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This is VAERS ID 39077

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 39077
VAERS Form:
Age:74.5
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA VACCINE 1991-1992 / WYETH 4918132 / - LA / IM

Administered by: Private      Purchased by: Unknown
Symptoms: SYNCOPE, INFARCT MYOCARD

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: 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;


Changed on 12/8/2009

VAERS ID: 39077 Before After
VAERS Form:
Age:74.5
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-29 1992-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA VACCINE 1991-1992 INFLUENZA (SEASONAL) (NO BRAND NAME, 91-92) / WYETH WYETH PHARMACEUTICALS, INC 4918132 / - LA / IM

Administered by: Private      Purchased by: Unknown Private
Symptoms: Myocardial infarction, Syncope, SYNCOPE, INFARCT MYOCARD

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: 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;


Changed on 8/31/2010

VAERS ID: 39077 Before After
VAERS Form:
Age:74.5
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (NO BRAND NAME, 91-92) INFLUENZA (SEASONAL) (NO BRAND NAME) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 4918132 / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Myocardial infarction, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: 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;


Changed on 7/7/2013

VAERS ID: 39077 Before After
VAERS Form:
Age:74.5
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918132 / - LA / IM
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918132 / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Myocardial infarction, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: 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;


Changed on 12/14/2016

VAERS ID: 39077 Before After
VAERS Form:
Age:74.5
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918132 / - LA / IM
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918132 / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Myocardial infarction, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: 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;


Changed on 2/14/2017

VAERS ID: 39077 Before After
VAERS Form:
Age:74.5 74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918132 / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Myocardial infarction, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: 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;


Changed on 5/14/2017

VAERS ID: 39077 Before After
VAERS Form:
Age:74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918132 / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Myocardial infarction, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: ~ ()~~~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;


Changed on 9/14/2017

VAERS ID: 39077 Before After
VAERS Form:(blank) 1
Age:74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: ~ ()~~~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;


Changed on 2/14/2018

VAERS ID: 39077 Before After
VAERS Form:1
Age:74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: ~ ()~~~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;


Changed on 6/14/2018

VAERS ID: 39077 Before After
VAERS Form:1
Age:74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: ~ ()~~~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;


Changed on 8/14/2018

VAERS ID: 39077 Before After
VAERS Form:1
Age:74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: ~ ()~~~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;


Changed on 9/14/2018

VAERS ID: 39077 Before After
VAERS Form:1
Age:74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: ~ ()~~~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;


Changed on 10/14/2018

VAERS ID: 39077 Before After
VAERS Form:1
Age:74.0
Sex:Male
Location:Tennessee
Vaccinated:1991-11-20
Onset:1991-11-20
Submitted:1992-01-20
Entered:1992-01-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-11-20
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: ~ ()~~~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;

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


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