VAERS 2513936
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) · Charge UJ875AB
- Staat
- IN
- Alter
- 68,0
- Geschlecht
- F
- Eingang
- 22.11.2022
- Impfdatum
- 20.11.2022
- Beginn
- 21.11.2022
- Tage bis Beginn
- 1,0
- Dosis
- UNK
- Route/Site
- SYR / -
Symptomtext
Document Type: ED Physician Progress Note Document Subject: ED Progress Note Performed By: DO on November 21, 2022 21:32 EST Encounter Info: Emergency, 11/21/22 - 11/22/22 * Preliminary Report * Basic Information Time Seen: DO / 11/21/2022 21:23 Chief Complaint Foot injury - Minor (Complaint of) Supporting Nursing Comments: c/o pain in right foot from wound on top of the foot and 2 toes, has not been able to be seen by any wound management. reports that she has a blood clot in each thigh History of Present Illness 68-year-old female presents to the ER for multiple complaints. Patient reports that she has had a right foot wound on the top of her foot for over 6 months. She has not been able to get into wound clinic. She did try to get into her family doctor however they cannot see her for over a week. She reports history of blood clots in bilateral lower extremities. She is taking Lovenox for this. She states that she is on the Lovenox as she developed worsening clots despite being on oral anticoagulants. Last ultrasound she reports was about a month ago. She does not report any new calf pain or swelling. She has been having ongoing right foot pain. She did recently have someone stepped on her foot. Otherwise denies any trauma to her foot. She has some purple discoloration to several toes that she reports has been present for over a year. Family member states that she has to areas that have opened up recently yesterday. Family member also reports patient has been weak and pale. Today she was so weak she could barely stand. She noted weakness in her arms and her legs. As well as all over. Denies any black or bloody stools. Patient has a history of anemia. Denies any head pain. She did have a recent fall sounds as though she has frequent falls. She did hit her head. Denies any loss of consciousness. She reports chronic neck and back pain however denies any acute change. No loss of bowel or bladder function. No unilateral weakness. Again just the generalized weakness that she noted above. No vomiting or diarrhea. No cough or fever. Review of Systems All other systems reviewed & negative. Physical Exam/Objective Vitals & Measurements last 24 hours VITAL SIGNS Temp C: 36.9 DegC Heart Rate: 72 bpm Resp Rate: 22 br/min BP: 147 / 79 mmHg SpO2 (%): 100 % O2 Device: Room air Height CM: 162.6 cm Weight KG: 100 kg Ideal Body Weight: 54.74 kg Vital Signs Per nurse's notes. Oxygen saturation. General: Alert, no acute distress. Skin: Warm, dry, intact. Head: Normocephalic, ecchymosis to the left chin. no raccoon eyes . No septal hematoma. no battle sign. no periorbital ecchymosis or proptosis. Neck: Supple, trachea midline, no tenderness, no JVD, no carotid bruit. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate. Cardiovascular: Normal peripheral perfusion, No edema, clear heart sounds S1 and S2 . Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal, Symmetrical chest wall expansion. Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds. Musculoskeletal: Normal ROM, no deformity. No C, T, or LS midline tenderness, step-offs or deformities. B/L Radial pulses intact. B/L DP & PT pulses intact. Extremities warm & well perfused. Right dorsal foot has a about a 4 cm superficial appearing wound. It is malodorous however no drainage surrounding redness or crepitance. Chronic skin changes to bilateral lower extremities. Neurological: GCS 15. AAO*3, PERRL, EOMI, Visual Fields full, no dysarthria, face symmetric, symmetric facial strength, symmetric facial sensation, tongue midline, uvula raises midline, symmetric shoulder shrugs, hearing intact, no upper extremity drift, symmetric grip strengths, 5/5 MS in both upper extremities, no lower extremity drift, symmetric dorsi & plantar flexion, 5/5 MS in both lower extremities. No limb ataxia. No aphasia or neglect. Sensation intact. Lymphatics: No lymphadenopathy. Psychiatric: Cooperative. Follow Up No qualifying data available Chronic Problem List Acute epigastric pain Asthma Bronchitis CVA (cerebrovascular accident) Depression Factor V Leiden History of DVT in adulthood Hypothyroidism Leg edema Mobility impaired Port-A-Cath in place Recurrent deep vein thrombosis (DVT) S/P IVC filter Seizure disorder Severe obesity Skin change Tobacco use Type II diabetes mellitus Ulcer of bile duct Procedure/Surgical History ?back fusion ?back surg x5 ?bil scope of knees ?chole ?hernia repair ?hysterectomy ?pacemaker ?port placement ?right foot surgery ?right shoulder scope ?stomach surgery Surgical History Internal 12/05/2021 Angiogram 11/23/2016 Portacath Insertion 09/22/2014 EGD ENDO Ultrasound 05/23/2008 Colonscpy Diagnostic/Screen Medications Home Medications (16) Active atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime carBAMazepine 200 mg oral tablet, extended release 400 mg = 2 Tablet, Orally, BID CLonazePAM 0.5 mg oral tablet 0.5 mg = 1 Tablet, Orally, BID cyanocobalamin 1000 mCg/mL injectable solution See Instructions, 1 mL IM once weekly for 4 weeks, then 1 mL IM every 2 weeks x 2 doses then 1 mL IM monthly enoxaparin 40 mg/0.4 mL injectable solution 1 Syringe, Subcutaneous, Daily EPINEPHrine 0.3 mg injectable kit (2 pack) 0.3 mg, PRN, IM, ONCE gabapentin 300 mg oral capsule 300 mg = 1 Capsule, Orally, BID hydroCODONE-acetaminophen 10 mg-325 mg oral tablet See Instructions, 1-2 tablets every 4 to 6 hrs PRN levothyroxine 150 mCg (0.15 mg) oral tablet 150 mCg = 1 Tablet, Orally, Daily Mirapex 1 mg oral tablet 1 mg = 1 Tablet, Orally, TID Misc Supplies See Instructions, Needles and syringes to go with B12 injections omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily PARoxetine 30 mg oral tablet 60 mg = 2 Tablet, Orally, Daily promethazine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q8H tiZANidine , Orally, Daily traZODONE 100 mg oral tablet 100 mg = 1 Tablet, Orally, At Bedtime Allergies Ceclor CeleBREX (rash) Dilaudid ([D]Chest pain, DIB - Difficulty in breathing) Keflex Keppra (rash) LaMICtal (blisters) Reglan Septra doxycycline (rash) erythromycin (Rash) penicillin (Anaphylaxis) sulfADIAZINE (Rash) Social History Alcohol - Denies Alcohol Use Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Hobbies/Interests watch games shows, reading Creative:. watching farm animals Outdoor:. church Social. Church Activities, Reading Enrichment. Substance Abuse - Denies Substance Abuse Denies Tobacco - Denies Tobacco Use Tobacco Use: Former smoker, quit more than 30 days ago. Started age 18.0 Years. Stopped age 30 Years. Family History Blood clot: Mother. Breast cancer: Grandmother (P). Factor 5 Leiden mutation: Sister and Brother. Heart attack: Father. Lung cancer: Sister.Negative: Mother, Father and Grandmother (P). Lab Results Hemogram-Platelets-WBC Differential FS LATEST RESULTS HISTORICAL RESULTS WBC 11/21/22 22:30 4.3 10/25/22 4.7 RBC 11/21/22 22:30 3.28 Low 10/25/22 3.16 Low Hgb 11/21/22 22:30 10.7 Low 10/25/22 10.3 Low Hct 11/21/22 22:30 32.1 Low 10/25/22 30.9 Low MCV 11/21/22 22:30 98 10/25/22 98 MCH 11/21/22 22:30 32.6 10/25/22 32.6 MCHC 11/21/22 22:30 33.3 10/25/22 33.4 RDW 11/21/22 22:30 14.6 High 10/25/22 15.1 High Platelet 11/21/22 22:30 135 Low 10/25/22 166 MPV 11/21/22 22:30 7.3 10/25/22 6.8 Low Neutrophils % 11/21/22 22:30 64 10/25/22 66 Lymphocytes % 11/21/22 22:30 22 10/25/22 23 Monocytes % 11/21/22 22:30 6 10/25/22 7 Eosinophils % 11/21/22 22:30 7 10/25/22 4 Basophils % 11/21/22 22:30 1 10/25/22 1 Absolute Neutrophil 11/21/22 22:30 2.7 10/25/22 3.1 Absolute Lymphocyte 11/21/22 22:30 0.9 Low 10/25/22 1.1 Absolute Monocyte 11/21/22 22:30 0.3 10/25/22 0.3 Absolute Eosinophil 11/21/22 22:30 0.3 10/25/22 0.2 Absolute Basophil 11/21/22 22:30 0.0 10/25/22 0.0 Routine Chemistry Tests FS LATEST RESULTS HISTORICAL RESULTS Sodium SerPl QN 11/21/22 22:30 140 10/25/22 143 Potassium SerPl QN 11/21/22 22:30 4.6 10/25/22 3.9 Chloride SerPl QN 11/21/22 22:30 107 10/25/22 108 Carbon Dioxide SerPl QN 11/21/22 22:30 28 10/25/22 27 Anion Gap 11/21/22 22:30 5 10/25/22 8 BUN SerPl QN 11/21/22 22:30 20 10/25/22 18 Creatinine SerPl QN 11/21/22 22:30 0.96 10/25/22 0.84 Estimated GFR (CKD-EPI, no race) 11/21/22 22:30 64 10/25/22 76 Estimated CRCL (CG) 11/21/22 22:30 64 10/25/22 73 Glucose SerPl QN 11/21/22 22:30 143 High 10/25/22 140 High Calcium Total SerPl QN 11/21/22 22:30 8.2 Low 10/25/22 8.8 Alkaline Phos SerPl QN 11/21/22 22:30 126 High 10/25/22 141 High ALT SerPl QN 11/21/22 22:30 10 10/25/22 14 AST SerPl QN 11/21/22 22:30 10 Low 10/25/22 14 Bilirubin Total SerPl QN 11/21/22 22:30 0.3 10/25/22 0.3 Total Protein SerPl QN 11/21/22 22:30 5.8 Low 10/25/22 6.2 Low Albumin SerPl QN 11/21/22 22:30 3.5 10/25/22 3.6 Lipase SerPl QN 11/21/22 22:30 35 03/23/22 22 Troponin-I High Sensitivity 11/21/22 22:30 11 10/25/22 5 BNP Pl QN 11/21/22 22:30 294 High Lactate Venous Pl QN 11/21/22 22:30 0.8 03/24/22 1.0 Urinalysis FS LATEST RESULTS HISTORICAL RESULTS Color 11/22/22 01:32 Yellow 07/11/22 Yellow Clarity 11/22/22 01:32 Clear 07/11/22 Clear Specific Gravity 11/22/22 01:32 1.015 07/11/22 1.020 pH 11/22/22 01:32 7.5 07/11/22 7.0 Protein 11/22/22 01:32 Negative 07/11/22 Negative Glucose 11/22/22 01:32 Negative 07/11/22 Negative Ketones 11/22/22 01:32 Negative 07/11/22 Negative Bilirubin 11/22/22 01:32 Negative 07/11/22 Negative Hgb Ur 11/22/22 01:32 Negative 07/11/22 Negative Nitrite 11/22/22 01:32 Negative 07/11/22 Negative Urobilinogen 11/22/22 01:32 Normal 07/11/22 Normal Leukocyte Esterase Ur 11/22/22 01:32 Negative 07/11/22 Negative Molecular Diagnostic Tests LATEST RESULTS HISTORICAL RESULTS COVID 19 Specimen Source 11/21/22 22:41 Nasopharyngeal 10/25/22 Nasopharyngeal Coronavirus SARS-CoV2 Rapid 11/21/22 22:41 Not Detected 10/25/22 Not Detected Viral FS LATEST RESULTS HISTORICAL RESULTS Rapid Influenza Method 11/21/22 22:41 PCR - Liat 10/25/22 PCR - Liat Rapid Influenza A PCR 11/21/22 22:41 Not Detected 10/25/22 Not Detected Rapid Influenza B PCR 11/21/22 22:41 Not Detected 10/25/22 Not Detected Diagnostic Results CT Cervical Spine W/o IV Contrast 11/22/22 00:40:06 IMPRESSION: 1. No evidence of acute fracture or traumatic subluxation in the cervical spine. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case further can contact. Electronically Signed by: MD ************************************************** CT Head W/o IV Contrast 11/22/22 00:28:42 IMPRESSION: 1. No acute CT abnormality of the head. No acute intracranial hemorrhage, hydrocephalus, or large mass Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss this case further can contact. Electronically Signed by: MD ************************************************** XR Chest PA or AP Portable 11/21/22 23:53:06 IMPRESSION: Constellation of findings as above be seen with interstitial edema in the setting of cardiac decompensation. However, underlying atypical/viral pneumonia can have a similar appearance. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case. Electronically Signed by: Signed By: MD ************************************************** XR Foot 3 View Right 11/21/22 23:56:43 IMPRESSION: 1. No acute bony findings, though radiographs are generally not considered sensitive for the above reasons. 2. There is prominent soft tissue swelling about the foot. Underlying soft tissue infection cannot be excluded. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case further can contact. Electronically Signed by: Signed By: MD EKG 11/21/2022. 10:37 PM. Rate 64. Atrial paced rhythm with prolonged AV conduction. Left bundle branch block. Signature Line ________________________________________________________ DO
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