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This is VAERS ID 91623

Case Details

VAERS ID: 91623 (history)  
Form: Version 1.0  
Age: 96.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:1996-10-16
Onset:1996-10-18
   Days after vaccination:2
Submitted: 1996-10-24
   Days after onset:6
Entered: 1996-11-05
   Days after submission:12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00986P / 1 - / IM A

Administered by: Private       Purchased by: Other
Symptoms: Agitation, Apnoea, Hypotension, Lung disorder, Pulmonary oedema, Pyrexia, Right ventricular failure, Somnolence
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (narrow), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1996-10-19
   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: Verapamil, Percocet
Current Illness: NONE
Preexisting Conditions: hx of HTN, dementia, arthritis, vaginosis, atrial flutter, NKA;
Allergies:
Diagnostic Lab Data: NONE PROVIDED;
CDC Split Type: 0010150960037

Write-up: pt recv vax 16OCT96 & devel a low grade temp of 99.5;18OCT96 pt devel rales in both lobes, a BP of 90/40, periods of apnea lasting 3 to 4 sec & sleepiness alternated w/restlessness;pt died on 19OCT96;reporter states pt health had been


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