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This is VAERS ID 57611

Case Details

VAERS ID: 57611 (history)  
Form: Version 1.0  
Age: 67.0  
Sex: Male  
Location: New York  
Vaccinated:1993-10-07
Onset:1993-10-08
   Days after vaccination:1
Submitted: 1993-11-10
   Days after onset:33
Entered: 1993-11-22
   Days after submission:12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00573P / UNK - / IM
PPV: PNEUMO (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / IM

Administered by: Private       Purchased by: Other
Symptoms: Arrhythmia
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1993-10-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: only condition listed #19
Preexisting Conditions: hx of caridac problems/MI 11AUG93; was due for stress test surgery testing 8OCT93;
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was found dead at home, no s/s or complaints, pt had existing condition of severe arrhythmia, severe cardiac conditions;


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