VAERS 2723119
SEQIRUS, INC. · INFLUENZA (SEASONAL) (FLUCELVAX QUADRIVALENT) · Charge au3129b
- Staat
- -
- Alter
- 29,0
- Geschlecht
- M
- Eingang
- 12.12.2023
- Impfdatum
- 27.11.2023
- Beginn
- 11.12.2023
- Tage bis Beginn
- 14,0
- Dosis
- N/A
- Route/Site
- SYR / -
Symptomtext
Document Type: History and Physical Document Subject: History & Physical Note Performed By: MD on December 11, 2023 11:46 Verified By: MD on December 11, 2023 15:02 Encounter Info: Hospital, Observation, 12/11/23 - * Final Report * History of Present Illness/Subjective Chief complaint shortness of breath HPI: Patient is a 29-year-old male with history of asthma, kidney transplant, hypertension, hyperlipidemia, cerebral palsy presented to emergency department via private vehicle complaining of shortness of breath that started 2 days ago. He also states that he has been having congestion as well. Patient denied fever and stated that his father is also ill for couple of days. Patient is not wearing any oxygen at home and usually has inhalers for asthma but is out of them currently. Patient is a smoker have smokes 2 days ago when his symptoms started. When he was not evaluated in the emergency room patient presented with a white count of 15.2 with tachycardia and tachypnea. A chest x-ray showed mediastinal contour and heart size are stable and within normal limits radiolucent object projecting over the left midlung favored to represent external paraphernalia. No focal consolidation no edema no pneumothorax no pleural effusion. Patient was requiring oxygen in the emergency room 4 L nasal cannula since his dropped his oxygen to 86%. Despite giving him multiple respiratory treatment patient did not respond it was decided to bring in the patient for influenza treatment which was found to be positive on testing. Patient also shows mild dehydration. Review of Systems All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI Physical Exam/Objective Vitals & Measurements most recent past 24 hours T: 37.1 ?C (Oral) BP: 115/80 HR: 116 (Monitored) RR: 24 SpO2: 94% Oxygen Therapy: Nasal Cannula Oxygen Flow Rate: 4 (L/min) WT: 115.4 kg Hemodynamics Neurologic Glasgow Coma Score: 15 Patient Weight Current Daily Weight: 115.4 kg 12/11/23 Previous Daily Weight: 115.4 kg 12/11/23 Patient Height Current Height: 170 cm 12/11/23 General: Alert and oriented Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: mild oropharynx erythema, post nasal drip Respiratory: Lungs are clear to auscultation. decreased air entry bilaterally Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect Assessment/Plan 1. Asthma exacerbation J45.901 Patient is having asthma exacerbation secondary to influenza A. -Patient was given methylprednisolone multiple Nedra DuoNebs and a dose of Tamiflu in the emergency room. -We will continue with the same and monitor patient on medical floor. -Oxygen as needed. 2. Hypoxia R09.02 See above 3. Influenza A J10.1 Patient is positive for influenza A and has been given first dose of Tamiflu in the emergency room. -We will continue with the same. -Pharmacy to dose Tamiflu since patient is a renal transplant patient. 4. Kidney transplant Z94.0 Noted. Home medications can be started. 5. Cerebral palsy G80.9 Noted 6. Chronic Kidney Disease, Stage III (Moderate) N18.30 This appears to have resolved in the past. 7. Hypertension I10 Resume home medications 8. Hyperlipidemia E78.5 Resume home meds 9. Hypothyroid E03.9 Noted. Resume home medications. Last TSH checked in August of this year was normal. Code Status None Recorded Chronic Problem List Aftercare Following Organ Transplant Anemia Asthma Cerebral palsy Chronic diarrhea Chronic Kidney Disease, Stage III (Moderate) Complications of Transplanted Kidney Dyspepsia Hyperlipidemia Hypertension Hypothyroid IBS (irritable bowel syndrome) Kidney transplant Secondary Hyperparathyroidism (Of Renal Origin) Severe obesity Tobacco use Procedure/Surgical History ?Repair upper extremity laceration and palmaris longus tendon (06/14/2020) ?EGD and Colonoscopy (01/23/2015) ?kidney transplant (03/25/2009) ?hernia surgery ?left side venticuloperitoneal shunt ?tonsillectomy Surgical History Internal 06/13/2020 Upper Extremity I and D MD 05/19/2009 Cystoscopy Stent Removal MD 03/25/2009 Kidney Transplant MD 03/16/2009 Hemodialysis Catheter Placement MD Medications Home Medications (22) Active Advair Diskus 250 mCg-50 mCg inhalation powder 1 Puff, Inhalation, BID albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Inhalation, Q4H albuterol HFA MDI 90mCg/puff inhalation aerosol 180 mCg = 2 Puff, PRN, Inhalation, Q2H amantadine 100 mg oral capsule 100 mg = 1 Capsule, Orally, Daily atenolol 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily cholecalciferol 5000 intl units oral tablet 5,000 Units = 1 Tablet, Orally, Daily cyanocobalamin 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily Envarsus XR 0.75 mg oral tablet, extended release 1.5 mg = 2 Tablet, Orally, QAM, Dx: Z94.0increased dose from 1mg to 1.5mg every morning Envarsus XR 1 mg oral tablet, extended release 1 mg = 1 Tablet, Orally, QAM, Dx: Z94.0 Envarsus XR 1 mg oral tablet, extended release 2 mg = 2 Tablet, Orally, QAM, Dx: Z94.0, T86.10obtain lab asap, 0 refills levothyroxine 25 mCg (0.025 mg) oral tablet 25 mCg = 1 Tablet, Orally, Daily Misc Supplies See Instructions, supplies for nebulizer machineJ45.909 mycophenolate mofetil 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID, Dx: Z94 Nebulizer Compressor See Instructions, Use as directed for asthma 493.90 x 99 monthsCROWDER'S Nebulizer with supplies Not Applicable, Other, Unscheduled, J45.909 Norvasc 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily ondansetron 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q8H Prevacid 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID traZODONE 50 mg oral tablet 50 mg = 1 Tablet, PRN, Orally, At Bedtime Welchol 625 mg oral tablet 625 mg = 1 Tablet, Orally, BID Zyrtec 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, Daily Active Scheduled Inpatient Medications None Reported One-Time Medications Given 12/10/23 00:00:00 TO 12/11/23 11:46:49 albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 10 mg, Neb Inhal, ONCE, (1 DOSE 12/11/23 08:36:00) methylPREDNISolone (methylPREDNISolone sodium succinate), Injection, 125 mg, IV Push, ONCE, (1 DOSE 12/11/23 09:22:00) oseltamivir (Tamiflu), Capsule, 75 mg, Orally, ONCE, (1 DOSE 12/11/23 10:55:00) Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/11/23 09:22:00) PRN Medications (0600 - 0559) from 12/10 - 12/11 albuterol, 2.5 mg, Neb Inhal, Q4H, 0 Dose(s) Allergies statins (Muscle pain, Unknown) Augmentin (Hives) Bactrim (hives) Ceftin Lorabid Tequin (Hives) Zithromax (critical) penicillin (Hives) Social History Alcohol Current, Beer, 1-2 times per month Electronic Cigarette/Vaping E-Cigarette Use Never. Employment/School Unemployed, States "I only got about a 5th grade education because of my health." Hx of CP and kidney transplant. Home/Environment Lives with Parents. Living situation: Home/Independent. Smoker in household: Yes. Feels unsafe at home: Yes. Substance Abuse Denies Tobacco Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days. Family History Anxiety: Mother. Arthritis...: Son. Breast cancer: Aunt and Grandmother (M). Cancer of colon: Uncle.Negative: Aunt. Depression: Mother. Diabetes mellitus type 2: Mother. Drug abuse: Son. Hypertension..: Mother and Father. Oral cancer...: Negative: Aunt. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 15.2 k/cumm High (12/11/23 08:45:00) RBC: 5.83 million/cumm High (12/11/23 08:45:00) Hgb: 17 GM/dL (12/11/23 08:45:00) Hct: 49.8 % (12/11/23 08:45:00) MCV: 85 fL (12/11/23 08:45:00) MCH: 29.2 pg (12/11/23 08:45:00) MCHC: 34.1 GM/dL (12/11/23 08:45:00) RDW: 13.8 % (12/11/23 08:45:00) Platelet: 145 k/cumm Low (12/11/23 08:45:00) MPV: 10.2 fL (12/11/23 08:45:00) Neutrophils %: 83 % (12/11/23 08:45:00) Lymphocytes %: 8 % (12/11/23 08:45:00) Monocytes %: 9 % (12/11/23 08:45:00) Eosinophils %: 0 % (12/11/23 08:45:00) Basophils %: 0 % (12/11/23 08:45:00) Absolute Neutrophil: 12.6 k/cumm High (12/11/23 08:45:00) Absolute Lymphocyte: 1.3 k/cumm (12/11/23 08:45:00) Absolute Monocyte: 1.4 k/cumm High (12/11/23 08:45:00) Absolute Eosinophil: 0 k/cumm (12/11/23 08:45:00) Absolute Basophil: 0 k/cumm (12/11/23 08:45:00) Chemistry: Sodium SerPl QN: 138 mmol/L (12/11/23 08:45:00) Potassium SerPl QN: 3.9 mmol/L (12/11/23 08:45:00) Chloride SerPl QN: 106 mmol/L (12/11/23 08:45:00) Carbon Dioxide SerPl QN: 23 mmol/L (12/11/23 08:45:00) Anion Gap: 9 mmol/L (12/11/23 08:45:00) BUN SerPl QN: 20 mg/dL (12/11/23 08:45:00) Creatinine SerPl QN: 1.7 mg/dL High (12/11/23 08:45:00) Estimated GFR (CKD-EPI, no race): 55 mL/min/1.73m2 Low (12/11/23 08:45:00) Estimated CRCL (CG): 78 mL/min (12/11/23 08:45:00) Glucose SerPl QN: 124 mg/dL High (12/11/23 08:45:00) Calcium Total SerPl QN: 8.8 mg/dL (12/11/23 08:45:00) Lactate Venous Pl QN: 1 mmol/L (12/11/23 08:45:00) pH Bld Venous QN: 7.35 (12/11/23 08:45:00) PCO2 Bld Venous QN: 42 mmHg (12/11/23 08:45:00) PO2 Bld Venous QN: 71 mmHg High (12/11/23 08:45:00) Base Excess Bld Venous: -2 mmol/L (12/11/23 08:45:00) Bicarb Bld Venous Calc: 23 mmol/L (12/11/23 08:45:00) O2 Sat Bld Venous Calc: 93 % (12/11/23 08:45:00) Patient Temperature: 37 DegC (12/11/23 08:45:00) All Other Labs: COVID 19 Specimen Source: Nasal (12/11/23 08:47:00) Coronavirus SARS-CoV2 Rapid: Not Detected (12/11/23 08:47:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (12/11/23 09:25:00) Rapid Influenza A PCR: Detected Abnormal (12/11/23 09:25:00) Rapid Influenza B PCR: Not Detected (12/11/23 09:25:00) Diagnostics Radiology Results - Last 24 hours Across Visits 12/11/2023 09:20 - XR Chest PA or AP IMPRESSION: Mediastinal contour and heart size are stable and within normallimits. Radiolucent object projecting over left midlung favored torepresent external paraphernalia. No focal consolidation, pulmonaryedema, pneumothorax, or pleural effusion. No new acutecardiopulmonary abnormalities since the previous examination. Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the EmergencyRadiology reading room. Signature Line Electronically Signed on 12/11/23 15:02 MD
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