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This is VAERS ID 36656

Case Details

VAERS ID: 36656 (history)  
Form: Version 1.0  
Age: 70.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:1991-11-07
Onset:1991-11-07
   Days after vaccination:0
Submitted: 1991-11-21
   Days after onset:14
Entered: 1991-11-26
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Bradycardia, Dizziness, Dyspnoea, Hypotonia, Nausea
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (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, 4 days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Atenolol, Norpace, synthroid
Current Illness:
Preexisting Conditions: arrythmias (PAT, RBBB) xmany yrs; goiter; depression; peptic ulcer disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt recvd vax 7NOV91 & approx 1030 7NOV, pt felt lightheaded, nauseous, SOB; pt collapsed w/o LOC, & ambulance was called; pt was bradycardic (pulse 20''s) atropine & epi given en route to ER; In ER had resp distress;


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