VAERS 2512500
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) · Charge uj904aa
- Staat
- IN
- Alter
- 65,0
- Geschlecht
- F
- Eingang
- 20.11.2022
- Impfdatum
- 01.11.2022
- Beginn
- 17.11.2022
- Tage bis Beginn
- 16,0
- Dosis
- UNK
- Route/Site
- SYR / -
Symptomtext
Document Type: ED Physician Progress Note Document Subject: ED Progress Note Performed By: on November 17, 2022 04:29 Verified By: on November 17, 2022 04:29 Encounter Info: Emergency, 11/17/22 - 11/17/22 * Final Report * Basic Information Time Seen: 11/17/2022 02:47 Chief Complaint SOA History of Present Illness 65-year-old who appears older than her stated age presents to the emergency department with EMS in extremis. History obtained primarily via EMS. Patient had shortness of breath with significant hypoxia on room air. Patient's initial room air sats were in the upper 70s to low 80s. Patient was speaking in short sentences. She denied chest pain or fevers. Onset of symptoms is unclear. Per chart she has a past medical history of CHF peripheral vascular disease venous insufficiency and NSTEMI. Patient did not receive any breathing treatments prehospital. Was satting in the mid 80s on 2 L nasal cannula upon arrival Review of Systems Unable to obtain review of systems secondary to severity of disease. Physical Exam/Objective Vitals & Measurements last 24 hours VITAL SIGNS Heart Rate: 86 bpm Resp Rate: 20 br/min BP: 124 / 73 mmHg SpO2 (%): 95 % O2 Flow (l/min): 4 L/min O2 Device: BIPAP FiO2 (%): 0.50 Height CM: 157.5 cm Weight KG: 63.1 kg Ideal Body Weight: 50.12 kg Heart Rate: 117 bpm High (11/17/22 02:43:00) Height CM: 157.5 cm (11/17/22 02:43:00) Respiratory Rate: 38 br/min High (11/17/22 02:43:00) Weight KG: 63.1 kg (11/17/22 02:43:00) Systolic Blood Pressure: 124 mmHg (11/17/22 02:43:00) Ideal Body Weight: 50.12 kg (11/17/22 02:43:00) Diastolic Blood Pressure: 82 mmHg (11/17/22 02:43:00) Oxygen Delivery: Nasal Cannula (11/17/22 02:43:00) Constitutional: Severe distress, Skin: Dry, warm, pale HENT: Normocephalic, Atraumatic Neck: Supplenormal ROM Cardiovascular: tachycardic, regular rhythm, symmetric distal pulsesNo edema Pulmonary: Severe respiratory distress, tachypnea, speaking in short sentences, satting in the low 80s on 2 L nasal cannula good air movement bilaterally but somewhat diminished in both bases. Abdomen: Nondistended, no tenderness, guarding none, rebound none, signs none Musculoskeletal: No deformities, no tenderness to palpation Neurologic: Alert,, No focal neuro deficit, Motor strength normal, Coordination intact Psych: Anxious, Medical Decision Making ED nursing documentation reviewed Per prior chart review: Discharge summary from November 1, 2022 patient presented to ED with increasing shortness of breath was found to have CHF exacerbation with elevated troponin and renal disease. Per chart most recent echo showed an EF of over 50%. Personal interpretation of EKG: 2:50 AM normal sinus rhythm rate of 98 prolonged QTC at 551, ST segment depression in the lateral precordial leads, the 4 through 6-lead I and lead II. These ST segments depressions are more significant in the lateral precordial leads then they have been on most recent EKG. ST depression in I and II are new. Labs for this visit: reviewed Imaging studies for this visit: reviewed, personal interpretation right lower lobe infiltrate with bilateral pulmonary edema and enlarged cardiac silhouette. Started patient on BiPAP to aid work of breathing and hypoxia. Patient's oxygenation status is significantly improved with a 50% FiO2 and her respiratory work of breathing has also significantly improved after just a short period of being on BiPAP. 11/17/22 03:10:37 Sent inquiry to see if ICU beds are available as pt will need admission and is on rescue Bipap. Patient is tachycardic, hypoxic, hypothermic and has leukocytosis all chest x-ray. Have started broad-spectrum antibiotics to cover respiratory bacteria. Selected doxycycline over azithromycin secondary to prolongation of QTC. She is at her baseline anemia. Also given single dose of diuretics as patient's chest x-ray shows bilateral pulmonary edema and cardiomegaly. K significantly low. Am replacing. 11/17/22 04:26:00 Pt accepted to ICU. Procedures Critical Care Procedure Note: 75 minutes Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent the critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patients response to treatment, frequent reassessment, and discussions with other providers. The critical care time was performed to asses and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see the section and the rest of this note for further information on patient assessment and treatment. Condition guarded Transfer to ICU Assessment/Plan 1. Sepsis A41.9 2. PNA (pneumonia) J18.9 3. Pulmonary edema J81.1 4. Hypokalemia E87.6 5. Sepsis with acute hypoxic respiratory failure A41.9 6. Acute exacerbation of CHF (congestive heart failure) I50.9 Orders: ampicillin-sulbactam, 3 GM, IVPB, Injection, ONCE, 11/17/22 9:00:00, 11/17/22 9:00:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100 potassium chloride, 20 mEq, IVPB, Infusion, Q2H, 11/17/22 4:00:00, for 2 Doses, 11/17/22 6:00:00, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100 **Coronavirus SARS-CoV2 Rapid Auto Diff Basic Metabolic Panel BIPAP Continuous Blood CX Blood CX Blood Gas Venous QN BNP Pl QN Cardiac Monitor CBC w/Differential Continuous Oxygen Saturation COVID 19 PCR CTA Chest Pulm Embolism W/IV Contrast Electrocardiogram Electrocardiogram Lactate Pl Venous QN Lactate Pl Venous QN Peripheral IV Insertion Resp Evaluation or Assessment Sepsis Tracking Troponin-I High Sensitivity XR Chest PA or AP Portable Chronic Problem List Atherosclerosis of left lower extremity with intermittent claudication Atherosclerosis of right lower extremity with intermittent claudication Bilateral iliac artery stenosis CHF exacerbation Dissection of left iliac artery Dissection of right iliac artery Elevated troponin Varicose veins of right lower extremity with pain Venous insufficiency of right leg Procedure/Surgical History ?CEA - Carotid endarterectomy (2006) ?abscess on right neck removed ?Cesarean section Surgical History Internal 08/04/2016 Carotid Endarterectomy (Left) 07/25/2016 Arteriogram Arch Medications Home Medications (10) Active amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily aspirin 81 mg oral tablet, delayed release 81 mg = 1 Tablet, Orally, Daily atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, QHS clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily metoPROLOL tartrate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID pantoprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, Daily rivaroxaban 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily sertraline 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily Vitamin D3 (cholecalciferol) 25 mCg, Orally, Daily Medication Administration Given ampicillin-sulbactam, IVPB doxycycline, IVPB furosemide, 40 mg, IV Push potassium chloride IVPB, IVPB Allergies NKA Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Home/Environment Lives with Alone. Substance Abuse Denies Tobacco Tobacco Use: Quit June 2022. Family History Diabetes mellitus: Mother, Father and Grandmother. Hypertension: Mother and Grandmother. Lung cancer: Father. Lab Results Hemogram-Platelets-WBC Differential LATEST RESULTS HISTORICAL RESULTS WBC 11/17/22 02:50 14.6 High 11/01/22 9.8 RBC 11/17/22 02:50 3.46 Low 11/01/22 3.55 Low Hgb 11/17/22 02:50 9.7 Low 11/01/22 10.2 Low Hct 11/17/22 02:50 30.1 Low 11/01/22 30.2 Low MCV 11/17/22 02:50 87 11/01/22 85 MCH 11/17/22 02:50 28.0 11/01/22 28.8 MCHC 11/17/22 02:50 32.2 11/01/22 33.8 RDW 11/17/22 02:50 16.3 High 11/01/22 16.9 High Platelet 11/17/22 02:50 453 High 11/01/22 302 MPV 11/17/22 02:50 7.3 11/01/22 7.7 Neutrophils % 11/17/22 02:50 56 11/01/22 72 Lymphocytes % 11/17/22 02:50 33 11/01/22 15 Monocytes % 11/17/22 02:50 7 11/01/22 9 Eosinophils % 11/17/22 02:50 3 11/01/22 3 Basophils % 11/17/22 02:50 1 11/01/22 1 Absolute Neutrophil 11/17/22 02:50 8.2 High 11/01/22 7.0 Absolute Lymphocyte 11/17/22 02:50 4.8 High 11/01/22 1.4 Absolute Monocyte 11/17/22 02:50 1.0 11/01/22 0.9 Absolute Eosinophil 11/17/22 02:50 0.5 High 11/01/22 0.3 Absolute Basophil 11/17/22 02:50 0.1 11/01/22 0.1 Routine Chemistry Tests LATEST RESULTS HISTORICAL RESULTS Sodium SerPl QN 11/17/22 02:50 142 11/01/22 138 Potassium SerPl QN 11/17/22 02:50 2.7 Critical 11/01/22 4.3 Chloride SerPl QN 11/17/22 02:50 96 Low 11/01/22 97 Low Carbon Dioxide SerPl QN 11/17/22 02:50 20 Low 11/01/22 29 Anion Gap 11/17/22 02:50 26 High 11/01/22 12 High BUN SerPl QN 11/17/22 02:50 41 High 11/01/22 27 High Creatinine SerPl QN 11/17/22 02:50 1.76 High 11/01/22 1.53 High Estimated GFR (CKD-EPI, no race) 11/17/22 02:50 32 Low 11/01/22 38 Low Estimated CRCL 11/17/22 02:50 28 Low 11/01/22 31 Low Glucose SerPl QN 11/17/22 02:50 384 High 11/01/22 95 Calcium Total SerPl QN 11/17/22 02:50 9.9 11/01/22 9.3 Troponin-I High Sensitivity 11/17/22 02:50 34 High 10/31/22 15 High BNP Pl QN 11/17/22 02:50 1045 High 11/01/22 1057 High Lactate Venous Pl QN 11/17/22 02:50 11.7 High 08/30/22 0.8 Blood Gases LATEST RESULTS HISTORICAL RESULTS pH Bld Venous QN 11/17/22 02:50 7.24 Low 10/31/22 7.48 High PCO2 Bld Venous QN 11/17/22 02:50 47 10/31/22 40 PO2 Bld Venous QN 11/17/22 02:50 60 High 10/31/22 46 High Base Excess Bld Venous 11/17/22 02:50 -7 Low 10/31/22 6 High Bicarb Bld Venous Calc 11/17/22 02:50 20 Low 10/31/22 30 High O2 Sat Bld Venous Calc 11/17/22 02:50 85 10/31/22 85 Patient Temperature 11/17/22 02:50 37.0 10/31/22 37.0 Molecular Diagnostic Tests LATEST RESULTS HISTORICAL RESULTS COVID 19 Specimen Source 11/17/22 02:54 Nasal 08/29/22 Nasopharyngeal Coronavirus SARS-CoV2 Rapid 11/17/22 02:54 Not Detected 08/29/22 Not Detected Diagnostic Results XR Chest PA or AP Portable 11/17/22 03:29:12 IMPRESSION: 1. Bilateral patchy airspace and interstitial infiltrates in the mid to lower lung and pulmonary vascular prominence. Consider either CHF or multifocal pneumonia in the correct clinical setting. Template Version: Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss this case further can contact. Electronically Signed by: ************************************************** CTA Chest Pulm Embolism W/IV Contrast 11/17/22 04:15:37 IMPRESSION: 1. No obvious pulmonary embolism. 2. Bilateral layering small pleural effusion, multifocal patchy diffuse infiltrates and mild to moderate cardiomegaly likely represent CHF in the correct clinical setting. The differential diagnosis includes multifocal pneumonia. 3. Severe central canal stenosis at T6-7 secondary to a posterior marginal osteophyte. Template Version: Thank you for consulting. Healthcare providers wishing to discuss this case further can contact the ER. Thank you for consulting our team of subspecialty radiologist. Healthcare providers wishing to discuss this case further can contact. Electronically Signed by: Signature Line Electronically Signed on 11/17/22 04:29 ________________________________________________________
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- Acute respiratory failure
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