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This is VAERS ID 106403

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 106403
VAERS Form:
Age:90.3
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUZONE 1997-1998 / CONNAUGHT LABS 7F81816 / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 12/8/2009

VAERS ID: 106403 Before After
VAERS Form:
Age:90.3
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-16 1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUZONE 1997-1998 INFLUENZA (SEASONAL) (FLUZONE 97-98) / CONNAUGHT LABS CONNAUGHT LABORATORIES 7F81816 / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event, REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 8/31/2010

VAERS ID: 106403 Before After
VAERS Form:
Age:90.3
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE 97-98) INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 7/7/2013

VAERS ID: 106403 Before After
VAERS Form:
Age:90.3
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / - - / -
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 2/14/2017

VAERS ID: 106403 Before After
VAERS Form:
Age:90.3 90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 5/14/2017

VAERS ID: 106403 Before After
VAERS Form:
Age:90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 9/14/2017

VAERS ID: 106403 Before After
VAERS Form:(blank) 1
Age:90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / - UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 2/14/2018

VAERS ID: 106403 Before After
VAERS Form:1
Age:90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 6/14/2018

VAERS ID: 106403 Before After
VAERS Form:1
Age:90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 8/14/2018

VAERS ID: 106403 Before After
VAERS Form:1
Age:90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 9/14/2018

VAERS ID: 106403 Before After
VAERS Form:1
Age:90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;


Changed on 10/14/2018

VAERS ID: 106403 Before After
VAERS Form:1
Age:90.0
Sex:Male
Location:Unknown
Vaccinated:1997-10-13
Onset:1997-10-13
Submitted:1997-10-20
Entered:1998-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Lanoxin;lasix;K-Dur;Allopurinol;
Current Illness: metastatic melanoma;
Preexisting Conditions: hx of CHF;metastatic melanoma;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt followed for metastatic melanoma recv flu vax & apparently had sudden death approx 45min later;no prev rxn to flu vax;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=106403&WAYBACKHISTORY=ON


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