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This is VAERS ID 91791

Case Details

VAERS ID: 91791 (history)  
Form: Version 1.0  
Age: 79.0  
Sex: Female  
Location: Unknown  
Vaccinated:1996-10-15
Onset:1996-10-17
   Days after vaccination:2
Submitted: 1996-10-22
   Days after onset:5
Entered: 1996-11-08
   Days after submission:17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH - / UNK - / IM

Administered by: Private       Purchased by: Other
Symptoms: Abdominal pain, Diarrhoea, Nausea, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-10-17
   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: Cardizem, Cyodur,asthma shot, pred
Current Illness: unk
Preexisting Conditions: asthma, heart problems, arthritis, aortic aneurysm
Allergies:
Diagnostic Lab Data:
CDC Split Type: 896297025L

Write-up: pt recv vax 15OCT96 & 6PM on 17OCT96 pt fainted;upon arousal pt c.o stomach pain, diarrhea, & nausea;pt dies in home 8:45Pm;


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