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This is VAERS ID 39743

Case Details

VAERS ID: 39743 (history)  
Form: Version 1.0  
Age: 104.0  
Sex: Female  
Location: Hawaii  
Vaccinated:1991-10-27
Onset:0000-00-00
Submitted: 1991-11-25
Entered: 1992-03-02
   Days after submission:98
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918147 / UNK GM / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea, Arteriosclerosis, Bronchitis, Cardiac arrest, Dehydration
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-11-16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: UNK~ ()~~0.00~In Patient
Other Medications: Dulcolax, APAP, MOM, Synthroid, Colase, MVI, CA supplement, Cipro;
Current Illness: pneumonia, malnutrition, s/p femur fract
Preexisting Conditions: NKA, alzheimer''s dementia, chronic dermatitis, HTN, osteoporosis, osteoarthritis, hypothyroidism, incontinent, fragil skin w/some tears, poor appetite, & non ambulatory;
Allergies:
Diagnostic Lab Data:
CDC Split Type: HI9203

Write-up: Adm dx: ORIF-rt supracondylar fracture, gastric ulcer; final dx cardiorespiratory arrest, acute bronchitis, demantia-alzheimer''s type, secondary dx malnutrition, dehydrat, ASCVD, osteoporosis, osteoarthritis;


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