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This is VAERS ID 104253

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 104253
VAERS Form:
Age:71.3
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUVIRIN 1997-1998 / MEDEVA PHARMS LI E20017HC / - - / IM
PPV: PNU-IMUNE(R)23 / LEDERLE 441214 / 0 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: CYANOSIS, DYSPNEA, ASTHENIA, EDEMA PERIPH, HYPOTHERMIA

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of alcohol, tobacco use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 28OCT97 & that day devel swelling of the lt arm from forearm to hand;4NOV (7 days post vax) presented to MD w/SOB, weakness, cyanosis & pallor;refused diagnostic lab work & went home;died @ home 4NOV;


Changed on 12/8/2009

VAERS ID: 104253 Before After
VAERS Form:
Age:71.3
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-07 1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUVIRIN 1997-1998 INFLUENZA (SEASONAL) (FLUVIRIN 97-98) / MEDEVA PHARMS LI MEDEVA PHARMA, LTD. E20017HC / - - / IM
PPV: PNU-IMUNE(R)23 PNEUMO (PNU-IMUNE) / LEDERLE LEDERLE LABORATORIES 441214 / 0 RA / IM

Administered by: Public      Purchased by: Unknown Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor, CYANOSIS, DYSPNEA, ASTHENIA, EDEMA PERIPH, HYPOTHERMIA

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of alcohol, tobacco use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': (blank) 897314001L

Write-up: pt recv vax 28OCT97 & that day devel swelling of the lt arm from forearm to hand;4NOV (7 days post vax) presented to MD w/SOB, weakness, cyanosis & pallor;refused diagnostic lab work & went home;died @ home 4NOV;


Changed on 8/31/2010

VAERS ID: 104253 Before After
VAERS Form:
Age:71.3
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUVIRIN 97-98) INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / - - / IM
PPV: PNEUMO (PNU-IMUNE) / LEDERLE LABORATORIES 441214 / 0 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of alcohol, tobacco use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 897314001L

Write-up: pt recv vax 28OCT97 & that day devel swelling of the lt arm from forearm to hand;4NOV (7 days post vax) presented to MD w/SOB, weakness, cyanosis & pallor;refused diagnostic lab work & went home;died @ home 4NOV;


Changed on 7/7/2013

VAERS ID: 104253 Before After
VAERS Form:
Age:71.3
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / - - / IM
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / - - / IM
PPV: PNEUMO (PNU-IMUNE) / LEDERLE LABORATORIES 441214 / 0 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of alcohol, tobacco use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 897314001L

Write-up: pt recv vax 28OCT97 & that day devel swelling of the lt arm from forearm to hand;4NOV (7 days post vax) presented to MD w/SOB, weakness, cyanosis & pallor;refused diagnostic lab work & went home;died @ home 4NOV;


Changed on 2/14/2017

VAERS ID: 104253 Before After
VAERS Form:
Age:71.3 71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / - - / IM
PPV: PNEUMO (PNU-IMUNE) / LEDERLE LABORATORIES 441214 / 0 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of alcohol, tobacco use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 897314001L

Write-up: pt recv vax 28OCT97 & that day devel swelling of the lt arm from forearm to hand;4NOV (7 days post vax) presented to MD w/SOB, weakness, cyanosis & pallor;refused diagnostic lab work & went home;died @ home 4NOV;


Changed on 5/14/2017

VAERS ID: 104253 Before After
VAERS Form:
Age:71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / - - / IM
PPV: PNEUMO (PNU-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 441214 / 0 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of alcohol, ETOH, tobacco use use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC 'Split Type': 897314001L (blank)

Write-up: pt recv vax 28OCT97 & that day devel presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling of the lt arm from arm-lateral forearm to hand;4NOV (7 days post vax) presented to MD w/SOB, weakness, cyanosis & pallor;refused diagnostic lab work & went home;died hand;swollen since inj;T96.8;expired 4NOV97 @ home 4NOV; home;


Changed on 9/14/2017

VAERS ID: 104253 Before After
VAERS Form:(blank) 1
Age:71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / - UNK - / IM
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441214 / 0 1 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx ETOH, tobacco use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC 'Split Type':

Write-up: presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling lt arm-lateral forearm to hand;swollen since inj;T96.8;expired 4NOV97 @ home;


Changed on 2/14/2018

VAERS ID: 104253 Before After
VAERS Form:1
Age:71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / UNK - / IM
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441214 / 1 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx ETOH, tobacco use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC 'Split Type':

Write-up: presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling lt arm-lateral forearm to hand;swollen since inj;T96.8;expired 4NOV97 @ home;


Changed on 6/14/2018

VAERS ID: 104253 Before After
VAERS Form:1
Age:71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / UNK - / IM
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441214 / 1 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx ETOH, tobacco use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC 'Split Type':

Write-up: presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling lt arm-lateral forearm to hand;swollen since inj;T96.8;expired 4NOV97 @ home;


Changed on 8/14/2018

VAERS ID: 104253 Before After
VAERS Form:1
Age:71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / UNK - / IM
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441214 / 1 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx ETOH, tobacco use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC 'Split Type':

Write-up: presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling lt arm-lateral forearm to hand;swollen since inj;T96.8;expired 4NOV97 @ home;


Changed on 9/14/2018

VAERS ID: 104253 Before After
VAERS Form:1
Age:71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / UNK - / IM
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441214 / 1 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx ETOH, tobacco use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC 'Split Type':

Write-up: presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling lt arm-lateral forearm to hand;swollen since inj;T96.8;expired 4NOV97 @ home;


Changed on 10/14/2018

VAERS ID: 104253 Before After
VAERS Form:1
Age:71.0
Sex:Male
Location:Maryland
Vaccinated:1997-10-28
Onset:1997-10-28
Submitted:1997-11-04
Entered:1997-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / UNK - / IM
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441214 / 1 RA / IM

Administered by: Public      Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-04
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: NONE
Current Illness: NONE
Preexisting Conditions: hx ETOH, tobacco use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC 'Split Type':

Write-up: presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling lt arm-lateral forearm to hand;swollen since inj;T96.8;expired 4NOV97 @ home;

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