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This is VAERS ID 404258

History of Changes from the VAERS Wayback Machine

First Appeared on 11/3/2010

VAERS ID: 404258
VAERS Form:
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3566BA / - RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 4/13/2011

VAERS ID: 404258 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3566BA / - RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bronchopneumonia, Death, Pulse absent, Resuscitation, Splenomegaly, Sudden death, Klebsiella infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 5/13/2011

VAERS ID: 404258 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3566BA / - RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Bronchopneumonia, Death, Pulse absent, Resuscitation, Splenomegaly, Sudden death, Klebsiella infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 7/12/2011

VAERS ID: 404258 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / - RL / IM
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3566BA / - RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 7/7/2013

VAERS ID: 404258 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / - RL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / - RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 6/14/2014

VAERS ID: 404258 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / - RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 3/14/2015

VAERS ID: 404258 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / - RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 9/14/2017

VAERS ID: 404258 Before After
VAERS Form:(blank) 1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / - UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / - UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / - UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / - UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, ora or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 2/14/2018

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 6/14/2018

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 8/14/2018

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 9/14/2018

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 10/14/2018

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 12/24/2020

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 12/30/2020

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 5/7/2021

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.


Changed on 5/14/2021

VAERS ID: 404258 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Nebraska
Vaccinated:2010-10-11
Onset:2010-10-18
Submitted:2010-10-18
Entered:2010-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3566BA / UNK RL / IM
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB441BA / UNK LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0647Z / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0552Z / UNK LL / IM

Administered by: Private      Purchased by: Private
Symptoms: Apnoea, Death, Pulse absent, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-10-18
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: TYLENOL Children''s PO; QVAR 80, 1 inhaler, 10/14/2010, take 2 puffs by inhalation twice daily while awake; DIFLUCAN 10 MG/ML susr, 14 day supply, 10/11/2010, take 5 mL by mouth daily. Take 5 mls on day 1, then take 2.5 mls on days 2-14, or
Current Illness: None
Preexisting Conditions: Multiple congenital anomalies; Developmental delay; Esophageal reflux; Pneumonia, organism unspecified; Prematurity 36 weeks EGA; Hypothyroidism; Hypothalamic dysplasia; Bicuspid aortic valve; Oral thrush; Decreased sensation larynx; Stridor; GERD; Feeding difficulty; Dysphagia, pharyngeal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient was found pulseless and apneic in her bed by mom in the morning (0500). CPR performed and pt taken to ED. Unable to resuscitate.

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