| VAERS ID: |
26318 (history) |
| Form: |
Version 1.0 |
| Age: |
92.0 |
| Sex: |
Female |
| Location: |
Alabama |
| Vaccinated: | 1990-10-09 |
| Onset: | 1990-10-11 |
| Days after vaccination: | 2 |
| Submitted: |
1990-10-17 |
| Days after onset: | 6 |
| Entered: |
1990-10-22 |
| Days after submission: | 5 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES |
0F11216 / 1 |
- / IM A |
Administered by: Private Purchased by: Private
Symptoms: Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1990-10-12
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Dipyridamold, Furosemide,Dioctolose, Chloraseptic, Methyldopa ,MOM, Aldomet
Current Illness: Rt lacunar Infarct Temp Area, Hypertens.
Preexisting Conditions: Rt Hemispheric stroke /w lt hemiparesis, lt facial weakness, aphasia, dysarthria, hypertension, limited ambulatory ability 2nd to stoke
Allergies:
Diagnostic Lab Data: All lab work WNL
CDC Split Type:
Write-up: Pt vaccinated with Influenza Trivalent A&B at 11:00AM on 9OCT90 fever noted at 8:00AM 11OCT90 Pt died 2:30AM 12OCT90. |
