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This is VAERS ID 36624

Case Details

VAERS ID: 36624 (history)  
Form: Version 1.0  
Age: 85.0  
Sex: Male  
Location: South Dakota  
Vaccinated:1991-10-08
Onset:1991-10-09
   Days after vaccination:1
Submitted: 1991-10-28
   Days after onset:19
Entered: 1991-11-25
   Days after submission:28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918129 / UNK LA / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Diarrhoea, Nausea, Right ventricular failure, Vomiting
SMQs:, Cardiac failure (narrow), Acute pancreatitis (broad), Pseudomembranous colitis (broad), Pulmonary hypertension (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-10-14
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: HCTZ
Current Illness: NONE
Preexisting Conditions: arthritis, hypertension
Allergies:
Diagnostic Lab Data: total bilirubin results inconclusive;
CDC Split Type: SD91026

Write-up: Nausea, vomiting, diarrhea started 9OCT or 10OCT, diarrhea stopped but was still nauseated; MD ordered Phenergan supp 13OCT91; congestive heart failure was reason for death;


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