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This is VAERS ID 92136

Case Details

VAERS ID: 92136 (history)  
Form: Version 1.0  
Age: 63.0  
Sex: Female  
Location: Kansas  
Vaccinated:1996-11-05
Onset:1996-11-05
   Days after vaccination:0
Submitted: 1996-11-11
   Days after onset:6
Entered: 1996-11-20
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 1 - / IM A

Administered by: Private       Purchased by: Other
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-11-05
   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: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


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