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This is VAERS ID 36019

Case Details

VAERS ID: 36019 (history)  
Form: Version 1.0  
Age: 65.0  
Sex: Male  
Location: West Virginia  
Vaccinated:1991-09-22
Onset:1991-09-26
   Days after vaccination:4
Submitted: 1991-10-10
   Days after onset:14
Entered: 1991-11-04
   Days after submission:25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 010171P / UNK LA / IM

Administered by: Public       Purchased by: Unknown
Symptoms: Dyspnoea, Malaise
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations: NA~ ()~~~In patient
Other Medications: Theodur, Brethine
Current Illness: NONE
Preexisting Conditions: asthmatic-took allergy inject for dust, mold for about 18 months, recent testing-med d/c 3 mos ago;
Allergies:
Diagnostic Lab Data:
CDC Split Type: WV9140

Write-up: Pt recvd vax 22SEP91 c/o vague malaise beginning 25SEP but not enough discomfort to interfere w/daily activities; 26SEP91 @ home 5AM severe episodes of respiratory difficulty p/3 home ventilation treatments pt drove self to hosp ER;


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