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This is VAERS ID 40951

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 40951
VAERS Form:
Age:79.8
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUZONE 1991-1992 / CONNAUGHT LABS 1F21215 / - A / IM

Administered by: Private      Purchased by: Unknown
Symptoms: DYSPNEA, HEART ARREST, PHARYNGITIS, COAGUL DIS, ACIDOSIS LACTIC

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': lymphoma, leukemia

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 12/8/2009

VAERS ID: 40951 Before After
VAERS Form:
Age:79.8
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-03 1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUZONE 1991-1992 INFLUENZA (SEASONAL) (FLUZONE 91-92) / CONNAUGHT LABS CONNAUGHT LABORATORIES 1F21215 / - A / IM

Administered by: Private      Purchased by: Unknown Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis, DYSPNEA, HEART ARREST, PHARYNGITIS, COAGUL DIS, ACIDOSIS LACTIC

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': lymphoma, leukemia PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 8/31/2010

VAERS ID: 40951 Before After
VAERS Form:
Age:79.8
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE 91-92) INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A / IM

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 4/13/2011

VAERS ID: 40951 Before After
VAERS Form:
Age:79.8
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A / IM

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 5/13/2011

VAERS ID: 40951 Before After
VAERS Form:
Age:79.8
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A / IM

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 6/11/2011

VAERS ID: 40951 Before After
VAERS Form:
Age:79.8
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A / IM

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 7/7/2013

VAERS ID: 40951 Before After
VAERS Form:
Age:79.8
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A / IM

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 2/14/2017

VAERS ID: 40951 Before After
VAERS Form:
Age:79.8 79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A / IM

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 5/14/2017

VAERS ID: 40951 Before After
VAERS Form:
Age:79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - A - / IM IM A

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 9/14/2017

VAERS ID: 40951 Before After
VAERS Form:(blank) 1
Age:79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / - UNK - / IM A

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 2/14/2018

VAERS ID: 40951 Before After
VAERS Form:1
Age:79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / UNK - / IM A

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 6/14/2018

VAERS ID: 40951 Before After
VAERS Form:1
Age:79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / UNK - / IM A

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 8/14/2018

VAERS ID: 40951 Before After
VAERS Form:1
Age:79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / UNK - / IM A

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 9/14/2018

VAERS ID: 40951 Before After
VAERS Form:1
Age:79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / UNK - / IM A

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


Changed on 10/14/2018

VAERS ID: 40951 Before After
VAERS Form:1
Age:79.0
Sex:Male
Location:Pennsylvania
Vaccinated:1991-12-19
Onset:1991-12-27
Submitted:1992-03-24
Entered:1992-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / UNK - / IM A

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1992-01-05
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC 'Split Type': PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;

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