VAERS 2530085
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) · Charge uj882ab
- Staat
- -
- Alter
- 73,0
- Geschlecht
- F
- Eingang
- 13.12.2022
- Impfdatum
- 13.09.2022
- Beginn
- 22.11.2022
- Tage bis Beginn
- 70,0
- Dosis
- UNK
- Route/Site
- SYR / -
Symptomtext
Document Type: ED Physician Progress Note Document Subject: ED Progress Note Performed By: on November 22, 2022 09:50 Verified By: on November 22, 2022 14:29 Encounter Info: Emergency, 11/22/22 - 11/22/22 * Final Report * Basic Information Time Seen: 11/22/2022 09:44 Chief Complaint Shortness of breath (Complaint of) History of Present Illness Patient seen: 11/22/22 09:53:52 A 73 year old female with Hx of HTN and T2DM, presents to the ED via private vehicle c/o shortness of breath. Patient presents from outpatient CT found bilateral lower lobe PEs. She does not wear oxygen at home. Denies long car rides, swelling in legs, or calf pain. Chart Review: Patient had an outpatient CT scan today that showed bilateral lower lobe PEs. He was seen by NP yesterday for shortness of breath on exertion for 3 weeks that has been worse over the past week. He also reported questionable chest pressure. Review of Systems Constitutional: No fever, no chills Skin: No rash, no lesions Eyes: No recent vision problems, no icterus ENT: No ear pain, no sore throat, no sinus pain Resp: +SOB, no cough Cardio: No chest pain, no palpitations, no peripheral edema Gastro: No abdominal pain, no nausea, no vomiting, no diarrhea, no constipation Back: No back pain, no joint pain Neuro: No headache, no dizziness, no altered LOC, no numbness, no tingling Psych: No anxiety, no depression Additional ROS info: Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory. Physical Exam/Objective Vitals & Measurements last 24 hours VITAL SIGNS Temp C: 36.5 DegC Heart Rate: 102 bpm Resp Rate: 22 br/min BP: 194 / 86 mmHg SpO2 (%): 88 % O2 Device: Room air Height CM: 162.2 cm Weight KG: 97.7 kg Ideal Body Weight: 54.37 kg General: Alert, no acute distress, elevated BMI Skin: Warm, dry, intact Head: Normocephalic, atraumatic ENT: Oral mucosa moist, no pharyngeal erythema or exudates Neck: Supple, no tenderness Cardiovascular: Regular rate and rhythm, no murmur, no lower extremity edema or asymmetric swelling, symmetric distal pulses Respiratory: Lungs CTA, non-labored respirations, breath sounds equal, no wheezes, rales, or rhonchi. 88% on RA. upper 90s on 2L. Musculoskeletal: No tenderness or deformity Abdomen: Soft, non-tender, non-distended Back: Non-tender, normal ROM Neuro: No focal neuro deficits, normal sensory, normal motor, normal speech, normal coordination Psych: Cooperative, appropriate mood Medical Decision Making Notes reviewed: ED nurse, prior ED, prior records Diagnostic results: Labs: Reviewed Diagnostic imaging: Reviewed 11/22/22 11:37:12 Sent a message for bed request. 11/22/22 11:46:39 Dr. agrees to admit patient to inpatient Med/Surg for pulmonary embolism. 11/22/22 13:32:20 Spoke with Dr. At this time they are not recommending transfer for intraarterial treatment, but if patient begins to decline they would reconsider. Re-Assessment 11/22/22 11:39:12 Discussed plan for admission. Patient is agreeable with plan, all questions addressed. Condition Stable Disposition: 11/22/22 11:47:02 Admit to, Location: Med/Surg Scribe Attestation I, acting as a scribe for on 11/22/22 09:47:15. Signed, 11/22/22 09:47:15. I, MD, attest that the scribe's documentation has been prepared under my direction and personally reviewed by me in its entirety. I confirmed that the note above accurately reflects all work, treatment, procedures, and medical decision-making preformed by me. Assessment/Plan Pulmonary embolism I26.99 Orders: heparin 25,000 Units + Sodium Chloride 0.45% 250 mL, Total Volume (mL) = 250, IV, 11/22/22 9:47:00, Per Nomogram heparin infusion bolus dose, Per STANDARD Dose Heparin Nomogram, Via Infusion Pump, Infusion, Unscheduled, PRN, Other-See Comments, 11/22/22 9:47:00 **Coronavirus SARS-CoV2 Rapid aPTT Pl QN Auto Diff Basic Metabolic Panel Bed Request (Decision to Admit) BNP Pl QN Call Bleeding Call PTT Results Cardiac Monitor CBC w/Differential Collect Specimen Collect Specimen Collect Specimen Continuous Oxygen Saturation COVID 19 PCR Diagnosis Electrocardiogram Height and Weight PP Required: Initiate only Troponin-I High Sensitivity Chronic Problem List CTS (carpal tunnel syndrome) Diabetic neuropathy Essential hypertension Hyperlipidemia Left otitis media Major depression Major depression, recurrent Onychogryphosis Onychomycosis Pre-ulcerative calluses Type 2 diabetes mellitus without complication Procedure/Surgical History ?Colonoscopy (11/03/2022) ?EGD (esophagogastroduodenoscopy) gastric outlet reduction (11/03/2022) ?Colonoscopy (08/24/2011) ?Removal of toenail ?right knee replacement ?surgery from mrsa Surgical History Internal 11/03/2022 Colonscpy Diagnostic/Screen 06/17/2015 Knee Arthroplasty (Right) Medications Home Medications (10) Active FreeStyle Test Strips Check up to 3 times daily, Other, TID, E11.9, on insulin HumULIN N (insulin NPH) human recombinant 100 units/mL subcutaneous injection See Instructions, INJECT 50 UNITS IN THE AM AND 30 UNITS IN THE PMDx E11.9 Hyzaar 100 mg-25 mg oral tablet 1 Tablet, Orally, Daily Lexapro 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily Lipitor 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily metFORMIN 500 mg (Eqv-Glumetza) oral tablet, extended release 1,000 mg = 2 Tablet, Orally, Daily Norvasc 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily Pen Needles - Insulin Check up to 2 times daily, Other, Unscheduled, E11.9 traZODONE 50 mg oral tablet 50 mg = 1 Tablet, PRN, Orally, At Bedtime Medication Administration Given heparin additive (intermittent) 25,000 Units + Sodium Chloride 0.45% 250 mL, IV heparin infusion bolus dose (Freetext), 6000 Units, Via Infusion Pump Allergies NKA Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Employment/School Work/School description: homemaker. Home/Environment widow, 2 children Substance Abuse Denies Tobacco Tobacco Use: Never (less than 100 in lifetime). Family History Heart disease..: Father. Ovarian cancer..: Mother. Lab Results Hemogram-Platelets-WBC Differential FS LATEST RESULTS HISTORICAL RESULTS WBC 11/22/22 10:02 7.5 06/07/22 9.5 RBC 11/22/22 10:02 4.39 06/07/22 4.47 Hgb 11/22/22 10:02 12.0 06/07/22 12.3 Hct 11/22/22 10:02 36.4 06/07/22 37.6 MCV 11/22/22 10:02 83 06/07/22 84 MCH 11/22/22 10:02 27.3 06/07/22 27.4 MCHC 11/22/22 10:02 32.9 06/07/22 32.6 RDW 11/22/22 10:02 14.2 06/07/22 13.9 Platelet 11/22/22 10:02 243 06/07/22 386 MPV 11/22/22 10:02 8.0 06/07/22 8.6 Neutrophils % 11/22/22 10:02 54 06/07/22 53 Lymphocytes % 11/22/22 10:02 36 06/07/22 38 Monocytes % 11/22/22 10:02 8 06/07/22 6 Eosinophils % 11/22/22 10:02 2 06/07/22 3 Basophils % 11/22/22 10:02 1 06/07/22 0 Absolute Neutrophil 11/22/22 10:02 4.0 06/07/22 5.1 Absolute Lymphocyte 11/22/22 10:02 2.7 06/07/22 3.6 High Absolute Monocyte 11/22/22 10:02 0.6 06/07/22 0.5 Absolute Eosinophil 11/22/22 10:02 0.2 06/07/22 0.3 Absolute Basophil 11/22/22 10:02 0.0 06/07/22 0.0 Routine Coagulation Studies FS LATEST RESULTS aPTT 11/22/22 10:02 31.2 Routine Chemistry Tests FS LATEST RESULTS HISTORICAL RESULTS Sodium SerPl QN 11/22/22 10:02 133 Low 06/07/22 141 Potassium SerPl QN 11/22/22 10:02 3.8 06/07/22 4.0 Chloride SerPl QN 11/22/22 10:02 102 06/07/22 103 Carbon Dioxide SerPl QN 11/22/22 10:02 25 06/07/22 26 Anion Gap 11/22/22 10:02 6 06/07/22 12 High BUN SerPl QN 11/22/22 10:02 18 06/07/22 14 Creatinine SerPl QN 11/22/22 10:02 0.88 06/07/22 0.90 Estimated GFR (CKD-EPI, no race) 11/22/22 10:02 69 06/07/22 68 Estimated CRCL (CG) 11/22/22 10:02 64 06/07/22 61 Glucose SerPl QN 11/22/22 10:02 153 High 06/07/22 81 Calcium Total SerPl QN 11/22/22 10:02 9.6 06/07/22 8.6 Troponin-I High Sensitivity 11/22/22 10:02 19 High BNP Pl QN 11/22/22 10:02 70 Molecular Diagnostic Tests LATEST RESULTS COVID 19 Specimen Source 11/22/22 10:02 Nasal Coronavirus SARS-CoV2 Rapid 11/22/22 10:02 Not Detected Diagnostic Results No qualifying data available. EKG Time: 11/22/2022 09:53 Rate: 89 bpm Rhythm: normal sinus rhythm Axis: normal ST-T segments: no changes T waves: normal Ectopy: none P waves and PR interval: within normal limits QT interval:within normal limits QRS interval: within normal limits Previous EKG:none available Interpretation Signature Line Electronically Signed on 11/22/22 11:47 ________________________________________________________ Electronically Signed on 11/22/22 13:33 ________________________________________________________ Electronically Signed on 11/22/22 14:29 ________________________________________________________
Weitere VAERSDATA-Felder
- Praegender Schweregrund
- Pulmonary embolism
- Hospital-Tage
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- Labordaten
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- Aktuelle Erkrankungen
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- Vorgeschichte
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- Andere Medikamente
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- Allergien
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- Vorherige Impfungen
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