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This is VAERS ID 56919

Case Details

VAERS ID: 56919 (history)  
Form: Version 1.0  
Age: 67.0  
Sex: Male  
Location: North Carolina  
Vaccinated:1993-09-29
Onset:1993-09-30
   Days after vaccination:1
Submitted: 1993-10-27
   Days after onset:27
Entered: 1993-11-01
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4938147 / 1 - / IM

Administered by: Private       Purchased by: Private
Symptoms: Cardiovascular disorder, Hypertension, Stupor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1993-10-01
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Prolixin;
Current Illness: PVC/head injury;
Preexisting Conditions: hx of ventricular arrhythmia; chronic dementia, diabetes, CHF;
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 29SEP93 1800 vax given; 30SPE93 0830 pt nonresponsive to any stimuli; 1OCT93 0300 pt expired; COD hypertensive cardiovascular disease;


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