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This is VAERS ID 42021

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 42021
VAERS Form:
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLU-IMUNE 1991-1992 EVANS MED & LEDERLE / LEDERLE 312976 / - - / IM

Administered by: Private      Purchased by: Unknown
Symptoms: FEVER, ASTHENIA, TACHYCARDIA, COUGH INC, WEIGHT DEC

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type':

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 12/8/2009

VAERS ID: 42021 Before After
VAERS Form:
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-20 1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLU-IMUNE 1991-1992 EVANS MED & LEDERLE INFLUENZA (SEASONAL) (FLU-IMUNE 91-92) / LEDERLE LEDERLE LABORATORIES 312976 / - - / IM

Administered by: Private      Purchased by: Unknown Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased, FEVER, ASTHENIA, TACHYCARDIA, COUGH INC, WEIGHT DEC

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': (blank) 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 8/31/2010

VAERS ID: 42021 Before After
VAERS Form:
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLU-IMUNE 91-92) INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / - - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 7/7/2013

VAERS ID: 42021 Before After
VAERS Form:
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / - - / IM
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / - - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 5/14/2017

VAERS ID: 42021 Before After
VAERS Form:
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / - - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 9/14/2017

VAERS ID: 42021 Before After
VAERS Form:(blank) 1
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / - UNK - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 2/14/2018

VAERS ID: 42021 Before After
VAERS Form:1
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / UNK - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 6/14/2018

VAERS ID: 42021 Before After
VAERS Form:1
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / UNK - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 8/14/2018

VAERS ID: 42021 Before After
VAERS Form:1
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / UNK - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 9/14/2018

VAERS ID: 42021 Before After
VAERS Form:1
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / UNK - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


Changed on 10/14/2018

VAERS ID: 42021 Before After
VAERS Form:1
Age:62.0
Sex:Male
Location:California
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted:1992-03-26
Entered:1992-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / UNK - / IM

Administered by: Private      Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC 'Split Type': 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;

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