VAERS ID: |
28380 (history) |
Form: |
Version 1.0 |
Age: |
80.0 |
Sex: |
Male |
Location: |
Michigan |
Vaccinated: | 1990-10-01 |
Onset: | 1990-10-10 |
Days after vaccination: | 9 |
Submitted: |
1991-02-06 |
Days after onset: | 119 |
Entered: |
1991-02-18 |
Days after submission: | 12 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH |
4908209 / 1 |
- / IM A |
Administered by: Private Purchased by: Private Symptoms: Influenza,
Pharyngitis,
Pyrexia,
Sepsis SMQs:, Agranulocytosis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal infections (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient Other Medications: none Current Illness: Preexisting Conditions: pt has hx of cerebrovascular accident Allergies: Diagnostic Lab Data: CDC Split Type: 890291003B
Write-up: Pt developed flu like respiratory symptoms nine days /p receiving Flu vax(1990-91 formula).Pt was admitted to acute care facility /w a respiratory infection, sepsis, & T. F/U info,recvd 25Jan91 resulted in reclassification as a 15 day rept |