National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 39077

Case Details

VAERS ID: 39077 (history)  
Form: Version 1.0  
Age: 74.0  
Sex: Male  
Location: Tennessee  
Vaccinated:1991-11-20
Onset:1991-11-20
   Days after vaccination:0
Submitted: 1992-01-20
   Days after onset:61
Entered: 1992-01-27
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918132 / UNK LA / IM

Administered by: Private       Purchased by: Private
Symptoms: Myocardial infarction, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-11-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Calan, Synthroid, Feldene
Current Illness: NONE
Preexisting Conditions: No known allergies; hypertension, hypothyroidism, arthritis;
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Pt was administered flu vax @ approx 1215 PM 20NOV91 VS-nl; pt had taken flu vax previously remained in the clinic for 15 to 20mins p/inject; pt passed out on the golf course @ approx 2PM to ER dx MI; no evidence of allergic rxn;


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=39077


Copyright © 2020 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166