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This is VAERS ID 475000

History of Changes from the VAERS Wayback Machine

First Appeared on 12/11/2012

VAERS ID: 475000
VAERS Form:
Age:0.4
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 1/7/2013

VAERS ID: 475000 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No Yes
ER or ED Visit (V2.0)? No
Hospitalized? No Yes, days: (blank) 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 5/13/2013

VAERS ID: 475000 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 1 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 2/14/2017

VAERS ID: 475000 Before After
VAERS Form:
Age:0.4 0.35
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 9/14/2017

VAERS ID: 475000 Before After
VAERS Form:(blank) 1
Age:0.35
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 1 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 1 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 1 2 - MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 2/14/2018

VAERS ID: 475000 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 6/14/2018

VAERS ID: 475000 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 8/14/2018

VAERS ID: 475000 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 9/14/2018

VAERS ID: 475000 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


Changed on 10/14/2018

VAERS ID: 475000 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Virginia
Vaccinated:2012-11-16
Onset:2012-11-16
Submitted:2012-11-19
Entered:2012-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-11-19
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=475000&WAYBACKHISTORY=ON


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