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This is VAERS ID 36702

Case Details

VAERS ID: 36702 (history)  
Form: Version 1.0  
Age: 91.0  
Sex: Male  
Location: Missouri  
Vaccinated:1991-11-08
Onset:1991-11-09
   Days after vaccination:1
Submitted: 1991-11-18
   Days after onset:9
Entered: 1991-12-02
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918146 / 5 LA / IM

Administered by: Public       Purchased by: Public
Symptoms: Anorexia, Asthenia, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Allergic to penicillin;
Allergies:
Diagnostic Lab Data:
CDC Split Type: MO9191

Write-up: 09NOV91 became very weak, vomiting, poor appetite; continued to get weaker; 12NOV91 fever 101 continued for 2 days; 14NOV91 hospitalized for approx 1 day for tests; no rx - Home Health Nurse 3 x week;


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