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This is VAERS ID 36736

Case Details

VAERS ID: 36736 (history)  
Form: Version 1.0  
Age: 65.0  
Sex: Male  
Location: California  
Vaccinated:1991-11-11
Onset:1991-11-12
   Days after vaccination:1
Submitted: 1991-11-25
   Days after onset:13
Entered: 1991-12-02
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 10300080808020 / 1 LA / -

Administered by: Unknown       Purchased by: Private
Symptoms: Facial palsy
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Hearing impairment (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications:
Current Illness: ESRD
Preexisting Conditions: chronic renal failure NKA
Allergies:
Diagnostic Lab Data: bells palsy
CDC Split Type:

Write-up: Pt recvd Influenza A&B vax on 8NOV91 & 12NOV91 aobut 4PM pt devel a droopy mouth on rt side; Pt consulted MD & was referred to neurologist who dx bells palsy;


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