VAERS 2527819
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) · Charge uj933ac
- Staat
- IN
- Alter
- 84,0
- Geschlecht
- M
- Eingang
- 09.12.2022
- Impfdatum
- 10.11.2022
- Beginn
- 06.12.2022
- Tage bis Beginn
- 26,0
- Dosis
- UNK
- Route/Site
- SYR / -
Symptomtext
Document Type: History and Physical Document Subject: History & Physical Note Performed By: DO on December 06, 2022 07:39 EST Verified By: DO on December 06, 2022 07:39 EST Encounter Info: Inpatient, 12/06/22 - * Final Report * Chief Complaint shortness of breath History of Present Illness/Subjective Patient is an elderly male with history of COPD who presented to ED w/ cough and generalized weakness. Does have shortness of breath but reports no significant deviation from baseline. Symptoms started about 1 week ago and have progressively worsened since that time. Reports his wife had flulike symptoms about 2 days prior to his onset of symptoms. He has had significantly decreased oral intake. He has been so weak that he fell a couple days ago. However, denies head trauma or injuries. He is remained afebrile. He is unable to get up independently due to the severity of his weakness. In the ED he was discovered to have influenza A, elevated trop, aki, elevated bnp, and is requiring 4L O2 via oxymask. He denies chest pain, productive cough, admits to some wheezing. Patient states he is thirsty. Review of Systems A complete, 13-system review was performed and was negative except for as noted in the HPI. Physical Exam/Objective Vital Signs (most recent and range for last 24 hours) Temp (CEL) 37 (37-37) Temp (FAHR) 98.6 (98.6-98.6), BP 112/86 (112-112)/(86-86), HR 100 (100-107), RR 20 (18-20), O2Sat 92 (92-92) Neurologic (most recent and range for last 24 hours) GCS 15(15-15) Patient Weight Current Daily Weight: 68.7 kg 12/06/22 Previous Daily Weight: 68.7 kg 12/06/22 BMI: 24.1 12/06/22 Normal Weight (BMI 18.5-24.9) Patient Height Current Height: 169 cm 12/06/22 Constitutional: No acute distress, frail appearing, weak, appears dry Eyes: no scleral icterus, no conjunctival injection, dry mucuous membranes HENT: no edema, atraumatic Neck: normal ROM Cardiovascular: tachycardic, regular rhythm, No edema Pulmonary: no respiratory distress, rhonchi bilaterally, with mild wheeze Abdomen: nondistended, no tenderness, no rebound, noguarding MSK: atraumatic, no deformities, no cyanosis Neurologic: motor function grossly intact, sensation grossly intact Skin: dry, warm Psych: calm and cooperative Assessment/Plan admit to med/surg 1. Influenza A J10.1 2. CHF (congestive heart failure) I50.9 3. COPD exacerbation J44.1 supportive care and supplemental o2 not a candidate for tamiflu due to onset of symptoms being approx 7 days prior droplet isolation resp assessment doxycycline for possible atypical pneumonia duonebs likely not a chf exacerbation given patient is dry 4. Acute on chronic renal failure N17.9 renal function is improving with iv and supplemental o2 avoid nephrotoxic medications 5. Anemia D64.9 transfuse hg <7, drop in hg likely related to dilutional change, repeat hg in 4 hours 6. Thrombocytopenia D69.6 trend plt count, no dvt chemical ppx while platelets are <100K possibly due to influenza, cont to monitor 7. Elevated troponin R77.8 likely due to demand ischemia and initial hypoxia cont to trend trops until peaked, cardio eval prn if not improving no chest pain at present and ecg does not demonstrate evidence of ACS cont to monitor 8. Diabetes mellitus with hyperglycemia E11.65 accuchecks, iss, diabetic diet, hold home meds for now 9. Elevated bilirubin R17 resolved Orders: acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 12/06/22 4:46:00 EST Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 12/06/22 4:46:00 EST, PRN - See Comments doxycycline, 100 mg, IVPB, Injection, BID, 12/06/22 10:00:00 EST, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100 fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 12/06/22 9:00:00 EST glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 12/06/22 4:46:00 EST glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 12/06/22 4:46:00 EST insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 12/06/22 4:46:00 EST methylPREDNISolone, 40 mg, IV Push, Injection, Daily, 12/06/22 9:00:00 EST 180 gm Carb per day Diet Admit to Inpatient CAH Bladder Scan Call (Specify) Call Blood Glucose Call Diastolic Blood Pressure Call Heart Rate Call Mental Status Changes Call O2 Saturation Call Respiratory Distress Call Respiratory Rate Call Systolic Blood Pressure Call Temperature Call Urine Output CBC CBC w/Differential Comp Metabolic Panel Comp Metabolic Panel Electrocardiogram Fall Precautions Fluid Intake Requirement Gluc-Strip POC Hgb Hgb A1C HPLC Bld QN Initiate IV Care Protocols As Appropriate Initiate Mobility Protocol Initiate Oxygen Protocol Initiate Respiratory Protocol Initiate Skin and Wound Care Protocol Intake + Output Strict Level of Care Lipid Panel SerPl QN Magnesium SerPl QN Medical Service Medication Message to Nursing Message to Nursing Message to Nursing Nasal Cannula Notify Provider Notify Provider Notify Provider OT Evaluation and Treatment Patient Isolation Peripheral IV Insertion Phosphorus SerPl QN PT Evaluation and Treatment Reason for Not Ordering Long-acting Insulin Resp Evaluation or Assessment Resuscitation Status Sequential Compression Device Single Oxygen Saturation Telemetry Class III 24hr Recommendation Titrate FiO2 to Keep O2 Sat Troponin-I High Sensitivity TSH w FreeT4 reflex Turn Cough + Deep Breathe Vital Signs Weight Weight Code Status Resuscitation Status - Ordered -- 12/06/22 4:46:00 EST, Full Code Chronic Problem List Anemia CAD (coronary artery disease) Chronic cough Chronic HFrEF (heart failure with reduced ejection fraction) Chronic ITP (idiopathic thrombocytopenia) Colonic polyp COPD (chronic obstructive pulmonary disease) Dermatitis, atopic Diet-controlled diabetes mellitus Encounter for long-term current use of medication GERD (gastroesophageal reflux disease) Hematuria Hip pain History of hip replacement Hx of staphylococcal infection Hyperlipidemia Hypertension Intermittent claudication Macrocytosis Macrocytosis without anemia Mallet finger Nasal septal deviation Obstructive sleep apnea Psoriasis S/P implantation of automatic cardioverter/defibrillator (AICD) Skin lesion Snoring Stage 3 chronic kidney disease Tobacco use Vascular dementia Procedure/Surgical History ?Diabetic retinal eye exam (12/21/2021) ?Eye examination (12/20/2018) ?colonoscopy (08/01/2016) ?Hip replacement (07/01/2013) ?egd (05/09/2012) ?CABG - Coronary artery bypass graft (2002) ?Heart Sx 2004 ?Polypectomy ?Rt THR JWS 7/1/13 Surgical History Internal 08/01/2016 Colonscpy Diagnostic/Screen Medications Home Medications (17) Active acitretin 10 mg oral capsule 10 mg = 1 Capsule, Orally, Every Mon Wed Fri allopurinol 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID amLODIPine 2.5 mg oral tablet , TAKE 1 TABLET BY MOUTH EVERY DAY apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, QHS Breo Ellipta 200 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily Mapap Arthritis Pain 650 mg oral tablet, extended release 1,300 mg = 2 Tablet, Orally, Q8H memantine 5 mg oral tablet See Instructions, 1 Tablet Orally bid X 1 week then 2 in am 1 in pm x 1 week then 2 twice a day metoPROLOL tartrate 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID multivitamin 1 Tablet, Orally, Daily Nitrostat 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily valsartan 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily Vitamin C 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID Active Scheduled Inpatient Medications doxycycline, Injection, 100 mg, IVPB, BID, Start: 12/06/22 10:00:00 fluticasone-vilanterol (Breo Ellipta 200 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 12/06/22 09:00:00 methylPREDNISolone (soluMEDROL), Injection, 40 mg, IV Push, Daily, Start: 12/06/22 09:00:00 Lactated Ringers 1,000 mL IV 150 mL/hr Dextrose 10% in Water 500 mL IV PRN - See Comments One-Time Medications Given 12/05/22 00:00:00 TO 12/06/22 07:39:23 None Reported PRN Medications (0600 - 0559) from 12/05 - 12/06 acetaminophen, 650 mg, Orally, Q4H, 0 Dose(s) glucagon, 1 mg, IM, Unscheduled, 0 Dose(s) glucose, Per Glucose Level , IV Push, Unscheduled, 0 Dose(s) insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0 Dose(s) Allergies penicillins (Unknown) Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Home/Environment Lives with Spouse. Substance Abuse Denies Tobacco Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days. Family History CAD - Coronary artery disease: Mother and Brother. DM (diabetes mellitus)...: Grandmother. Kidney disease: Brother and Brother.Negative: Mother and Father. Stroke: Mother. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 4.1 k/cumm (12/06/22 05:31:00) RBC: 2.55 million/cumm Low (12/06/22 05:31:00) Hgb: 9.7 GM/dL Low (12/06/22 05:31:00) Hct: 28.2 % Low (12/06/22 05:31:00) MCV: 111 fL High (12/06/22 05:31:00) MCH: 38 pg High (12/06/22 05:31:00) MCHC: 34.3 GM/dL (12/06/22 05:31:00) RDW: 13.3 % (12/06/22 05:31:00) Platelet: 62 k/cumm Low (12/06/22 05:31:00) MPV: 8.4 fL (12/06/22 05:31:00) Neutrophils %: 83 % (12/05/22 20:18:00) Lymphocytes %: 8 % (12/05/22 20:18:00) Monocytes %: 10 % (12/05/22 20:18:00) Eosinophils %: 0 % (12/05/22 20:18:00) Basophils %: 0 % (12/05/22 20:18:00) Absolute Neutrophil: 4.2 k/cumm (12/05/22 20:18:00) Absolute Lymphocyte: 0.4 k/cumm Low (12/05/22 20:18:00) Absolute Monocyte: 0.5 k/cumm (12/05/22 20:18:00) Absolute Eosinophil: 0 k/cumm (12/05/22 20:18:00) Absolute Basophil: 0 k/cumm (12/05/22 20:18:00) RBC Morphology: See description UC (12/05/22 20:18:00) Dacryocyte: Few (1+). (12/05/22 20:18:00) Macrocyte: Few (1+). (12/05/22 20:18:00) Microcyte: Few (1+). (12/05/22 20:18:00) Platelet Estimate: Decreased. (12/05/22 20:18:00) Chemistry: Sodium SerPl QN: 139 mmol/L (12/06/22 05:31:00) Potassium SerPl QN: 4.2 mmol/L (12/06/22 05:31:00) Chloride SerPl QN: 100 mmol/L (12/06/22 05:31:00) Carbon Dioxide SerPl QN: 24 mmol/L (12/06/22 05:31:00) Anion Gap: 15 mmol/L High (12/06/22 05:31:00) BUN SerPl QN: 50 mg/dL High (12/06/22 05:31:00) Creatinine SerPl QN: 2.12 mg/dL High (12/06/22 05:31:00) Estimated GFR (CKD-EPI, no race): 30 mL/min/1.73m2 Low (12/06/22 05:31:00) Estimated CRCL (CG): 24 mL/min Low (12/06/22 05:31:00) Glucose SerPl QN: 186 mg/dL High (12/06/22 05:31:00) Calcium Total SerPl QN: 8.4 mg/dL Low (12/06/22 05:31:00) Phosphorus SerPl QN: 3 mg/dL (12/06/22 05:31:00) Alkaline Phos SerPl QN: 60 Units/L (12/06/22 05:31:00) ALT SerPl QN: 41 Units/L (12/06/22 05:31:00) AST SerPl QN: 89 Units/L High (12/06/22 05:31:00) Bilirubin Total SerPl QN: 0.8 mg/dL (12/06/22 05:31:00) Total Protein SerPl QN: 5.6 GM/dL Low (12/06/22 05:31:00) Albumin SerPl QN: 3.1 GM/dL Low (12/06/22 05:31:00) Magnesium SerPl QN: 1.7 mg/dL (12/06/22 05:31:00) Troponin-I High Sensitivity: 78 ng/L High (12/06/22 05:31:00) BNP Pl QN: 636 pg/mL High (12/05/22 20:18:00) Lactate Venous Pl QN: 1.3 mmol/L (12/05/22 20:18:00) pH Bld Venous QN: 7.44 (12/05/22 20:18:00) PCO2 Bld Venous QN: 36 mmHg Low (12/05/22 20:18:00) PO2 Bld Venous QN: <35 Low (12/05/22 20:18:00) Base Excess Bld Venous: 1 mmol/L (12/05/22 20:18:00) Bicarb Bld Venous Calc: 24 mmol/L (12/05/22 20:18:00) O2 Sat Bld Venous Calc: 68 % (12/05/22 20:18:00) Patient Temperature: 37 DegC (12/05/22 20:18:00) TSH 3rd Gen SerPl QN: 0.75 mcU/mL (12/06/22 06:00:00) All Other Labs: COVID 19 Specimen Source: Nasopharyngeal (12/05/22 19:50:00) Coronavirus SARS-CoV2 Rapid: Not Detected (12/05/22 19:50:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (12/05/22 19:50:00) Rapid Influenza A PCR: Detected Abnormal (12/05/22 19:50:00) Rapid Influenza B PCR: Not Detected (12/05/22 19:50:00) Diagnostics Radiology Results - Last 24 hours Across Visits 12/05/2022 20:20 - XR Chest PA or AP Portable IMPRESSION: Airspace opacities, left greater than right, which are new comparedto prior chest radiograph on 3/23/2022, however were present on theprior CT on 8/15/2022. Signature Line Electronically Signed on 12/06/22 07:39 EST ________________________________________________________ DO
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- Molecular Diagnostic Tests MRSA PCR * (c) See comment Modified Staph aureus PCR * (c) See comment Modified COVID 19 Specimen Source Nasopharyngeal Coronavirus SARS-CoV2 Rapid * Not Detected Microbiology Studies - Bacterial Blood CX NEG In Progress NEG In Progress Viral FS Rapid Influenza Method PCR - Liat Rapid Influenza A PCR * (A) Detected Rapid Influenza B PCR * Not Detected
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