VAERS 2536049
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) · Charge uj926ad
- Staat
- -
- Alter
- 83,0
- Geschlecht
- M
- Eingang
- 17.12.2022
- Impfdatum
- 07.12.2022
- Beginn
- 16.12.2022
- Tage bis Beginn
- 9,0
- Dosis
- UNK
- Route/Site
- SYR / -
Symptomtext
Document Type: History and Physical Document Subject: History & Physical Note Performed By: on December 16, 2022 17:46 Verified By: on December 16, 2022 18:03 Encounter Info: Emergency, 12/16/22 - 12/16/22 * Final Report * Document Contains Addenda Chief Complaint Altered mental status History of Present Illness/Subjective This is a 83 year old patient with a past medical history significant for Hx of benign prostatic hypertrophy, Abdominal aortic aneurysm, AF (atrial fibrillation), Gilbert's disease, Renal stones, Stroke, Anemia, Myocardial infarction, Major depression, that presented to ED from home with c/o altered mental status and is being admitted to inpatient for UTI. This patient was seen and evaluated while still in ED. He was found to be lying in bed, alert and in no distress. His wife is present at bedside and providing most of his history. She states that he was at his baseline yesterday and this morning he started vomiting was acting somewhat confused and disoriented. He is weak and needing assistance with ambulation. She said this is quite similar to an episode he had in October where he needed admission to the hospital for UTI. He does have known frequent UTIs. They tend to be all multidrug-resistant and need IV antibiotics. He has had no falls or head trauma. He has had no new medications. Vs stable. WBC wnl. Hgb 11.5. BUN 31, Cr 1.60, Glucose 153, bilirubin 1.6, protein 8.3. CXR shows Coarse interstitial opacities are noted in the mid and lower lung zones bilaterally. This is indeterminant and could be a chronic finding. Interstitial edema or an atypical infectious/inflammatory process could also appear similarly. Covid and flu negative. Large leuks and nitrite pos in urine. Review of Systems Constitutional: No fevers, no chills, no sweats Eyes: No changes in vision Ears, Nose, Mouth, Throat: No ear pain, no nasal congestion, no sore throat Respiratory: No shortness of breath, no cough, no wheeze Cardiovascular: No chest pain, no palpitations, no edema Gastrointestinal: No abdominal pain, + nausea, + vomiting, no diarrhea, no constipation Genitourinary: No frequency, no urgency, no dysuria, no hematuria Hematologic/Lymphatic: No bruising, no enlarged lymph nodes Allergic/Immunologic: No hives Endocrine: No cold intolerance, no heat intolerance, no polyuria, no polydipsia Musculoskeletal: No arthralgia, no myalgia Skin: No rash, no pruritus Neurological: No headache, no focal weakness, no numbness +confusion Psychiatric: No anxiety, no depression Physical Exam/Objective Vital Signs (most recent and range for last 24 hours) Temp (CEL) 36.5 (36.5-36.5) Temp (FAHR) 97.7 (97.7-97.7), BP 129/60 (129-132)/(60-82), HR 92 (92-94), RR 22 (22-22), O2Sat 97 (97-97) Patient Weight Current Daily Weight: 107.7 kg 12/16/22 Patient Height Current Height: 182.39 cm 12/16/22 Constitutional: No acute distress, well-nourished Eyes: PERRLA, EOMI, normal conjunctiva, no scleral icterus ENMT: Moist oral mucosa Neck: Supple, non-tender, intact range of motion Respiratory: Lungs CTAB Cardiovascular: Regular rate and rhythm Gastrointestinal: Soft, non-tender, non-distended Musculoskeletal: No joint swelling, no deformity, intact ROM Integumentary: Intact, warm, dry no rashes Neurologic: Mild cognitive impairment, no focal deficits Psychiatric: Cooperative, appropriate mood and affect Assessment/Plan This is a 83 year old patient with a past medical history significant for Hx of benign prostatic hypertrophy, Abdominal aortic aneurysm, AF (atrial fibrillation), Gilbert's disease, Renal stones, Stroke, Anemia, Myocardial infarction, Major depression, that presented to ED from home with c/o altered mental status and is being admitted to inpatient for UTI. 1. UTI (urinary tract infection) N39.0 acute on chronic does not meet sepsis criteria Pos urine culture with hx of ESBL that is multidrug resistant including carbapenems. Gentamicin given in ED. will continue with this. follows with dr. hx of bph and urinary retention holding on fluids given pulm edema noted on cxr and hx of CHF. 2. Encephalopathy G93.40 likely 2/2 above 3. Pneumonia J18.9 procal, Respiratory culture/stain, Legionella antigen, and strep pneumoniae antigen, and blood cx pending Could possibly be from aspiration as he was vomiting. Will cover with cefepime and Flagyl and obtain ST consult will will add doxy to cover atypicals, will deescalate antibiotics as appropriate RT eval keep O2 sats at or above 92% -- > currently 97% on RA supplemental O2 prn 4. Pulmonary edema J81.1 continue home lasix previous echo in 2019 was nonactionable new echo pending 5. Weakness R53.1 2/2 above PT/OT eval 6. AF (atrial fibrillation) I48.91 rate controlled cotinue home metoprolol and apixaban -- > changed dose to renal dosing 7. Anemia D64.9 stable and at baseline, will monitor 8. CVA (cerebrovascular accident) I63.9 noted 9. Chronic diastolic congestive heart failure I50.32 continue spironolactone 10. Depression F32.A continue home Cymbalta 11. GERD (gastroesophageal reflux disease) K21.9 resume home ppi 12. Hyperlipidemia E78.5 resume home statin 13. Hypertension I10 stable resume home meds 14. Hypothyroidism E03.9 resume home levothyroxine 15. On anticoagulant therapy Z79.01 resume home apixaban 16. Recurrent falls R29.6 pt/ot eval fall risk precautions 17. Stage 3 chronic kidney disease N18.30 noted and at baseline renally dose medications and avoid nephrotoxins 18. Type 2 diabetes mellitus with renal complication E11.29 AC and HS blood sugar checks with sliding scale. Carb controlled diet hold home oral meds 19. Monoclonal gammopathy D47.2 noted 20. Nausea and vomiting R11.2 likely d/t UTI zofran prn Inpatient, medical floor Daily labs - CBC, CMP Daily Low Carb Diet IV fluids SL Full Code VTE Prophylaxis - Fully anticoagulated with apixaban Code Status None Recorded Chronic Problem List Anemia Atrial fibrillation, chronic Chronic diastolic congestive heart failure CVA (cerebrovascular accident) Depression GERD (gastroesophageal reflux disease) History of arterial ischemic stroke Hyperlipidemia Hypertension Hypothyroidism Monoclonal gammopathy On anticoagulant therapy Recurrent falls Stage 3 chronic kidney disease Type 2 diabetes mellitus with renal complication Procedure/Surgical History ?Esophagogastroduodenoscopy (01/04/2019) ?Appendectomy ?Hernia repair ?Procedure on bladder ?TURP Surgical History Internal 01/04/2019 EGD Bx 10/14/2013 Prostatectomy HoLEP Medications Home Medications (17) Active Aldactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily Anoro Ellipta 62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID Blood Glucose Meter See Instructions, Tests twice dailyE11.9 Blood Glucose Test Strips See Instructions, Pt tests twice dailyE11.9 Contour Next Test Strips See Instructions, Use to test blood sugar TIDDX: E11.9 Cymbalta 60 mg oral delayed release capsule 60 mg = 1 Capsule, Orally, Daily, do not crush or chew Wheelchair Not Applicable, Other, Unscheduled, I63.9R29.6R26.81 glipiZIDE-metFORMIN 2.5 mg-250 mg oral tablet 1 Tablet, Orally, BID Lancet Device See Instructions, Tests twice dailyE11.9 Lancets See Instructions, Tests twice dailyE11.9 Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, 3x/WK Lipitor 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily Synthroid 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Daily Toprol-XL 25 mg oral tablet, extended release 25 mg = 1 Tablet, Orally, BID Active Scheduled Inpatient Medications None Reported One-Time Medications Given 12/15/22 00:00:00 TO 12/16/22 17:46:24 gentamicin, Injection, 560 mg, IVPB, ONCE, (1 DOSE 12/16/22 17:39:00) Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/16/22 14:57:00) PRN Medications (0600 - 0559) from 12/15 - 12/16 None Reported Allergies Contrast Dye (Anaphylaxis, Fainting) penicillins (hives) Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Substance Abuse Denies Tobacco Tobacco Use: Former smoker, quit more than 30 days ago. Family History Diabetes mellitus type 1: Father. Diabetes mellitus type 2: Sister. Heart disease..: Father. Hypertension: Sister. Prostate cancer: Child. Stroke: Mother and Father. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 7.4 k/cumm (12/16/22 14:19:00) RBC: 3.97 million/cumm Low (12/16/22 14:19:00) Hgb: 11.5 GM/dL Low (12/16/22 14:19:00) Hct: 34.4 % Low (12/16/22 14:19:00) MCV: 87 fL (12/16/22 14:19:00) MCH: 28.9 pg (12/16/22 14:19:00) MCHC: 33.4 GM/dL (12/16/22 14:19:00) RDW: 14.3 % (12/16/22 14:19:00) Platelet: 223 k/cumm (12/16/22 14:19:00) MPV: 7.1 fL (12/16/22 14:19:00) Neutrophils %: 78 % (12/16/22 14:19:00) Lymphocytes %: 16 % (12/16/22 14:19:00) Monocytes %: 4 % (12/16/22 14:19:00) Eosinophils %: 2 % (12/16/22 14:19:00) Basophils %: 0 % (12/16/22 14:19:00) Absolute Neutrophil: 5.7 k/cumm (12/16/22 14:19:00) Absolute Lymphocyte: 1.2 k/cumm (12/16/22 14:19:00) Absolute Monocyte: 0.3 k/cumm (12/16/22 14:19:00) Absolute Eosinophil: 0.1 k/cumm (12/16/22 14:19:00) Absolute Basophil: 0 k/cumm (12/16/22 14:19:00) Chemistry: Sodium SerPl QN: 138 mmol/L (12/16/22 14:19:00) Potassium SerPl QN: 4.5 mmol/L (12/16/22 14:19:00) Chloride SerPl QN: 100 mmol/L (12/16/22 14:19:00) Carbon Dioxide SerPl QN: 27 mmol/L (12/16/22 14:19:00) Anion Gap: 11 mmol/L (12/16/22 14:19:00) BUN SerPl QN: 31 mg/dL High (12/16/22 14:19:00) Creatinine SerPl QN: 1.6 mg/dL High (12/16/22 14:19:00) Estimated GFR (CKD-EPI, no race): 42 mL/min/1.73m2 Low (12/16/22 14:19:00) Estimated CRCL (CG): 45 mL/min Low (12/16/22 14:19:00) Glucose SerPl QN: 153 mg/dL High (12/16/22 14:19:00) Calcium Total SerPl QN: 10 mg/dL (12/16/22 14:19:00) Alkaline Phos SerPl QN: 82 Units/L (12/16/22 14:19:00) ALT SerPl QN: 7 Units/L (12/16/22 14:19:00) AST SerPl QN: 10 Units/L Low (12/16/22 14:19:00) Bilirubin Total SerPl QN: 1.6 mg/dL High (12/16/22 14:19:00) Total Protein SerPl QN: 8.3 GM/dL High (12/16/22 14:19:00) Albumin SerPl QN: 4.1 GM/dL (12/16/22 14:19:00) Lactate Venous Pl QN: 1.9 mmol/L (12/16/22 14:19:00) Urine Studies: Color: Yellow (12/16/22 15:40:00) Clarity: Clear (12/16/22 15:40:00) Specific Gravity: 1.015 (12/16/22 15:40:00) pH: 6.5 (12/16/22 15:40:00) Protein: NEGATIVE (12/16/22 15:40:00) Glucose: NEGATIVE (12/16/22 15:40:00) Ketones: NEGATIVE (12/16/22 15:40:00) Bilirubin: NEGATIVE (12/16/22 15:40:00) Hgb Ur: SMALL. Abnormal (12/16/22 15:40:00) Nitrite: POSITIVE Abnormal (12/16/22 15:40:00) Urobilinogen: 1.0. (12/16/22 15:40:00) Leukocyte Esterase Ur: LARGE. Abnormal (12/16/22 15:40:00) WBC: 21-50 Abnormal (12/16/22 15:40:00) RBC: 11-20 Abnormal (12/16/22 15:40:00) Bacteria: Moderate Abnormal (12/16/22 15:40:00) Squamous Epithelial: Few (12/16/22 15:40:00) All Other Labs: COVID 19 Specimen Source: Nasopharyngeal (12/16/22 14:19:00) Coronavirus SARS-CoV2 Rapid: Not Detected (12/16/22 14:19:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (12/16/22 14:19:00) Rapid Influenza A PCR: Not Detected (12/16/22 14:19:00) Rapid Influenza B PCR: Not Detected (12/16/22 14:19:00) Diagnostics Radiology Results - Last 24 hours Across Visits 12/16/2022 16:03 - XR Chest PA or AP Portable IMPRESSION:1. Coarse interstitial opacities are noted in the mid and lower lungzones bilaterally. This is indeterminant and could be a chronicfinding. Interstitial edema or an atypical infectious/inflammatoryprocess could also appear similarly.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact. For after-hours or emergency department cases. Signature Line Electronically Signed on 12/16/22 18:03 ________________________________________________________ Addendum on December 16, 2022 18:13:58 (Verified) General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. No added sounds Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact I saw and evaluated the patient in addition to the APP. I provided a substantive portion of the care for this patient. I personally performed in its entirety examfor this encounter. I have reviewed and verified this documentation and it accurately reflects our care. Hospital Medicine Signature Line Electronically Signed on 12/16/22 18:14 ________________________________________________________
Weitere VAERSDATA-Felder
- Praegender Schweregrund
- Cerebrovascular accident
- Hospital-Tage
- -
- Labordaten
- Hemogram-Platelets-WBC Differential 8.5 k/cumm 7.4 k/cumm (L) 3.71 million/cumm (L) 3.97 million/cumm (L) 10.6 GM/dL (L) 11.5 GM/dL (L) 32.3 % (L) 34.4 % 87 fL 87 fL 28.7 pg 28.9 pg 32.9 GM/dL 33.4 GM/dL (H) 14.8 % 14.3 % 209 k/cumm 223 k/cumm 7.1 fL 7.1 fL 75 % 78 % 18 % 16 % 6 % 4 % 1 % 2 % 0 % 0 % 6.4 k/cumm 5.7 k/cumm 1.5 k/cumm 1.2 k/cumm 0.5 k/cumm 0.3 k/cumm 0.1 k/cumm 0.1 k/cumm 0.0 k/cumm 0.0 k/cumm Routine Chemistry Tests 140 mmol/L 138 mmol/L 4.6 mmol/L 4.5 mmol/L 102 mmol/L 100 mmol/L 27 mmol/L 27 mmol/L 11 mmol/L 11 mmol/L (H) 28 mg/dL (H) 31 mg/dL (H) 1.70 mg/dL (H) 1.60 mg/dL * (L) 40 mL/min/1.73m2 * (L) 42 mL/min/1.73m2 * (L) 42 mL/min * (L) 45 mL/min (H) 133 mg/dL (H) 153 mg/dL * (H) 135 mg/dL * (H) 138 mg/dL * (H) 116 mg/dL * (H) 129 mg/dL 9.7 mg/dL 10.0 mg/dL 76 Units/L 82 Units/L (L) 6 Units/L 7 Units/L 13 Units/L (L) 10 Units/L (H) 1.8 mg/dL (H) 1.6 mg/dL * 8.0 GM/dL * (H) 8.3 GM/dL 4.0 GM/dL 4.1 GM/dL 1.9 mmol/L Urinalysis Color Yellow Clarity Clear Specific Gravity 1.015 pH 6.5 Protein Negative mg/dL Glucose Negative mg/dL Ketones Negative mg/dL Bilirubin * Negative mg/dL Hgb Ur (A) Small Nitrite (A) Positive Urobilinogen * Normal mg/dL Leukocyte Esterase Ur (A) Large WBC (A) 21-50 /hpf RBC (A) 11-20 /hpf Bacteria (A) Moderate /hpf Squamous Epithelial Few /hpf Molecular Diagnostic Tests COVID 19 Specimen Source Nasopharyngeal Coronavirus SARS-CoV2 Rapid * Not Detected Viral FS Rapid Influenza Method PCR Rapid Influenza A PCR * Not Detected Rapid Influenza B PCR * Not Detected
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