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This is VAERS ID 91623

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 91623
VAERS Form:
Age:96.2
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUOGEN 1996-1997 / PARKE-DAVIS 00986P / 0 A / IM

Administered by: Private      Purchased by: Unknown
Symptoms: AGITATION, FEVER, APNEA, EDEMA LUNG, HEART FAIL RIGHT

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: 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':

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


Changed on 12/8/2009

VAERS ID: 91623 Before After
VAERS Form:
Age:96.2
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-06 1996-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUOGEN 1996-1997 INFLUENZA (SEASONAL) (FLUOGEN 96-97) / PARKE-DAVIS 00986P / 0 A / IM

Administered by: Private      Purchased by: Unknown Other
Symptoms: Agitation, Apnoea, Hypotension, Lung disorder, Pulmonary oedema, Pyrexia, Right ventricular failure, Somnolence, AGITATION, FEVER, APNEA, EDEMA LUNG, HEART FAIL RIGHT

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: 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': (blank) 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


Changed on 8/31/2010

VAERS ID: 91623 Before After
VAERS Form:
Age:96.2
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUOGEN 96-97) INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00986P / 0 A / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Hypotension, Lung disorder, Pulmonary oedema, Pyrexia, Right ventricular failure, Somnolence

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: 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


Changed on 7/7/2013

VAERS ID: 91623 Before After
VAERS Form:
Age:96.2
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00986P / 0 A / IM
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00986P / 0 A / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Hypotension, Lung disorder, Pulmonary oedema, Pyrexia, Right ventricular failure, Somnolence

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: 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


Changed on 2/14/2017

VAERS ID: 91623 Before After
VAERS Form:
Age:96.2 96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00986P / 0 A / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Hypotension, Lung disorder, Pulmonary oedema, Pyrexia, Right ventricular failure, Somnolence

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: 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


Changed on 5/14/2017

VAERS ID: 91623 Before After
VAERS Form:
Age:96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00986P / 0 A - / IM IM A

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Hypotension, Lung disorder, Pulmonary oedema, Pyrexia, Right ventricular failure, Somnolence

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: ~ ()~~~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


Changed on 9/14/2017

VAERS ID: 91623 Before After
VAERS Form:(blank) 1
Age:96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00986P / 0 1 - / IM A

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Hypotension, Lung disorder, Pulmonary oedema, Pyrexia, Right ventricular failure, Somnolence

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: ~ ()~~~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


Changed on 2/14/2018

VAERS ID: 91623 Before After
VAERS Form:1
Age:96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: ~ ()~~~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


Changed on 6/14/2018

VAERS ID: 91623 Before After
VAERS Form:1
Age:96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: ~ ()~~~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


Changed on 8/14/2018

VAERS ID: 91623 Before After
VAERS Form:1
Age:96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: ~ ()~~~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


Changed on 9/14/2018

VAERS ID: 91623 Before After
VAERS Form:1
Age:96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: ~ ()~~~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


Changed on 10/14/2018

VAERS ID: 91623 Before After
VAERS Form:1
Age:96.0
Sex:Female
Location:New Hampshire
Vaccinated:1996-10-16
Onset:1996-10-18
Submitted:1996-10-24
Entered:1996-11-05
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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1996-10-19
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: ~ ()~~~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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