VAERS 2530029
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) · Charge uj933aa
- Staat
- -
- Alter
- 89,0
- Geschlecht
- F
- Eingang
- 13.12.2022
- Impfdatum
- 18.10.2022
- Beginn
- 11.12.2022
- Tage bis Beginn
- 54,0
- Dosis
- UNK
- Route/Site
- - / -
Symptomtext
Document Type: History and Physical Document Subject: History & Physical Note Performed By: DO on December 12, 2022 05:10 Verified By: DO on December 12, 2022 05:10 Encounter Info: Hospital, Observation, 12/11/22 - * Final Report * Chief Complaint cough History of Present Illness/Subjective Patient presents via private vehicle due to fatigue, generalized weakness, productive cough, DOE and low grade fever x 4 days. Patient was seen at Clinic on Thursday and diagnosed with bronchitis. She was started on amoxicillin and prednisone at that time. She was negative for Covid and flu at that time. Patient denies chest pain, n/v/d . Associated medical hx includes: Add'l medical hx includes: HTN, HLD, OA, MDD, neuropathy, Social hx: lives at home alone, non smoker CXR shows right sided infiltrate concerning for pneumonia. Patient is also Covid +. She is Covid vaccinated. Flu is negative. No leukocytosis, not septic. Not hypoxic at rest. Discussed discharge to home with antibiotic change to Augmentin and doxy with patient and her daughter to better cover for pneumonia. Also, advised to stop prednisone. Patient and her daughter are not comfortable with discharge at this time due to patient's general weakness since being ill. She lives at home alone, no one can stay with her. 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) 36.5 (36.5-36.5) Temp (FAHR) 97.7 (97.7-97.7), BP 167/70 (144-212)/(65-89), HR 53 (53-83), RR 16 (16-18), O2Sat 94 (94-94) Neurologic (most recent and range for last 24 hours) GCS 15(15-15) Patient Weight Current Daily Weight: 95 kg 12/11/22 Patient Height Current Height: 152.79 cm 12/11/22 Constitutional: No acute distress, well-nourished Eyes: PERRL, EOMI, normal conjunctiva, no scleral icterus ENMT: Moist oral mucosa Neck: Supple, non-tender, intact range of motion Respiratory: Lungs are coarse, scattered rhonchi, Respirations are labored, RLL Crackles, no wheezes 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: Alert & Oriented x 3, no cognitive impairment, no focal deficits Psychiatric: Cooperative, appropriate mood and affect, denies SI or HI Assessment/Plan 1. Weakness R53.1 Will place in observation and have PT OT eval's to make sure it is safe for patient to go home since she lives alone Likely due to #2 and #3, no focal deficits suggesting CVA or neurologic process 2. Pneumonia J18.9 Will cover for CAP with Rocephin Doxy, collect sputum cultures, Legionella, strep antigen, and continue to monitor 3. COVID-19 U07.1 At present time disease appears to be mild, will start fluticasone inhalation, respiratory assessment, collect inflammatory markers, start famotidine, and continue to monitor, supplemental O2 as needed 4. Anemia D64.9 Noted. Stable, no evidence of acute bleeding, maintain hemoglobin greater than 7 5. HTN (hypertension) I10 6. Hyperlipidemia E78.5 7. OA (osteoarthritis) M19.90 8. Major depression F32.9 9. Neuropathy G62.9 Noted. Continue home medications as appropriate 10. DVT prophylaxis Z29.9 Lovenox subcu and SCDs while in bed Code Status None Recorded Chronic Problem List Anxiety Arthritis Chronic right sacroiliac pain Cystitis cystica DDD (degenerative disc disease), lumbar Depression Essential hypertension Headache History of kidney stones Hyperlipidemia Hypothyroid Idiopathic neuropathy Kidney cysts Leg cramps Lichenoid drug reaction Limb pain LVH (left ventricular hypertrophy) Major depression Morbid obesity OA (osteoarthritis) OG (onychogryphosis) OM (onychomycosis) Onychomycosis of toenail Osteoporosis Peripheral neuropathy, hereditary/idiopathic Recurrent UTI Right hip pain Tremor Vertigo Procedure/Surgical History ?Diabetic retinal eye exam (08/09/2021) ?Eye examination (02/25/2019) ?Repair of bladder (2009) ?Total hysterectomy (2009) ?Cataract surgery ?Tonsillectomy Medications Home Medications (23) Active amoxicillin 500 mg oral capsule 500 mg = 1 Capsule, Orally, TID aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily Ativan 0.5 mg oral tablet 0.5 mg = 1 Tablet, PRN, Orally, TID carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID cholestyramine 4 g/5 g oral powder for reconstitution 4 GM, Orally, BID cranberry oral tablet doxazosin 2 mg oral tablet 2 mg = 1 Tablet, Orally, BID Estrace Vaginal Cream 0.1 mg/gm 1 GM, Vaginally, 2x/WK, Apply pea sized amount to outside vaginal area nightly before bed x 2 weeks then 2x/week thereafter. levothyroxine 50 mCg (0.05 mg) oral tablet 75 mCg = 1.5 Tablet, Orally, Daily Lexapro 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily Misc Med , D-Mannose1 pill BIDOTC Nexium 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily predniSONE 10 mg oral tablet See Instructions, 5 tab orally today, then 4 tab x 3 days, then 3 tab x 3 days, then 2 tab x 3 days, then 1 tab x 3 days ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H Sarna 0.5%-0.5% topical lotion See Instructions, PRN, Topical TID spironolactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID Systane Ultra preserved ophthalmic solution 1 Drop Tessalon Perles 100 mg oral capsule 100 mg = 1 Capsule, Orally, TID Vitamin C 1,000 mg, Orally, Daily Vitamin D3 (cholecalciferol) , Orally Voltaren Topical 1% topical gel 2 GM, Topical, 4 Times Daily, Use dosing card to measure dose Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q6H Active Scheduled Inpatient Medications None Reported One-Time Medications Given 12/11/22 00:00:00 TO 12/12/22 05:10:16 benzonatate (Tessalon Perles), Capsule, 200 mg, Orally, ONCE, (1 DOSE 12/12/22 01:25:00) ceftRIAXone, Injection, 2 GM, IVPB, ONCE, (1 DOSE 12/11/22 21:07:00) doxycycline, Injection, 100 mg, IVPB, ONCE, (1 DOSE 12/11/22 21:55:00) guaiFENesin (Mucinex 600 mg oral tablet, extended release), Tab, Extended Rel, 600 mg, Orally, ONCE, (1 DOSE 12/12/22 01:40:00) hydroCODONE-acetaminophen (hydroCODONE-acetaminophen 5 mg-325 mg oral tablet), Tablet, 1 Tablet, Orally, ONCE, (1 DOSE 12/11/22 22:19:00) PRN Medications (0600 - 0559) from 12/11 - 12/12 None Reported Allergies Dyazide (Unknown) Sular (Flushing) Yellow Dye (Sores in mouth, Unknown) Zocor (Unknown) sulfa drugs (Rash) Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Home/Environment Widow- 3 children, Lives with Alone. Substance Abuse Denies Tobacco Tobacco Use: Never (less than 100 in lifetime). Family History Congestive heart failure..: Father. Diabetes mellitus type 2: Grandmother. Diabetes...: Brother. Emphysema: Father. Heart disease..: Father. Hypertension..: Mother. Osteoarthritis: Mother. Uterine cancer: Mother. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 6.3 k/cumm (12/11/22 20:18:00) RBC: 3.42 million/cumm Low (12/11/22 20:18:00) Hgb: 11 GM/dL Low (12/11/22 20:18:00) Hct: 32.7 % Low (12/11/22 20:18:00) MCV: 96 fL (12/11/22 20:18:00) MCH: 32.1 pg (12/11/22 20:18:00) MCHC: 33.5 GM/dL (12/11/22 20:18:00) RDW: 12.8 % (12/11/22 20:18:00) Platelet: 250 k/cumm (12/11/22 20:18:00) MPV: 7.8 fL (12/11/22 20:18:00) Neutrophils %: 83 % (12/11/22 20:18:00) Lymphocytes %: 7 % (12/11/22 20:18:00) Monocytes %: 10 % (12/11/22 20:18:00) Eosinophils %: 0 % (12/11/22 20:18:00) Basophils %: 0 % (12/11/22 20:18:00) Absolute Neutrophil: 5.2 k/cumm (12/11/22 20:18:00) Absolute Lymphocyte: 0.4 k/cumm Low (12/11/22 20:18:00) Absolute Monocyte: 0.6 k/cumm (12/11/22 20:18:00) Absolute Eosinophil: 0 k/cumm (12/11/22 20:18:00) Absolute Basophil: 0 k/cumm (12/11/22 20:18:00) Chemistry: Sodium SerPl QN: 140 mmol/L (12/11/22 20:18:00) Potassium SerPl QN: 3.9 mmol/L (12/11/22 20:18:00) Chloride SerPl QN: 103 mmol/L (12/11/22 20:18:00) Carbon Dioxide SerPl QN: 26 mmol/L (12/11/22 20:18:00) Anion Gap: 11 mmol/L (12/11/22 20:18:00) BUN SerPl QN: 17 mg/dL (12/11/22 20:18:00) Creatinine SerPl QN: 1.14 mg/dL (12/11/22 20:18:00) Estimated GFR (CKD-EPI, no race): 46 mL/min/1.73m2 Low (12/11/22 20:18:00) Estimated CRCL (CG): 35 mL/min Low (12/11/22 20:18:00) Glucose SerPl QN: 129 mg/dL High (12/11/22 20:18:00) Calcium Total SerPl QN: 8.8 mg/dL (12/11/22 20:18:00) Alkaline Phos SerPl QN: 48 Units/L (12/11/22 20:18:00) ALT SerPl QN: 14 Units/L (12/11/22 20:18:00) AST SerPl QN: 17 Units/L (12/11/22 20:18:00) Bilirubin Total SerPl QN: 0.3 mg/dL (12/11/22 20:18:00) Total Protein SerPl QN: 6.2 GM/dL Low (12/11/22 20:18:00) Albumin SerPl QN: 3.7 GM/dL (12/11/22 20:18:00) Troponin-I High Sensitivity: 18 ng/L High (12/11/22 22:31:00) BNP Pl QN: 125 pg/mL High (12/11/22 20:18:00) Lactate Venous Pl QN: 1.3 mmol/L (12/11/22 20:18:00) Blood Gas Comment: venous (12/11/22 22:31:00) pH Bld Venous QN: 7.35 (12/11/22 22:31:00) PCO2 Bld Venous QN: 47 mmHg (12/11/22 22:31:00) PO2 Bld Venous QN: 46 mmHg High (12/11/22 22:31:00) Base Excess Bld Venous: 0 mmol/L (12/11/22 22:31:00) Bicarb Bld Venous Calc: 26 mmol/L (12/11/22 22:31:00) O2 Sat Bld Venous Calc: 79 % (12/11/22 22:31:00) Patient Temperature: 37 DegC (12/11/22 22:31:00) Urine Studies: Color: Yellow (12/11/22 22:17:00) Clarity: Clear (12/11/22 22:17:00) Specific Gravity: <=1.005 (12/11/22 22:17:00) pH: 6.5 (12/11/22 22:17:00) Protein: NEGATIVE (12/11/22 22:17:00) Glucose: NEGATIVE (12/11/22 22:17:00) Ketones: NEGATIVE (12/11/22 22:17:00) Bilirubin: NEGATIVE (12/11/22 22:17:00) Hgb Ur: NEGATIVE (12/11/22 22:17:00) Nitrite: NEGATIVE (12/11/22 22:17:00) Urobilinogen: NormalUro (12/11/22 22:17:00) Leukocyte Esterase Ur: NEGATIVE (12/11/22 22:17:00) All Other Labs: COVID 19 Specimen Source: Nasopharyngeal (12/11/22 20:18:00) Coronavirus SARS-CoV2 Rapid: Detected Abnormal (12/11/22 20:18:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (12/11/22 20:18:00) Rapid Influenza A PCR: Not Detected (12/11/22 20:18:00) Rapid Influenza B PCR: Not Detected (12/11/22 20:18:00) Coronavirus SARS Ag FIA, POC: Negat (12/06/22 11:50:00) Diagnostics Radiology Results - Last 24 hours Across Visits 12/11/2022 20:04 - XR Chest PA or AP IMPRESSION:Focal right basilar airspace disease concerning for pneumoniaThank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Cardiothoracic Reading Room. For after-hours or emergency department cases, pleasecall. Signature Line Electronically Signed on 12/12/22 05:10 ________________________________________________________ DO
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- Molecular Diagnostic Tests COVID 19 Specimen Source Nasopharyngeal Coronavirus SARS-CoV2 Rapid * (A) Detected Microbiology Studies - Bacterial Blood CX NEG In Progress; NEG In Progress Resp CX + Stn NEG In Progress Bacterial L pneumo Urine Ag QL Not Detected L pneumo Urine Ag QL Interp L pneumo Urine Ag QL Interp Strep pneumo Ag Ur Not Detected Strep pneumo Ag Ur Interp Negative Viral FS Rapid Influenza Method PCR - Liat Rapid Influenza A PCR * Not Detected Rapid Influenza B PCR * Not Detected
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