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This is VAERS ID 36624

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 36624
VAERS Form:
Age:85.7
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-12-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA VACCINE 1991-1992 / WYETH 4918129 / - LA / IM

Administered by: Private      Purchased by: Unknown
Symptoms: NAUSEA, VOMIT, DIARRHEA, HEART FAIL RIGHT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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':

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;


Changed on 12/8/2009

VAERS ID: 36624 Before After
VAERS Form:
Age:85.7 85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-12-02 1991-11-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA VACCINE 1991-1992 INFLUENZA (SEASONAL) (NO BRAND NAME, 91-92) / WYETH WYETH PHARMACEUTICALS, INC 4918129 / - LA / IM

Administered by: Private Unknown      Purchased by: Unknown
Symptoms: Diarrhoea, Nausea, Right ventricular failure, Vomiting, NAUSEA, VOMIT, DIARRHEA, HEART FAIL RIGHT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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': (blank) 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;


Changed on 8/31/2010

VAERS ID: 36624 Before After
VAERS Form:
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (NO BRAND NAME, 91-92) INFLUENZA (SEASONAL) (NO BRAND NAME) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 4918129 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Diarrhoea, Nausea, Right ventricular failure, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 7/7/2013

VAERS ID: 36624 Before After
VAERS Form:
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918129 / - LA / IM
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918129 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Diarrhoea, Nausea, Right ventricular failure, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 12/14/2016

VAERS ID: 36624 Before After
VAERS Form:
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918129 / - LA / IM
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918129 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Diarrhoea, Nausea, Right ventricular failure, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 9/14/2017

VAERS ID: 36624 Before After
VAERS Form:(blank) 1
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 2/14/2018

VAERS ID: 36624 Before After
VAERS Form:1
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 6/14/2018

VAERS ID: 36624 Before After
VAERS Form:1
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 8/14/2018

VAERS ID: 36624 Before After
VAERS Form:1
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 9/14/2018

VAERS ID: 36624 Before After
VAERS Form:1
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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;


Changed on 10/14/2018

VAERS ID: 36624 Before After
VAERS Form:1
Age:85.0
Sex:Male
Location:South Dakota
Vaccinated:1991-10-08
Onset:1991-10-09
Submitted:1991-10-28
Entered:1991-11-25
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=36624&WAYBACKHISTORY=ON


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