VAERS 2527848
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) · Charge uj932ac
- Staat
- -
- Alter
- 71,0
- Geschlecht
- M
- Eingang
- 09.12.2022
- Impfdatum
- 25.10.2022
- Beginn
- 06.12.2022
- Tage bis Beginn
- 42,0
- Dosis
- UNK
- Route/Site
- SYR / -
Symptomtext
Document Type: History and Physical Document Subject: History & Physical Note Performed: December 06, 2022 19:13 EST Verified: December 06, 2022 19:13 EST * Final Report * Document Contains Addenda History of Present Illness/Subjective 71 year old male presents to the ED from home via EMS for AMS and respiratory distress. bilateral wheezes, and increased weakness with last known normal Saturday. HPI limited due to AMS. ???????Upon ER evaluation his vital signs were stable with a temperature of 97, heart rate was 96, respiratory rate was 20 and room air sat was 96%. Initial blood pressure was 12 over 72. Lab work was completed which showed a normal white blood cell count of 6.5, hemoglobin was 10.9, sodium was elevated at 150 with repeat being 147. Initial potassium was 2.9 which was replaced and then came down to 2.8. His renal function was declined initially with a GFR of 24 which did come up to 27 after fluids. Patient's baseline is CKD stage III with a creatinine of 1.55, lactate initially was four-point 1 repeat was 1.5, troponin was 52 with repeat pending, BNP was 271, urinalysis revealed hematuria, no signs of acute infection. COVID SARS was positive flu was negative,. Due to altered mental status head CT was completed did not show any acute intracranial findings did show chronic small vessel ischemic disease. This was followed up with an MRI of the brain which did not show any acute infarction small focal acute left frontal deep white matter infarction at the level of the body of the left lateral ventricle, moderate volume loss with moderate chronic microvascular ischemia and diffuse para nasal sinus mucosal disease with bilateral mucosal disease with partial opacification of mastoid air cells. Chest x-ray showed ???????No acute findings in the chest. We will bring patient in for further evaluation management inpatient status for acute CVA, COVID, dehydration, AKI, hypokalemia and hyponatremia. 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 Vital Signs (most recent and range for last 24 hours) None reported this timeframe Patient Weight Patient Height None Reported Constitutional: No acute distress Eyes: no scleral icterus ENMT: Moist oral mucosa Respiratory: Breathing comfortably on room air Cardiovascular: Regular rate and rhythm Gastrointestinal: non-distended Musculoskeletal: intact ROM Integumentary: no rashes Neurologic: AMS, mild deficits Psychiatric: Cooperative, appropriate mood and affect Assessment/Plan 1. Acute CVA (cerebrovascular accident) -Will start ASA, statin and plavix -Monitor neuro status MRI Brain W/O IV Contrast 12/06/22 17:09:57 IMPRESSION: 1. Small focal acute left frontal deep white matter infarction at the level of the body of left lateral ventricle. 2. Moderate volume loss with moderate chronic microvascular ischemic disease. 3. Diffuse paranasal sinus mucosal disease with bilateral mucosal disease with partial opacifications of mastoid air cells. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case further can contact the Reading Room. ************************************************** CT Head W/o IV Contrast 12/06/22 12:25:30 IMPRESSION: No evidence of acute intracranial hemorrhage or mass effect. Moderate to severe likely chronic small vessel ischemic disease and diffuse volume loss, progressed compared to 2017. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case further can contact the Reading Room. 2. COVID-19 -on RA, monitor, RT protocol, monitor labs 3. Hypokalemia Replacement protocol 4. Hypernatremia Free water deficit 1.8L 5. AKI (acute kidney injury) Give IV fluids -Monitor labs daily 6. Chronic kidney disease, stage 3 noted 7. Dehydration noted 8. Cardiomyopathy noted 9. HTN (hypertension) Resume home meds 10. Mixed bipolar affective disorder, mild (disorder) resume home meds 11. Elevated troponin Repeating, elevated, NO ST elevation on EKG 12. Hematuria Renal US in am 13. Sinusitis, acute Start zosyn 14. CAD (coronary artery disease) resume home meds Orders: piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q8H, Indication: Other (MUST specify in Comments), 12/06/22 19:00:00 EST, Total Volume (mL) = 50 CK SerPl QN Troponin-I High Sensitivity US Renal and Bladder Pt is a full code status DVT prophylaxis with lovenox Code Status None Recorded Chronic Problem List Acute CVA (cerebrovascular accident) AKI (acute kidney injury) Alzheimer's dementia Bursitis CAD (coronary artery disease) Cardiomyopathy Charcot-Marie-tooth disease Chronic back pain Chronic kidney disease, stage 3 Chronic, continuous use of opioids COPD (chronic obstructive pulmonary disease) COVID-19 Dehydration Edema Elevated PSA Elevated troponin Heart disease Hematuria HTN (hypertension) Hypernatremia Hypokalemia Hypoxemia Major depression Mixed bipolar affective disorder, mild (disorder) Neck pain, chronic Onychogryphosis Prostate asymmetry Sinusitis, acute Tobacco use Procedure/Surgical History ?Colonoscopy (02/17/2022) ?Excision skin lesion chest (07/01/2020) ?Open heart surgery (01/01/1998) ?Amputated toe ?Appendectomy ?Tonsillectomy Surgical History Internal 02/17/2022 Colonscpy Snare Tmr Polyp Lsn 07/01/2020 Lesion Mass Excision 06/12/2020 Femur Proximal Neck Fracture Open Red (Right) Medications Home Medications (18) Active albuterol 2.5 mg/0.5mL (0.5%) inhalation solution 2.5 mg = 0.5 mL, Neb Inhal, Q6H albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, Neb Inhal, Q6H albuterol 90 mCg/inh inhalation powder 2 Puff, PRN, Inhalation, Q4H atorvastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, QHS calcium (as carbonate)-vitamin D3 600 mg-10 mCg (400 intl units) oral tablet 1 Tablet, Orally, BID cetirizine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily Coreg 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, Daily DME Oximeter Not Applicable, Other, Unscheduled ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, BID fluticasone-vilanterol 100 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily hydroCODONE-acetaminophen 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, BID Misc Supplies See Instructions, elevated toilet seat with arm rest Misc Supplies See Instructions, Tub transfer bench Nephrocaps oral capsule 1 Capsule, Orally, Daily nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, Sublingually, Q5min predniSONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily Prozac 40 mg oral capsule 40 mg = 1 Capsule, Orally, Daily umeclidinium 62.5 mCg inhalation powder 62.5 mCg = 1 Puff, Inhalation, Daily Active Scheduled Inpatient Medications Zosyn, Injection, 3.375 GM, IVPB, Q8H, Indication: Other (MUST specify in Comments), Start: 12/06/22 19:00:00 One-Time Medications Given 12/05/22 00:00:00 TO 12/06/22 19:12:43 None Reported PRN Medications (0600 - 0559) from 12/05 - 12/06 None Reported Allergies Bee Stings (critical) No Known Medication Allergies Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Employment/School Disability Home/Environment divorced, 3 children Substance Abuse Denies Tobacco Tobacco Use: 5-9 cigarettes (between 1/4 to 1/2 pack)/day in last 30 days. Family History CMT - Charcot-Marie-Tooth disease: Father and Sister. Heart attack..: Father. Heart disease..: Father. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 6.5 k/cumm (12/06/22 11:08:00) RBC: 3.11 million/cumm Low (12/06/22 11:08:00) Hgb: 10.9 GM/dL Low (12/06/22 11:08:00) Hct: 32.4 % Low (12/06/22 11:08:00) MCV: 104 fL High (12/06/22 11:08:00) MCH: 35.2 pg High (12/06/22 11:08:00) MCHC: 33.7 GM/dL (12/06/22 11:08:00) RDW: 16.2 % High (12/06/22 11:08:00) Platelet: 112 k/cumm Low (12/06/22 11:08:00) MPV: 8.3 fL (12/06/22 11:08:00) # WBC Counted in Diff: 100 (12/06/22 11:08:00) Neutrophil: 68 % (12/06/22 11:08:00) Lymphocyte: 31 % (12/06/22 11:08:00) Monocyte: 1 % (12/06/22 11:08:00) Absolute Neutrophil: 4.4 k/cumm (12/06/22 11:08:00) Abs Lymphocyte: 2 k/cumm (12/06/22 11:08:00) Absolute Monocyte: 0.1 k/cumm (12/06/22 11:08:00) RBC Morphology: See description UC (12/06/22 11:08:00) Hypochromasia: Moderate (2+), (12/06/22 11:08:00) Microcyte: Few (1+). (12/06/22 11:08:00) Platelet Estimate: Adequate. (12/06/22 11:08:00) Platelet Morphology: Normal, (12/06/22 11:08:00) Chemistry: Sodium SerPl QN: 147 mmol/L High (12/06/22 17:04:00) Potassium SerPl QN: 2.8 mmol/L Critical (12/06/22 17:04:00) Chloride SerPl QN: 111 mmol/L High (12/06/22 17:04:00) Carbon Dioxide SerPl QN: 26 mmol/L (12/06/22 17:04:00) Anion Gap: 10 mmol/L (12/06/22 17:04:00) BUN SerPl QN: 25 mg/dL High (12/06/22 17:04:00) Creatinine SerPl QN: 2.49 mg/dL High (12/06/22 17:04:00) Estimated GFR (CKD-EPI, no race): 27 mL/min/1.73m2 Low (12/06/22 17:04:00) Estimated CRCL (CG): 29 mL/min Low (12/06/22 17:04:00) Glucose SerPl QN: 96 mg/dL (12/06/22 17:04:00) Calcium Total SerPl QN: 7.9 mg/dL Low (12/06/22 17:04:00) Phosphorus SerPl QN: 2.2 mg/dL Low (12/06/22 12:54:00) Alkaline Phos SerPl QN: 76 Units/L (12/06/22 12:54:00) ALT SerPl QN: 10 Units/L (12/06/22 12:54:00) AST SerPl QN: 15 Units/L (12/06/22 12:54:00) Bilirubin Total SerPl QN: 1.3 mg/dL High (12/06/22 12:54:00) Total Protein SerPl QN: 5.1 GM/dL Low (12/06/22 12:54:00) Albumin SerPl QN: 3 GM/dL Low (12/06/22 12:54:00) Magnesium SerPl QN: 2.1 mg/dL (12/06/22 12:54:00) Troponin-I High Sensitivity: 52 ng/L High (12/06/22 11:08:00) BNP Pl QN: 271 pg/mL High (12/06/22 11:08:00) Lactate Venous Pl QN: 1.5 mmol/L (12/06/22 14:47:00) Urine Studies: Color: Yellow (12/06/22 12:12:00) Clarity: Clear (12/06/22 12:12:00) Specific Gravity: >=1.030 (12/06/22 12:12:00) pH: 5.5 (12/06/22 12:12:00) Protein: 100 Abnormal (12/06/22 12:12:00) Glucose: NEGATIVE (12/06/22 12:12:00) Ketones: TRACE. Abnormal (12/06/22 12:12:00) Bilirubin: SC Small Abnormal (12/06/22 12:12:00) Hgb Ur: LARGE. Abnormal (12/06/22 12:12:00) Nitrite: NEGATIVE (12/06/22 12:12:00) Urobilinogen: NormalUro (12/06/22 12:12:00) Leukocyte Esterase Ur: NEGATIVE (12/06/22 12:12:00) WBC: 0-5 (12/06/22 12:12:00) RBC: 3-5 Abnormal (12/06/22 12:12:00) Bacteria: TRACE. (12/06/22 12:12:00) Squamous Epithelial: NONE (12/06/22 12:12:00) Mucous: PRESENT. (12/06/22 12:12:00) Granular Casts: 3-5 Abnormal (12/06/22 12:12:00) Amorphous Crys Ur: PRESENT. (12/06/22 12:12:00) All Other Labs: COVID 19 Specimen Source: Nasal (12/06/22 10:59:00) Coronavirus SARS-CoV2 Rapid: Detected Abnormal (12/06/22 10:59:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (12/06/22 10:59:00) Rapid Influenza A PCR: Not Detected (12/06/22 10:59:00) Rapid Influenza B PCR: Not Detected (12/06/22 10:59:00) Diagnostics Radiology Results - Last 24 hours Across Visits 12/06/2022 11:35 - XR Chest PA or AP Portable IMPRESSION: No acute findings in the chest.Thank you for consulting withRadiology. If you are a clinicianand would like to discuss this case further, please contact the Hospital reading room. 12/06/2022 11:52 - CT Head W/o IV Contrast IMPRESSION: No evidence of acute intracranial hemorrhage or mass effect.Moderate to severe likely chronic small vessel ischemic disease anddiffuse volume loss, progressed compared to 2017. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Reading Room. 12/06/2022 16:57 - MRI Brain W/O IV Contrast IMPRESSION: 1. Small focal acute left frontal deep white matter infarction atthe level of the body of left lateral ventricle.2. Moderate volume loss with moderate chronic microvascular ischemicdisease.3. Diffuse paranasal sinus mucosal disease with bilateral mucosaldisease with partial opacifications of mastoid air cells.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Reading Room. I saw and evaluated the patient in addition to other provider. I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care. General: Alert and oriented, No acute distress. Eyes: Extraocular movements are intact, no scleral icterus HEENT: Normocephalic, Normal hearing, Moist oral mucosa Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness. Cardiovascular: Regular rate and rhythm Gastrointestinal: Soft, nontender, nondistended, normal bowel sounds Musculoskeletal: intact ROM Integumentary: no rashes Neurologic: Alert, no focal deficits Psychiatric: Cooperative, appropriate mood and affect
Weitere VAERSDATA-Felder
- Praegender Schweregrund
- Cerebrovascular accident
- Hospital-Tage
- -
- Labordaten
- Bacterial Staphylococcus spp (A) Detected Staphylococcus aureus Not Detected Staphylococcus epidermidis (A) Detected Staphylococcus lugdunensis Not Detected Streptococcus spp Not Detected Streptococcus agalactiae (Group B) Not Detected Streptococcus pneumoniae Not Detected Streptococcus pyogenes (Group A) Not Detected Enterococcus faecalis Not Detected Enterococcus faecium Not Detected Listeria monocytogenes Not Detected Enteric gram-negative bacilli Not Detected Enterobacter cloacae complex Not Detected Escherichia coli Not Detected Klebsiella aerogenes Not Detected Klebsiella oxytoca Not Detected Klebsiella pneumoniae group Not Detected Proteus spp Not Detected Salmonella spp Not Detected Serratia marcescens Not Detected Haemophilus influenzae Not Detected Neisseria meningitidis Not Detected Pseudomonas aeruginosa Not Detected Stenotrophomonas maltophilia Not Detected Acinetobacter baumannii cmplx Not Detected Bacteroides fragilis Not Detected CTX-M Test Not Performed IMP Test Not Performed KPC Test Not Performed mcr-1 Test Not Performed mecA/C (A) Detected mecA/C and MREJ (MRSA) Test Not Performed NDM Test Not Performed OXA-48-like Test Not Performed vanA/B Test Not Performed VIM Test Not Performed Candida albicans Not Detected Candida auris Not Detected Candida glabrata Not Detected Candida krusei Not Detected Candida parapsilosis Not Detected Candida tropicalis Not Detected Cryptococcus neoformans/gattii Not Detected Blood Pathogen Interp * Blood Pathogen Interp Viral FS Rapid Influenza Method PCR - Liat Rapid Influenza A PCR * Not Detected Rapid Influenza B PCR * Not Detected
- Aktuelle Erkrankungen
- -
- Vorgeschichte
- -
- Andere Medikamente
- -
- Allergien
- -
- Vorherige Impfungen
- -