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This is VAERS ID 414065

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2011

VAERS ID: 414065
VAERS Form:
Age:0.4
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 4/13/2011

VAERS ID: 414065 Before After
VAERS Form:
Age:0.4
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Computerised tomogram abnormal, Cyanosis, Diet refusal, Epistaxis, Irritability, Respiratory arrest, Resuscitation, Vomiting, Brain oedema, Scan brain, Viral test negative, Bacterial test negative, Endotracheal intubation, Hypoxic-ischaemic encephalopathy

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 5/13/2011

VAERS ID: 414065 Before After
VAERS Form:
Age:0.4
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Computerised tomogram abnormal, Cyanosis, Diet refusal, Epistaxis, Irritability, Respiratory arrest, Resuscitation, Vomiting, Brain oedema, Scan brain, Viral test negative, Bacterial test negative, Endotracheal intubation, Hypoxic-ischaemic encephalopathy

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 5/13/2013

VAERS ID: 414065 Before After
VAERS Form:
Age:0.4
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 2/14/2017

VAERS ID: 414065 Before After
VAERS Form:
Age:0.4 0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 9/14/2017

VAERS ID: 414065 Before After
VAERS Form:(blank) 1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 1 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 1 2 - MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 2/14/2018

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 6/14/2018

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 8/14/2018

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 9/14/2018

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 10/14/2018

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 12/24/2020

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 12/30/2020

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 5/7/2021

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest


Changed on 5/14/2021

VAERS ID: 414065 Before After
VAERS Form:1
Age:0.38
Sex:Female
Location:Ohio
Vaccinated:2010-11-01
Onset:2010-11-16
Submitted:2011-01-05
Entered:2011-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B099BA / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0524Z / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest, Computerised tomogram abnormal, Respiratory arrest, Brain oedema, Scan brain, Viral test negative, Bacterial test negative

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-11-17
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Patient was tested for viral and bacterial infections, all results were negative. CT showed significant swelling of the brain but no evidence of trauma or bleed.
CDC 'Split Type':

Write-up: Cessation of respiration, cardiac arrest

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=414065&WAYBACKHISTORY=ON

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