| VAERS ID: |
36558 (history) |
| Form: |
Version 1.0 |
| Age: |
63.0 |
| Sex: |
Female |
| Location: |
West Virginia |
| Vaccinated: | 1991-10-29 |
| Onset: | 1991-10-29 |
| Days after vaccination: | 0 |
| Submitted: |
1991-11-14 |
| Days after onset: | 16 |
| Entered: |
1991-11-21 |
| Days after submission: | 7 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS |
01401P / 1 |
LA / IM |
Administered by: Public Purchased by: Public
Symptoms: Amblyopia,
Asthenia,
Hypotension,
Palpitations
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Optic nerve disorders (broad), Cardiomyopathy (broad), Dehydration (broad), Hypokalaemia (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, 3 days
Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Zantac & Pepzid tabs
Current Illness: alcoholic liver cirrhosis
Preexisting Conditions: peptic ulcer disease
Allergies:
Diagnostic Lab Data: EKG''s, cardiac enzymes & extensive stress test-all normal
CDC Split Type: WV9149
Write-up: Approx 3 hrs p/vax recvd pt exp palpitaitons, weakness & blurred vision; Also was hypotensive 50-60/40 requiring IV fluids & hospitalization; |
