VAERS 2660576
SANOFI PASTEUR · TDAP (ADACEL) · Charge u7666aa
- Staat
- -
- Alter
- 87,0
- Geschlecht
- M
- Eingang
- 25.07.2023
- Impfdatum
- 24.05.2023
- Beginn
- 24.07.2023
- Tage bis Beginn
- 61,0
- Dosis
- N/A
- Route/Site
- SYR / -
Symptomtext
Document Type: History and Physical Document Subject: History & Physical Note Performed By: on July 24, 2023 17:57 Verified By: on July 24, 2023 17:57 Encounter Info: Inpatient, 07/24/23 - * Final Report * History of Present Illness/Subjective Patient is a 87 year old male, hx of a-fib, HTN, CVA, MI, CAD, peripheral vascular disease, who presents to the ED via private vehicle with confusion, difficulty word-finding, and repetitive nonsensical speech onset 3 days ago. The patient's significant other at bedside reports that these symptoms onset suddenly 3 days ago. While obtaining history, the patient does not have any of these symptoms and is A&Ox4. The patient has been experiencing difficulty with ambulation secondary to complaint of fatigue, unclear exact onset. Denies any focal weakness, headache, neck pain, chest pain, abdominal pain, or other complaints. Denies hx of DM. The patient is established with primary care. Denies any pertinent PSHx. NKDA. Social history negative for tobacco use and current alcohol use. ???Upon ED evaluation imaging as below. His initial heart rate was 39, respiratory rate is 20, blood pressure was 192/59, ED EKG showed A-fib with slow ventricular response and left bundle branch block. Lab work revealed a normal white blood cell count of 5.5, hemoglobin was 10.6, potassium was 3.3, GFR was 21 which appears to be his baseline, troponin was 37 with repeat being the same. Lactate was 2.1 with repeat being 1.3. UA showed positive nitrates large leukocyte Estrace and 51-100 WBCs. COVID-19 testing was negative. Urology was consulted recommended admission here continuation of stroke work-up. ???????Patient will be admitted for further evaluation management of acute CVA, bradycardia and hypertension MRI Brain W/O IV Contrast 07/24/23 14:59:44 IMPRESSION: 1. Acute left MCA territory infarct involving predominantly the cortex of the inferior division without associated hemorrhage or significant mass effect. 2. Old left parieto-occipital infarct. 3. Technically degraded MRA, limiting evaluation. 4. Lack of flow-related signal in the left PCA, which may reflect chronic occlusion. 5. Suspected high-grade stenosis of the right P1-P2 junction. 6. Likely moderate stenoses of the left M1 segment. 7. Slight prominence of the basilar tip, nonspecific but possibly representing an aneurysm. 8. Further characterization of the above findings with CTA of the head is advised. Findings to be communicated to the ordering provider by clerical. Thank you for consulting our team of subspecialty radiologists Electronically Signed by: ************************************************** CT Head W/o IV Contrast 07/24/23 15:16:01 IMPRESSION: 1. The acute left MCA territory infarct is better depicted on MRI. 2. No acute intracranial hemorrhage or significant mass effect. Thank you for consulting our team of subspecialty radiologists. Electronically Signed by: ************************************************** XR Chest PA or AP Portable 07/24/23 13:03:49 IMPRESSION: 1. No acute findings in the chest. Thank you for consulting our team of subspecialty radiologists. Electronically Signed by: ************************************************** MRA Brain W/O IV Contrast 07/24/23 14:59:44 IMPRESSION: 1. Acute left MCA territory infarct involving predominantly the cortex of the inferior division without associated hemorrhage or significant mass effect. 2. Old left parieto-occipital infarct. 3. Technically degraded MRA, limiting evaluation. 4. Lack of flow-related signal in the left PCA, which may reflect chronic occlusion. 5. Suspected high-grade stenosis of the right P1-P2 junction. 6. Likely moderate stenoses of the left M1 segment. 7. Slight prominence of the basilar tip, nonspecific but possibly representing an aneurysm. 8. Further characterization of the above findings with CTA of the head is advised. Findings to be communicated to the ordering provider by clerical. Thank you for consulting our team of subspecialty radiologists. Electronically Signed by: 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 Hemodynamics Neurologic Patient Weight Patient Height None Reported Constitutional: No acute distress, well-nourished Eyes: PEERL, EOMI, normal conjunctiva, no scleral icterus ENMT: Moist oral mucosa Neck: Supple, non-tender, intact range of motion Respiratory: Lungs CTAB Cardiovascular: Bradycardic Gastrointestinal: Soft, non-tender, non-distended Musculoskeletal: No joint swelling, no deformity, intact ROM Integumentary: Intact, warm, dry no rashes Neurologic: mild confusion, mild aphasia Psychiatric: Cooperative, appropriate mood and affect Assessment/Plan 1. CVA (cerebrovascular accident) I63.9 Acute left-sided CVA on MRI, neurology was consulted from ER ? We will continue aspirin, started a statin. Try to keep systolic blood pressures less than 200 but can allow permissive hypertension ? Echocardiogram carotid Dopplers ordered for the morning ? PT OT and speech consults ? Bedside swallowing eval for tonight then can start diet -he is not on anticoagulation for a fib due to high risk of bleeding, will discuss with neurology 2. Bradycardia R00.1 We have reduced Coreg dosing with hold orders for heart rate less than 65 patient does have a history of A-fib 3. HTN (hypertension) I10 Holding Lasix at this time, resume Coreg at lower dosin,g continue amlodipine in a.m. Continue Imdur as well 4. UTI (urinary tract infection) N39.0 UA evidence of UTI ? Culture pending ? Continue with cefepime for now as previous micro showed Pseudomonas sensitivity to cefepime 5. A-fib I48.91 Not on anticoagulation due to high risk of bleeding, patient has been compliant with his aspirin at home, I will discuss with neurology tomorrow whether or not they suggest starting anticoagulation ? Continue rate control meds reduced dosage due to current bradycardia 6. BPH with urinary obstruction N40.1 Continue tamsulosin 7. Hypothyroidism E03.9 Continue levothyroxine, check TSH 8. CKD (chronic kidney disease), stage IV N18.4 Noted appears to be at baseline 9. Hypokalemia E87.6 replacement protocol Urinary retention R33.9 Continue tamsulosin ???????Patient is a full code, DVT prophylaxis with Lovenox Ordered: tamsulosin, 0.4 mg, Orally, Capsule, Daily, 07/25/23 9:00:00 Orders: amLODIPine, 10 mg, Orally, Tablet, Daily, 07/25/23 9:00:00 carvedilol, 6.25 mg, Orally, Tablet, BID, 07/25/23 9:00:00 cefePIME, 1 GM, IVPB, Injection, Q12H, Indication: UTI, 07/24/23 18:00:00, Total Volume (mL) = 50 levothyroxine, 25 mCg, Orally, Tablet, Daily, 07/25/23 6:00:00 magnesium sulfate, 4 GM, IVPB, Injection, Q12H, PRN, Lab (Details Required), 07/24/23 17:42:00 potassium chloride, 30 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 07/24/23 17:42:00 potassium chloride, 40 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 07/24/23 17:42:00 potassium phosphate-sodium phosphate, 1 Packet, Orally, Powder, Unscheduled, PRN, Lab (Details Required), 07/24/23 17:42:00 potassium phosphate-sodium phosphate, 1 Packet, Orally, Powder, Unscheduled, PRN, Lab (Details Required), 07/24/23 17:42:00 Bed Request (Decision to Admit) Collect Specimen Collect Specimen Collect Specimen Echocardiogram with Cardiac Doppler PW/CW/Color Message to Nursing Notify Provider Notify Provider Notify Provider Notify Provider TSH 3rd Gen SerPl QN US Carotid Doppler Bilat Code Status None Recorded Chronic Problem List A-fib BPH with urinary obstruction Bradycardia CKD (chronic kidney disease), stage IV CVA (cerebrovascular accident) Decreased hearing of both ears Diastolic dysfunction Encounter for medication management HTN (hypertension) Hypokalemia Hypothyroidism Ingrown toenail of both feet Pulmonary hypertension Toe pain Urinary retention UTI (urinary tract infection) Procedure/Surgical History ?bil ingrown toenail removal ?left inguinal hernia repair ?left leg/ankle reconstuction Medications Home Medications (7) Active amLODIPine 5 mg oral tablet 10 mg = 2 Tablet, Orally, Daily aspirin 81 mg oral tablet, chewable carvedilol 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, BID Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily, Take one pill, 30 minutes after dinner. isosorbide mononitrate 30 mg oral tablet, extended release 30 mg = 1 Tablet, Orally, QAM Lasix 20 mg oral tablet 20 mg = 1 Tablet, Orally, BID levothyroxine 25 mCg (0.025 mg) oral tablet 25 mCg = 1 Tablet, Orally, Daily Active Scheduled Inpatient Medications amLODIPine, Tablet, 10 mg, Orally, Daily, Start: 07/25/23 09:00:00 carvedilol (Coreg), Tablet, 6.25 mg, Orally, BID, Start: 07/25/23 09:00:00 cefePIME, Injection, 1 GM, IVPB, Q12H, Indication: UTI, Start: 07/24/23 18:00:00 levothyroxine, Tablet, 25 mCg, Orally, Daily, Start: 07/25/23 06:00:00 tamsulosin (Flomax), Capsule, 0.4 mg, Orally, Daily, Start: 07/25/23 09:00:00 One-Time Medications Given 07/23/23 00:00:00 TO 07/24/23 17:57:04 None Reported PRN Medications (0600 - 0559) from 07/23 - 07/24 magnesium sulfate, 4 GM, IVPB, Q12H, 0 Dose(s) potassium chloride, 30 mEq, Orally, Unscheduled, 0 Dose(s) potassium chloride, 40 mEq, Orally, Unscheduled, 0 Dose(s) potassium phosphate-sodium phosphate, 250 mg, Orally, Unscheduled, 0 Dose(s) Allergies NKA No Known Medication Allergies Social History Alcohol Past Electronic Cigarette/Vaping E-Cigarette Use Never. Substance Abuse Denies Tobacco Tobacco Use: Never (less than 100 in lifetime). Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 5.5 k/cumm (07/24/23 12:00:00) RBC: 3.94 million/cumm Low (07/24/23 12:00:00) Hgb: 10.6 GM/dL Low (07/24/23 12:00:00) Hct: 33 % Low (07/24/23 12:00:00) MCV: 84 fL (07/24/23 12:00:00) MCH: 27 pg (07/24/23 12:00:00) MCHC: 32.2 GM/dL (07/24/23 12:00:00) RDW: 17.3 % High (07/24/23 12:00:00) Platelet: 162 k/cumm (07/24/23 12:00:00) MPV: 9.5 fL (07/24/23 12:00:00) Neutrophils %: 69 % (07/24/23 12:00:00) Lymphocytes %: 18 % (07/24/23 12:00:00) Monocytes %: 9 % (07/24/23 12:00:00) Eosinophils %: 3 % (07/24/23 12:00:00) Basophils %: 1 % (07/24/23 12:00:00) Absolute Neutrophil: 3.8 k/cumm (07/24/23 12:00:00) Absolute Lymphocyte: 1 k/cumm (07/24/23 12:00:00) Absolute Monocyte: 0.5 k/cumm (07/24/23 12:00:00) Absolute Eosinophil: 0.2 k/cumm (07/24/23 12:00:00) Absolute Basophil: 0 k/cumm (07/24/23 12:00:00) Chemistry: Sodium SerPl QN: 141 mmol/L (07/24/23 12:00:00) Potassium SerPl QN: 3.3 mmol/L Low (07/24/23 12:00:00) Chloride SerPl QN: 108 mmol/L (07/24/23 12:00:00) Carbon Dioxide SerPl QN: 23 mmol/L (07/24/23 12:00:00) Anion Gap: 10 mmol/L (07/24/23 12:00:00) BUN SerPl QN: 48 mg/dL High (07/24/23 12:00:00) Creatinine SerPl QN: 2.87 mg/dL High (07/24/23 12:00:00) Estimated GFR (CKD-EPI, no race): 21 mL/min/1.73m2 Low (07/24/23 12:00:00) Estimated CRCL (CG): 16 mL/min Low (07/24/23 12:00:00) Glucose SerPl QN: 148 mg/dL High (07/24/23 12:00:00) Calcium Total SerPl QN: 8.5 mg/dL (07/24/23 12:00:00) Alkaline Phos SerPl QN: 53 Units/L (07/24/23 12:00:00) ALT SerPl QN: 9 Units/L (07/24/23 12:00:00) AST SerPl QN: 16 Units/L (07/24/23 12:00:00) Bilirubin Total SerPl QN: 1.3 mg/dL High (07/24/23 12:00:00) Total Protein SerPl QN: 6.8 GM/dL (07/24/23 12:00:00) Albumin SerPl QN: 3.9 GM/dL (07/24/23 12:00:00) Magnesium SerPl QN: 2.1 mg/dL (07/24/23 12:00:00) Troponin-I High Sensitivity: 37 ng/L High (07/24/23 12:56:00) Lactate Venous Pl QN: 1.3 mmol/L (07/24/23 14:55:00) Coagulation: PT: 15.2 seconds High (07/24/23 12:00:00) INR: 1.32 High (07/24/23 12:00:00) aPTT: 34.5 seconds (07/24/23 12:00:00) Urine Studies: Color: Yellow (07/24/23 15:18:00) Clarity: Slightly Cloudy (07/24/23 15:18:00) Specific Gravity: 1.014 (07/24/23 15:18:00) pH: 6.5 (07/24/23 15:18:00) Protein: 70 Abnormal (07/24/23 15:18:00) Glucose: Normal (07/24/23 15:18:00) Ketones: NEGATIVE (07/24/23 15:18:00) Bilirubin: NEGATIVE (07/24/23 15:18:00) Hgb Ur: Small 1+ Abnormal (07/24/23 15:18:00) Nitrite: Positive 2+ Abnormal (07/24/23 15:18:00) Urobilinogen: Normal (07/24/23 15:18:00) Leukocyte Esterase Ur: Large500 Abnormal (07/24/23 15:18:00) WBC: 51-100 Abnormal (07/24/23 15:18:00) RBC: 3-5 Abnormal (07/24/23 15:18:00) Bacteria: Few Abnormal (07/24/23 15:18:00) Squamous Epithelial: Few (07/24/23 15:18:00) All Other Labs: COVID 19 Specimen Source: Nasal (07/24/23 16:15:00) Coronavirus SARS-CoV2 Rapid: Not Detected (07/24/23 16:15:00) Diagnostics Radiology Results - Last 24 hours Across Visits 07/24/2023 12:42 - XR Chest PA or AP Portable IMPRESSION:1. No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists. 07/24/2023 14:43 - MRI Brain W/O IV Contrast IMPRESSION: 1. Acute left MCA territory infarct involving predominantly thecortex of the inferior division without associated hemorrhage orsignificant mass effect.2. Old left parieto-occipital infarct.3. Technically degraded MRA, limiting evaluation.4. Lack of flow-related signal in the left PCA, which may reflectchronic occlusion.5. Suspected high-grade stenosis of the right P1-P2 junction.6. Likely moderate stenoses of the left M1 segment.7. Slight prominence of the basilar tip, nonspecific but possiblyrepresenting an aneurysm.8. Further characterization of the above findings with CTA of thehead is advised.Findings to be communicated to the ordering provider by clerical.Thank you for consulting our team of subspecialty radiologists. 07/24/2023 14:44 - MRA Brain W/O IV Contrast IMPRESSION: 1. Acute left MCA territory infarct involving predominantly thecortex of the inferior division without associated hemorrhage orsignificant mass effect.2. Old left parieto-occipital infarct.3. Technically degraded MRA, limiting evaluation.4. Lack of flow-related signal in the left PCA, which may reflectchronic occlusion.5. Suspected high-grade stenosis of the right P1-P2 junction.6. Likely moderate stenoses of the left M1 segment.7. Slight prominence of the basilar tip, nonspecific but possiblyrepresenting an aneurysm.8. Further characterization of the above findings with CTA of thehead is advised.Findings to be communicated to the ordering provider by clerical.Thank you for consulting our team of subspecialty radiologists. 07/24/2023 14:52 - CT Head W/o IV Contrast IMPRESSION: 1. The acute left MCA territory infarct is better depicted on MRI.2. No acute intracranial hemorrhage or significant mass effect.Thank you for consulting our team of subspecialty radiologists. Signature Line Electronically Signed on 07/24/23 17:57 ________________________________________________________ ________________________________________________________
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