VAERS 2643532
SANOFI PASTEUR · INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) · Charge uj945ab
- Staat
- -
- Alter
- 58,0
- Geschlecht
- F
- Eingang
- 09.06.2023
- Impfdatum
- 22.11.2022
- Beginn
- 06.06.2023
- Tage bis Beginn
- 196,0
- Dosis
- UNK
- Route/Site
- SYR / -
Symptomtext
Document Type: History and Physical Document Subject: History & Physical Note Performed By: MD on June 06, 2023 13:27 EDT Verified By: MD on June 06, 2023 16:10 EDT Encounter Info: Hospital, Emergency, 06/06/23 - 06/06/23 * Final Report * History of Present Illness/Subjective Chief complaint: Abdominal pain Patient is a 59-year-old female history CAD hypertension hypothyroid smoker complains of upper abdominal pain x3 days, constant, dull, radiates to her back, nothing makes it better or worse. She has tried tylenol and other otc medications without relief. Woken up in the middle of the night w/ cold sweats. Denies chest pain shortness of breath nausea vomiting or dysuria. Denies any surgical abdominal history. States pancreatitis diagnosed a few years ago but was sent home and does not know etiology of her pancreatitis. Still currently drinks alcoholic beverages 2-3 times a week. Upon evluation in ER found to have mild pancreatitis without abscess. Present on CT imaging. 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 Vitals & Measurements most recent past 24 hours T: 36.7 ?C (Oral) BP: 148/100 HR: 96 (Monitored) HR: 97 (Peripheral) RR: 17 SpO2: 95% Oxygen Therapy: Room air WT: 101.20 kg (WFC) Hemodynamics Neurologic Glasgow Coma Score: 15 Patient Weight Current Daily Weight: 101.2 kg 06/06/23 Patient Height Current Height: 172.7 cm 06/06/23 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 Assessment/Plan 1. Pancreatitis K85.90 Patient has pancreatitis on the imaging at the time of presentation to the emergency room. -Keep patient n.p.o. start patient on normal saline 125 mill an hour -Nausea control with Zofran and pain control via Dilaudid and Norco. -Reintroduce diet tomorrow if patient is doing better. -Obtain GI consult if needed. -No need to trend lipase. 2. Upper abdominal pain R10.10 See problem #1 3. Alcohol abuse F10.10 Patient is known to have alcohol use disorder. -Check alcohol levels today and monitor for withdrawal. 4. CAD (coronary artery disease) I25.10 Noted. Resume home medications. Patient is chest pain-free. 5. Hypertension I10 Resume home medications. -Withhold lisinopril due to current pancreatitis. 6. Hypothyroidism E03.9 Resume home medications. Code Status None Recorded Chronic Problem List Affective disorder Alcohol abuse Alcohol intoxication Allergic rhinitis Black stools CAD (coronary artery disease) CAD in native artery Cervicalgia Chronic gastritis Dyslipidemia Dyspnea Hypertension Hypokalemia Hypothyroidism Hypovitaminosis D Left ankle pain Low back pain Lumbosacral Spondylosis without Myelopathy Osteoarthrosis, Unspecified Whether Generalized or Localized, Involving Other Specified Sites Polypharmacy Preventive measure Rheumatoid Arthritis Spinal cord stimulator status Tobacco use Tobacco use Procedure/Surgical History ?Appendectomy ?Ear surgery - rebuilt ear drums ?Hysterectomy ?T & A Surgical History Internal 07/31/2012 Spinal Drug Pump Revise Remove MD 06/29/2009 Spinal Drug Pump Revise Remove MD Medications Home Medications (14) Active albuterol-ipratropium , Neb Inhal aspirin 81 mg, Orally, Daily Combivent 103 mcg-18 mcg/inh inhalation aerosol with adapter 2 Puff, Inhalation, Daily DME Compression Stockings Not Applicable, Other, Unscheduled, Dispense 1 pair of stockings; wear as directed. Above the knee DME Shower Chair Not Applicable, Other, Unscheduled GaviLyte-G With Lemon Flavor Pack oral powder for reconstitution See Instructions, as directed. levothyroxine 25 mCg, Orally, Daily Lipitor 10 mg, Orally, Daily lisinopril 2.5 mg oral tablet , TAKE 1 TABLET BY MOUTH ONCE DAILY Lyrica 75 mg oral capsule 75 mg = 1 Capsule, Orally, TID Nexium 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, BID oxygen 2 liters Prenatal Multivitamins 1 Tablet, Orally, Daily ProAir HFA , PRN, Inhalation Active Scheduled Inpatient Medications None Reported One-Time Medications Given 06/05/23 00:00:00 TO 06/06/23 13:27:48 HYDROmorphone (Dilaudid), Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 06/06/23 10:34:00) HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 1 mg, IV Push, ONCE, (1 DOSE 06/06/23 13:16:00) metoCLOPramide, Injection, 10 mg, IV Push, ONCE, (1 DOSE 06/06/23 12:33:00) ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 06/06/23 09:19:00) ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 06/06/23 11:12:00) Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 06/06/23 12:22:00) PRN Medications (0600 - 0559) from 06/05 - 06/06 None Reported Allergies sulfa drugs Arthrotec (Numbness) Darvocet (Nausea) Effexor ("feels wierd") Keflex (Rash) Neurontin (Nausea) Paxil (Nausea) Topamax (Nausea) Ultram (Nausea) morphine (Hives) sulfADIAZINE (Rash) Social History Alcohol Current, Liquor, 1-2 times per week Electronic Cigarette/Vaping E-Cigarette Use Never. Substance Abuse - Denies Substance Abuse Current, Marijuana Tobacco Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days. Family History Diabetes mellitus: Mother and Sister. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 15 k/cumm High (06/06/23 09:13:00) RBC: 4.99 million/cumm (06/06/23 09:13:00) Hgb: 16.6 GM/dL High (06/06/23 09:13:00) Hct: 48.9 % (06/06/23 09:13:00) MCV: 98 fL (06/06/23 09:13:00) MCH: 33.3 pg (06/06/23 09:13:00) MCHC: 33.9 GM/dL (06/06/23 09:13:00) RDW: 14.4 % (06/06/23 09:13:00) Platelet: 244 k/cumm (06/06/23 09:13:00) MPV: 7.8 fL (06/06/23 09:13:00) Chemistry: Sodium SerPl QN: 137 mmol/L (06/06/23 09:13:00) Potassium SerPl QN: 3.6 mmol/L (06/06/23 09:13:00) Chloride SerPl QN: 97 mmol/L Low (06/06/23 09:13:00) Carbon Dioxide SerPl QN: 30 mmol/L High (06/06/23 09:13:00) Anion Gap: 10 mmol/L (06/06/23 09:13:00) BUN SerPl QN: 18 mg/dL (06/06/23 09:13:00) Creatinine SerPl QN: 0.72 mg/dL (06/06/23 09:13:00) Estimated GFR (CKD-EPI, no race): >90 (06/06/23 09:13:00) Estimated CRCL (CG): 105 mL/min (06/06/23 09:13:00) Glucose SerPl QN: 108 mg/dL High (06/06/23 09:13:00) Calcium Total SerPl QN: 9.1 mg/dL (06/06/23 09:13:00) Alkaline Phos SerPl QN: 70 Units/L (06/06/23 09:13:00) ALT SerPl QN: 78 Units/L High (06/06/23 09:13:00) AST SerPl QN: 66 Units/L High (06/06/23 09:13:00) Bilirubin Direct SerPl QN: 0.1 mg/dL (06/06/23 09:13:00) Bilirubin Total SerPl QN: 0.6 mg/dL (06/06/23 09:13:00) Total Protein SerPl QN: 6.9 GM/dL (06/06/23 09:13:00) Albumin SerPl QN: 4.1 GM/dL (06/06/23 09:13:00) Amylase SerPl QN: 69 Units/L (06/06/23 10:44:00) Lipase SerPl QN: 496 Units/L High (06/06/23 09:13:00) Troponin-I High Sensitivity: 10 ng/L (06/06/23 09:13:00) Urine Studies: Color: Yellow (06/06/23 10:43:00) Clarity: Clear (06/06/23 10:43:00) Specific Gravity: 1.026 (06/06/23 10:43:00) pH: 6.5 (06/06/23 10:43:00) Protein: 10 Abnormal (06/06/23 10:43:00) Glucose: Normal (06/06/23 10:43:00) Ketones: NEGATIVE (06/06/23 10:43:00) Bilirubin: NEGATIVE (06/06/23 10:43:00) Hgb Ur: NEGATIVE (06/06/23 10:43:00) Nitrite: NEGATIVE (06/06/23 10:43:00) Urobilinogen: Normal (06/06/23 10:43:00) Leukocyte Esterase Ur: NEGATIVE (06/06/23 10:43:00) WBC: 0-5 (06/06/23 10:43:00) RBC: 0-2 (06/06/23 10:43:00) Bacteria: NONE (06/06/23 10:43:00) Squamous Epithelial: Few (06/06/23 10:43:00) Diagnostics Radiology Results - Last 24 hours Across Visits 06/06/2023 10:19 - XR Chest PA or AP Portable IMPRESSION:Cervical spine stimulator.No acute findings. 06/06/2023 11:51 - CT Abd/Pelvis W/IV Contrast IMPRESSION: Diffuse hepatic steatosis.Subtle inflammation around the head of the pancreas and descendingportion of the duodenum may represent mild pancreatitis versusduodenitis. Correlate clinically.Status post hysterectomy.Retained spine stimulator electrode. Signature Line Electronically Signed on 06/06/23 16:10 EDT ________________________________________________________ MD
Weitere VAERSDATA-Felder
- Praegender Schweregrund
- Coma scale
- Hospital-Tage
- -
- Labordaten
- -
- Aktuelle Erkrankungen
- -
- Vorgeschichte
- -
- Andere Medikamente
- -
- Allergien
- -
- Vorherige Impfungen
- -