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This is VAERS ID 471819

Case Details

VAERS ID: 471819 (history)  
Form: Version 1.0  
Age: 95.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2012-10-23
Onset:2012-10-24
   Days after vaccination:1
Submitted: 2012-10-26
   Days after onset:2
Entered: 2012-10-29
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UH732AA / UNK LA / IM

Administered by: Other       Purchased by: Private
Symptoms: Asthenia, Cardiac failure congestive, Condition aggravated, Nausea
SMQs:, Cardiac failure (narrow), Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-10-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF; Aortic aneurysm; Advanced age
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient hospitalized 10/16-10/21 with CHF exacerbation and increased weakness. Assessment by HH 10/23/12 and vaccine given. Patient developed nausea later in the day. Called EMS morning of 10/24 and patient taken to E.R.


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