased by: Unknown
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-10-15
   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: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type: MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


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