| VAERS ID: |
83553 (history) |
| Form: |
Version 1.0 |
| Age: |
82.0 |
| Sex: |
Female |
| Location: |
Georgia |
| Vaccinated: | 1995-10-27 |
| Onset: | 1995-10-29 |
| Days after vaccination: | 2 |
| Submitted: |
1995-11-01 |
| Days after onset: | 3 |
| Entered: |
1996-03-11 |
| Days after submission: | 131 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH |
4958139 / 3 |
RA / IM |
Administered by: Public Purchased by: Public
Symptoms: Apnoea,
Cardiac arrest,
Myocardial infarction
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1995-10-29
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:
Preexisting Conditions: arhtritis
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA96001
Write-up: deceased 28OCT95 |
