| VAERS ID: |
25553 (history) |
| Form: |
Version 1.0 |
| Age: |
0.2 |
| Sex: |
Male |
| Location: |
Tennessee |
| Vaccinated: | 1990-06-25 |
| Onset: | 1990-06-27 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
1990-07-23 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES |
9J01114 / UNK |
- / - |
| OPV: POLIO VIRUS, ORAL (NO BRAND NAME) / UNKNOWN MANUFACTURER |
- / UNK |
- / - |
Administered by: Private Purchased by: Private
Symptoms: Adrenal cortex necrosis,
Adrenal haemorrhage,
Lung disorder,
Neoplasm,
Petechiae,
Pulmonary oedema,
Stupor,
Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypoglycaemia (broad), Non-haematological tumours of unspecified malignancy (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: none
Current Illness: routine well baby checkup given
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pt found in crib unresponsive at 09:00 6-27-90; DTP & OPV given on 06-25-90 at 15:00. Pt to ER via ambo, no spontaneous heartbeat, pulse or resp. CPR and defib attempted, could not convert v-fib to NSR. Pupils fixed & unresp. See WORM. |
