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This is VAERS ID 414753

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2011

VAERS ID: 414753
VAERS Form:
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(10-11): INFLUENZA (SEASONAL) (FLULAVAL 10-11) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 4/13/2011

VAERS ID: 414753 Before After
VAERS Form:
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(10-11): INFLUENZA (SEASONAL) (FLULAVAL 10-11) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Acute respiratory failure, Cardiac arrest, Cardiac failure congestive, Chronic respiratory failure, Condition aggravated, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Malaise, Nasopharyngitis, Nausea, Pain, Pulmonary congestion, Pulse abnormal, Quadriplegia, Resuscitation, Unresponsive to stimuli, Vaccination complication, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 5/13/2011

VAERS ID: 414753 Before After
VAERS Form:
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(10-11): INFLUENZA (SEASONAL) (FLULAVAL 10-11) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Acute respiratory failure, Cardiac arrest, Cardiac failure congestive, Chronic respiratory failure, Condition aggravated, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Malaise, Nasopharyngitis, Nausea, Pain, Pulmonary congestion, Pulse abnormal, Quadriplegia, Resuscitation, Unresponsive to stimuli, Vaccination complication, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 7/12/2011

VAERS ID: 414753 Before After
VAERS Form:
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM
FLU(10-11): INFLUENZA (SEASONAL) (FLULAVAL 10-11) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 7/7/2013

VAERS ID: 414753 Before After
VAERS Form:
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 6/14/2014

VAERS ID: 414753 Before After
VAERS Form:
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 4/14/2017

VAERS ID: 414753 Before After
VAERS Form:
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 9/14/2017

VAERS ID: 414753 Before After
VAERS Form:(blank) 1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / - UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 2/14/2018

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 6/14/2018

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 8/14/2018

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 9/14/2018

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 10/14/2018

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 12/24/2020

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 12/30/2020

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 5/7/2021

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.


Changed on 5/14/2021

VAERS ID: 414753 Before After
VAERS Form:1
Age:36.0
Sex:Male
Location:Utah
Vaccinated:2010-12-13
Onset:2010-12-16
Submitted:2011-01-15
Entered:2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLULAVAL) / GLAXOSMITHKLINE BIOLOGICALS AFLLA595AA / UNK LA / IM

Administered by: Other      Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation, Increased bronchial secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-20
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: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.

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