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This is VAERS ID 839106

History of Changes from the VAERS Wayback Machine

First Appeared on 10/14/2019

VAERS ID: 839106
VAERS Form:1
Age:18.0
Sex:Male
Location:Idaho
Vaccinated:2019-10-01
Onset:2019-10-01
Submitted:2019-10-08
Entered:2019-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLULAVAL QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS 2277M / 1 RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Incoherent, Lethargy, Speech disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2019-10-01
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: Abilify, fluoxetine
Current Illness:
Preexisting Conditions: Cerebral palsy, Generalized anxiety disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. presented to clinic (Urgent Care) with mom on 10/1/19 at approx. 1945. He was lathargic, responsive to sternal rub, nonverbal and incoherent. 911 was called, pt. was taken by ambulance to the ED. Pt passed away on the evening of 10/1/19.


Changed on 12/24/2020

VAERS ID: 839106 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:Idaho
Vaccinated:2019-10-01
Onset:2019-10-01
Submitted:2019-10-08
Entered:2019-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLULAVAL QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS 2277M / 1 RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Incoherent, Lethargy, Speech disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2019-10-01
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: Abilify, fluoxetine
Current Illness:
Preexisting Conditions: Cerebral palsy, Generalized anxiety disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. presented to clinic (Urgent Care) with mom on 10/1/19 at approx. 1945. He was lathargic, responsive to sternal rub, nonverbal and incoherent. 911 was called, pt. was taken by ambulance to the ED. Pt passed away on the evening of 10/1/19.


Changed on 12/30/2020

VAERS ID: 839106 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:Idaho
Vaccinated:2019-10-01
Onset:2019-10-01
Submitted:2019-10-08
Entered:2019-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLULAVAL QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS 2277M / 1 RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Incoherent, Lethargy, Speech disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2019-10-01
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: Abilify, fluoxetine
Current Illness:
Preexisting Conditions: Cerebral palsy, Generalized anxiety disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt. presented to clinic (Urgent Care) with mom on 10/1/19 at approx. 1945. He was lathargic, responsive to sternal rub, nonverbal and incoherent. 911 was called, pt. was taken by ambulance to the ED. Pt passed away on the evening of 10/1/19.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=839106&WAYBACKHISTORY=ON


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