Found 2,937 cases where Vaccine is COVID19 and FLU4

Administered by: Private       Purchased by: ?
Symptoms: Upper gastrointestinal haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal haemorrhage (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Acute upper gastrointestinal bleeding. ED visit to hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient should have received COVID19 PFIZER UPDATED BOOSTER 12+(BIVALENT) and received COVID19 (PRIZER AGE 12+) GRAY CAP.

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient should have received COVID19 PFIZER UPDATED BOOSTER 12+(BIVALENT) and received COVID19 (PRIZER AGE 12+) GRAY CAP.

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient should have received COVID19 PFIZER UPDATED BOOSTER 12+(BIVALENT) and received COVID19 (PRIZER AGE 12+) GRAY CAP.

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient should have received COVID19 PFIZER UPDATED BOOSTER 12+(BIVALENT) and received COVID19 (PRIZER AGE 12+) GRAY CAP.

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was expecting to receive COVID19 PFIZER UPDATED BOOSTER 12+, instead received COVID19 (PFIZER AGE 12+) GRAY CAP

Administered by: Unknown       Purchased by: ?
Symptoms: Wrong product administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was expecting to receive COVID19 PFIZER UPDATED BOOSTER 12+, instead received COVID19 (PFIZER AGE 12+) GRAY CAP

Administered by: Unknown       Purchased by: ?
Symptoms: Wrong product administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was expecting to receive COVID19 PFIZER UPDATED BOOSTER 12+, instead received COVID19 (PFIZER AGE 12+) GRAY CAP

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was expecting to receive COVID19 PFIZER UPDATED BOOSTER 12+, instead received COVID19 (PFIZER AGE 12+) GRAY CAP

Administered by: Pharmacy       Purchased by: ?
Symptoms: Rib fracture
SMQs:, Accidents and injuries (narrow), Osteoporosis/osteopenia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Closed fracture of multiple ribs of right side. ED visit to hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Cellulitis
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cellulitis. ED visit to hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: Chest X-ray, Pain in extremity, Tuberculin test
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: CORTISONE [CORTISONE ACETATE]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Welts (Twenty-five or thirty years ago she had a TB test with ppd. After that test, her entire arm "blew up" instantly with a giant welt).
Allergies:
Diagnostic Lab Data: Test Name: chest x ray; Test Result: Negative ; Test Name: PPD; Result Unstructured Data: test was contaminated with something
CDC Split Type: USMODERNATX, INC.MOD20226

Write-up: little soreness in her arm; This spontaneous case was reported by a consumer and describes the occurrence of PAIN IN EXTREMITY (little soreness in her arm) in a 64-year-old female patient who received mRNA-1273 BIVALENT .222 (MODERNA COVID-19 VACCINE, BIVALENT (ORIGINAL AND OMICRON BA.4/BA.5)) for COVID-19 prophylaxis. Co-suspect products included non-company products VARICELLA ZOSTER VACCINE RGE (CHO) (SHINGRIX) for an unknown indication and INFLUENZA VACCINE INACT SPLIT 4V (FLUZONE HIGH DOSE QUADRIVALENT) for an unknown indication. The patient''s past medical history included Welts (Twenty-flve or thirty years ago she had a TB test with ppd. After that test, her entire arm "blew up" instantly with a giant welt.). Previously administered products included for Drug use for unknown indication: Flu Shots, TD and Typhoid. Past adverse reactions to the above products included No adverse event with TD and Typhoid; and Pain in extremity with Flu Shots. Concomitant products included CORTISONE ACETATE (CORTISONE [CORTISONE ACETATE]) for an unknown indication. On 09-Sep-2022, the patient received dose of INFLUENZA VACCINE INACT SPLIT 4V (FLUZONE HIGH DOSE QUADRIVALENT) (unknown route) at an unspecified dose. On an unknown date, the patient received dose of mRNA-1273 BIVALENT .222 (MODERNA COVID-19 VACCINE, BIVALENT (ORIGINAL AND OMICRON BA.4/BA.5)) (unknown route) 1 dosage form and dose of VARICELLA ZOSTER VACCINE RGE (CHO) (SHINGRIX) (unknown route) at an unspecified dose. On an unknown date, the patient experienced PAIN IN EXTREMITY (little soreness in her arm). At the time of the report, PAIN IN EXTREMITY (little soreness in her arm) was resolving. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Chest X-ray: Negative. On an unknown date, Tuberculin test: test was contaminated with something. Patient dermatologist gave her a shot Of cortisone and she took antihistamines. Both her dermatologist and internist were not sure if the Fluzone HD could be the cause, especially with the 4-day delay Of onset, however the patient could not think of anything else that she might had been exposed to that would have caused the hives. When the hives began, they started in the armpit of her right arm at that same level as the injection site. She discussed her previous experience with other vaccines as to how it was so unusual for her to had hives after Fluzone HD QIV. She received Moderna Covid vaccines. The bivalent Covid booster a week ago caused her to have a little soreness in her arm. All of the other Covid boosters did not cause problems for her. She has taken vaccines against pneumonia without problems. Twenty-five or thirty years ago she had a TB test with ppd. After that test, her entire arm blewed up instantly with a giant welt. She was told at first that she had T B. A follow-up chest x-ray was negative. It was realized that she did not have TB and that instead something was wrong with that test. She later had subsequent ppd tests without reactions. No treatment medications were provided. This case was linked to MOD-2022-679659 (Patient Link).

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive for COVID-19.

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive for COVID-19.

Administered by: Unknown       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Anaemia, Anion gap, Anticoagulant therapy, Aspartate aminotransferase normal, Asthenia, Bacterial test, Base excess, Basophil count decreased, Basophil percentage decreased, Bilirubin urine, Blood albumin normal, Blood alkaline phosphatase normal, Blood bicarbonate, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood culture negative, Blood gases, Blood glucose normal, Blood lactic acid normal, Blood pH normal, Blood potassium normal, Blood sodium normal, Blood urea normal, Brain natriuretic peptide increased, Breath sounds abnormal, Bronchitis, COVID-19, Carbon dioxide normal, Chest X-ray abnormal, Chromaturia, Coma scale, Creatinine renal clearance, Culture positive, Dyspnoea, Dyspnoea exertional, Eosinophil count decreased, Eosinophil percentage decreased, Fatigue, Glomerular filtration rate decreased, Glucose urine absent, Haematocrit decreased, Haemoglobin decreased, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Lung infiltration, Lymphocyte count decreased, Lymphocyte percentage decreased, Malaise, Mean cell haemoglobin concentration increased, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume normal, Microbiology test, Monocyte count normal, Monocyte percentage decreased, Neutrophil count normal, Neutrophil percentage increased, Nitrite urine absent, PCO2 normal, Platelet count normal, Pneumonia, Productive cough, Protein total decreased, Protein urine absent, Pyrexia, Rales, Red blood cell count decreased, Red cell distribution width normal, Rhonchi, SARS-CoV-2 test positive, Streptococcus test negative, Troponin I, Urine analysis, Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine, Viral test, White blood cell count normal, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 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
CDC Split Type:

Write-up: 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

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive COVID-19

Administered by: Private       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Refill for Epi Pen. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive COVID-19

Administered by: Unknown       Purchased by: ?
Symptoms: Dizziness, Nausea
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USSA2022SA516805

Write-up: dizziness; lightheaded; nausea; nauseated; Initial information received on 19-Dec-2022 regarding an non-serious case received from via consumer/non-hcp. This case involves a 26 years old male patient who was diagnosed with dizziness; lightheaded and nausea; nauseated after receiving influenza quadrival a-b high dose hv vaccine [Fluzone High-Dose Quadrivalent] and vaccines covid-19 vaccine. The patient''s past medical history, medical treatment(s), vaccination(s) and family history were not provided. On 21-Nov-2022, the patient received a dose suspect influenza quadrival a-b high dose hv vaccine at dose 1 (batch number: UT7701MA) (strength, frequency, formulation, expiry date: unknown) via intramuscular route in the right arm for Influenza immunization. On 21-Nov-2022, the patient received suspect covid-19 vaccine produced by unknown manufacturer at dose 2 in injection form (batch number: 4302MF023) (strength, expiry date: unknown) via intramuscular route in the left arm for COVID-19 immunisation On 21-NOV-2022 the patient diagnosed with a non-serious events of dizziness; lightheaded (dizziness), nausea; nauseated (nausea) (same day latency) following the administration of influenza quadrival a-b high dose hv vaccine and following the administration of covid-19 vaccine. Action taken was not applicable for both suspects. It was not reported if the patient received a corrective treatment for both the events. At time of reporting, the outcome was Unknown for both events.

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive COVID-19

Administered by: Unknown       Purchased by: ?
Symptoms: SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive COVID-19

Administered by: Pharmacy       Purchased by: ?
Symptoms: Musculoskeletal disorder, Pain in extremity
SMQs:, Rhabdomyolysis/myopathy (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hypertension, type 2 diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient woke up at 3am to use the restroom and her legs and arms would not work. She couldn''t sit or stand. She denies numbness or tingling in her limbs. She called 911 which brought her to the ED. She was given a "pain shot" because her arm hurt, and an injection for her blood pressure and diabetes. She was not treated with anything specifically for the loss of function in her limbs. Arm and leg function returned to normal around 11am.

Administered by: Private       Purchased by: ?
Symptoms: Cardioversion, Gastrointestinal tube insertion, Hypothermia, Hypoxia, Intensive care, Postoperative adhesion, Respiratory arrest, Respiratory distress, Resuscitation, Small intestinal obstruction
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Accidents and injuries (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 12 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Small bowel obstruction due to postoperative adhesions. Patient developed increased respiratory distress after multiple NG tube placement attempts, he then developed hypoxia and respiratory arrest. Patient received 15 minutes of CPR, 4 doses of epinephrine, and 2 doses of bicarbonate, and 1 cardioversion. Patient initially required ICU support along with a hypothermic protocol and 3 pressor support. Patient slowly stabilized and hypothermia reversal began and support was slowly weaned. ED visit and hospital admission within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Gangrene, Osteomyelitis acute, Skin discolouration
SMQs:, Osteonecrosis (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 11 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: ER visit on 11/21 - concerns of a blackened right fifth toe. Biotic ointment and Call your podiatrist or surgeon early next week and consider early amputation before spreading infection does occur. 12/3 - hospital admission gangrene. Procedure - Acute osteomyelitis of right foot. ED visit and hospital admission were within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Anticoagulant therapy, Cardiopulmonary bypass, Coronary artery bypass
SMQs:, Embolic and thrombotic events, arterial (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 11 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Coronary artery bypass grafting x3 - left internal mammary artery grafted to LAD and reverse saphenous vein grafts placed to diagonal and right posterior descending coronary arteries on cardiopulmonary bypass. The patient was discharged on ASA, statin and beta blocker therapy. Plavix was added by CT surgery post-op and should be continued for one year (smaller targets). ED visit and hospital admission within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Catheter placement, Fall, Head injury, Incisional drainage, Oedema, Pain, Pyrexia, Skin abrasion, Swelling face, Tenderness
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fell and had swelling and a large abrasion to the forehead, extending into the scalp. ED visit; Patient given tramadol for pain with a small prescription for this. Hospital admission for history of progressive left vulvar edema tenderness and febrile sensation. Incision and drainage was performed with placement of a Word catheter. She was deemed to have achieved maximal benefit of inpatient therapy on the third postoperative day and discharged to home care on doxycycline. ED visit and hospital admission were separate and both within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Rash pruritic
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: allergic type, itchy rash on full body. treated with dexamethasone and vistaril.

Administered by: Other       Purchased by: ?
Symptoms: Alcohol withdrawal syndrome, Suicidal ideation
SMQs:, Suicide/self-injury (narrow), Psychosis and psychotic disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Patient admitted to the hospital within 30 days of receiving MODERNA COVID-19 vaccine. Patient is admitted for alcohol withdrawal with suicidal ideation.

Administered by: Private       Purchased by: ?
Symptoms: C-reactive protein abnormal, Pneumonia, Pneumonia bacterial, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: ED visit to hospital admission for Community acquired bacterial pneumonia. At the time of admission he was also requiring 4 L supplemental oxygen versus chronic 3 L supplemental oxygen at home to maintain oxygen saturations greater than 90%. On 10/4/2021 WBC remained elevated but stable, CRP continued to trend down, and oxygen requirements returned to baseline 3 L/min. Patient was transition to oral Augmentin and azithromycin, IV steroids were decreased in frequency, and patient continued on scheduled and as needed breathing treatments. He will be discharged on oral azithromycin for 1 additional day to complete a 5-day course, as well as an additional 6 days of oral Augmentin to complete a 7-day course. This visit was within 6 weeks of receivingthe COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Dehydration, Hypophagia, Urinary tract infection
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 23 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: ER admission for dehydration on 10/28/2021. Patient was found to have a urinary tract infection. First dose of nitrofurantoin was given in the emergency department with remaining prescription sent to the pharmacy. ED to hospital admission on 11/9/2021. AKI - resolved with hydration, stable off IV fluids although PO Intake is poor. ER visits and hospital admission within 6 weeks of receiving the COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: Arterial graft, Peripheral artery bypass, Peripheral ischaemia, Vascular stent occlusion
SMQs:, Myocardial infarction (broad), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Acute class IIb right lower extremity ischemia secondary to occluded right superficial to popliteal artery stents s/p right common femoral to above-knee popliteal artery bypass with PTFE. deemed appropriate for discharge after 3 days. Hospital admission within 6 weeks of receiving the COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered, No adverse event
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was given a monovalent pfizer vaccine as a booster. Patient should have been given the bivalent pfizer vaccine. No adverse outcomes. PCP consulted. Patient advised per CDC that repeat dose needed in at least two months.

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive COVID-19

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered, No adverse event
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was given a monovalent pfizer vaccine as a booster. Patient should have been given the bivalent pfizer vaccine as a booster. No adverse outcomes. PCP consulted. Patient advised per CDC that repeat dose needed in at least two months.

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect product formulation administered, No adverse event
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was given a monovalent pfizer vaccine as a booster. Patient should have been given the bivalent pfizer vaccine as a booster. No adverse outcomes. PCP consulted. Patient advised per CDC that repeat dose needed in at least two months.

Administered by: Private       Purchased by: ?
Symptoms: Cervical radiculopathy, Intervertebral disc operation, Pain, Spinal osteoarthritis
SMQs:, Arthritis (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted with cervical spondylosis and cervical radiculopathy failing medical management. Procedure: Anterior discectomy and fusion. At time of Dc tolerating general diet, ambulating safely in corridors, voiding without difficulty, and pain acceptably controlled with oral pain medications. Hospital admission within 6 weeks of receiving the COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: Expired product administered, No adverse event
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Covid19 Pfizer 12 and up was given and was expired on 11-7-22. No reaction.

Administered by: Private       Purchased by: ?
Symptoms: Small intestinal obstruction, Surgery
SMQs:, Gastrointestinal obstruction (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Small bowel obstruction. Acute care surgery. Discharged to home. ED visit to hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure acute, Left ventricular failure
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad), Noninfectious myocarditis/pericarditis (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Acute on chronic systolic heart failure. Patient was diuresed with an improvement in symptoms. She remains rate controlled on BB therapy. ED visit to hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Product storage error
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bupropion XL, Lisinopril-HCTZ, Dulaglutide, fluticasone propionate, metformin, buspirone, montelukast, albuterol
Current Illness: N/A
Preexisting Conditions: Diabetes Type II, Hypertension, Mixed anxiety and depression, PTSD, Asthma, hyperlipidemia
Allergies: Aspirin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Gave pt a Covid booster vaccine that had been opened more than 12Hrs before administration. Vaccine Opened documenation stated 10/05/2022 13:45 Exp- 10/06/2022 1945. My mistake was that i just verified exp date and time and not opened time and date. Did review this information with Pt pcp and he reviewed the vaccine information and information stated vaccine was good refrigirated for 10 weeks room temperature 12 hrs. Unable to find information for vaccine stability once opened. He stated vaccine should be ok. Manager was also notiifed vial was discarded

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain, Headache, Illness, Insomnia, Interchange of vaccine products, Off label use, Product use issue, Pyrexia, SARS-CoV-2 test
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Medication errors (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: Covid-19 test; Test Result: Negative ; Comments: tested for negative for covid
CDC Split Type: USPFIZER INC202201318613

Write-up: she has been sick since then/She has been sick for 6 days; headache; abdominal pain; difficulty in sleeping/could not sleep properly; fever; she received the vaccine last 15Nov2022, and at the same day, she also received the flu vaccine; she received the vaccine last 15Nov2022, and at the same day, she also received the flu vaccine; Interchange of vaccine products; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non-HCP) from medical information team. The reporter is the patient. A 77-year-old female patient received BNT162b2, BNT162b2 omi ba.4-5 (BNT162B2, BNT162B2 OMI BA.4-5), on 15Nov2022 as dose 5 (booster), single (Lot number: GK3724) for covid-19 immunisation; influenza vaccine inact split 4v (FLUZONE HIGH DOSE QUADRIVALENT), on 15Nov2022 as dose number unknown, single (Batch/Lot number: unknown) for immunisation. The patient''s relevant medical history and concomitant medications were not reported. Vaccination history included: Moderna covid vaccine (DOSE 4 (Booster), she received 4 doses of the Moderna covid vaccine), administration date: 13May2022, for Covid-19 Immunization; Moderna covid vaccine (DOSE 3 (Booster), she received 4 doses of the Moderna covid vaccine), for Covid-19 Immunization; Moderna covid vaccine (DOSE 2, she received 4 doses of the Moderna covid vaccine), for Covid-19 Immunization; Moderna covid vaccine (DOSE 1, she received 4 doses of the Moderna covid vaccine), for Covid-19 Immunization. The following information was reported: INTERCHANGE OF VACCINE PRODUCTS (non-serious) with onset 15Nov2022, outcome "unknown"; OFF LABEL USE (non-serious), PRODUCT USE ISSUE (non-serious) all with onset 15Nov2022, outcome "unknown" and all described as "she received the vaccine last 15Nov2022, and at the same day, she also received the flu vaccine"; ILLNESS (non-serious), outcome "unknown", described as "she has been sick since then/She has been sick for 6 days"; HEADACHE (non-serious), outcome "unknown"; ABDOMINAL PAIN (non-serious), outcome "unknown"; INSOMNIA (non-serious), outcome "unknown", described as "difficulty in sleeping/could not sleep properly"; PYREXIA (non-serious), outcome "unknown", described as "fever". The event "she has been sick since then/she has been sick for 6 days" required physician office visit. Relevant laboratory tests and procedures are available in the appropriate section. Additional Information: Patient stated that she received the vaccine last 15Nov2022, and at the same day, also received the flu vaccine. Patient was told by the nurse who administered the vaccines that it was okay to receive them together, while some told her that it should not be given together. Patient added that she has been sick since then. Patient had been sick for 6 days and had visited the urgent care last Saturday where patient was tested for negative for covid. Patient further explained that she had been healthy before getting the mentioned vaccines, but she had been experiencing headache, abdominal pain, difficulty in sleeping/could not sleep properly, and fever. Patient added that she frequently used the bathroom due to the abdominal pain. Patient also mentioned that previously, received 4 doses of the Moderna covid vaccine. Patient was worried that she may die due to these SEs and that her son died from Covid, and she does not want to happen to her as well. Consumer stated, "It was good now you could talk to me, before I cannot talk and did not even get up from bed. I just eat my lunch. No follow-up attempts are possible. No further information is expected.

Administered by: Private       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Multivitamin daily
Current Illness: None
Preexisting Conditions: None
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Given 0.3 ml of Pfizer Covid vaccine at 8 years old .

Administered by: Pharmacy       Purchased by: ?
Symptoms: Nodal arrhythmia
SMQs:, Disorders of sinus node function (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Junctional bradycardia. ED visit and hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Chronic obstructive pulmonary disease
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 12 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: COPD, moderate. ED visit to hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Pharmacy       Purchased by: ?
Symptoms: Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Syncope and collapse. ED visit and hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Colon cancer metastatic, Metastases to liver
SMQs:, Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 14 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Metastatic colon cancer spread to liver. ED visit and hospital admission. This visit was within 6 weeks of receiving the COVID-19 vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Underdose
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna yellow cap 0.2mL/10ug given instead of higher dose of Moderna bivalent 0.25vmL/25ug

Administered by: Unknown       Purchased by: ?
Symptoms: Anion gap, Base excess, Basophil count decreased, Basophil percentage decreased, Blood bicarbonate increased, Blood calcium decreased, Blood chloride decreased, Blood creatinine normal, Blood gases abnormal, Blood glucose normal, Blood lactic acid normal, Blood pH increased, Blood potassium decreased, Blood sodium decreased, Blood urea normal, Brain natriuretic peptide normal, Carbon dioxide normal, Chest X-ray abnormal, Chronic obstructive pulmonary disease, Computerised tomogram thorax abnormal, Condition aggravated, Creatinine renal clearance normal, Culture, Differential white blood cell count, Dyspnoea, Eosinophil count normal, Eosinophil percentage, Fraction of inspired oxygen, Full blood count, Gastrooesophageal reflux disease, Glomerular filtration rate normal, Haematocrit decreased, Haematology test abnormal, Haemoglobin decreased, Heart rate increased, Hypoxia, Laboratory test, Laboratory test abnormal, Lung disorder, Lymphocyte count, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Metabolic function test, Monocyte count, Monocyte percentage, Neutrophil count increased, Neutrophil percentage increased, Oxygen saturation decreased, PCO2 normal, PO2 normal, Platelet count normal, Pneumonia, Procalcitonin, Productive cough, Pyrexia, Rales, Red blood cell count decreased, Red cell distribution width normal, Renal function test normal, SARS-CoV-2 test negative, Sepsis, Staphylococcus test, Streptococcus test, Troponin, Troponin I, Wheezing, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific dysfunction (narrow), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Document Type: History and Physical Document Subject: History & Physical Note Performed By: NP on May 29, 2023 17:25 Verified By: NP on May 29, 2023 17:25 Encounter Info: Inpatient, 05/29/23 - * Final Report * Document Has Been Revised And Contains Addenda History of Present Illness/Subjective 59 year old female w/ a hx of COPD on 2L O2 at baseline presents to the ED via private vehicle for evaluation of worsening SOA, fever, and productive cough over the last 24 hours. Pt was admitted on 5/6/2023 hospital for sepsis, COPD, and pneumonia. She explains that her current systems feel worse than then, and she has had to raise her O2 to 4L last night. Pt had a CT performed on 5/25/2023 which shows evidence of pneumonia, and she was informed of this. Denies vomiting or diarrhea. Denies hx of tobacco use. Upon ER evaluation her room air sat dropped below 88% and he was requiring up to 5 L per nasal cannula. Temperature was 37.4, heart rate was elevated at 118 respiratory rate was 20 and blood pressure was initially 105/73. Lab work obtained white blood cell count was elevated at 12.2, hemoglobin was 10.7, sodium was 135, potassium was 3.3, renal function was at her baseline with GFR greater than 90, glucose was 97, troponin was 27 BN P was 56, lactate was 1.2, VBG obtained with a pH of 7.48 and PCO2 was 40, COVID testing was negative. CXR showed Worsening multifocal airspace disease, likely infectious. Due to failure to improve with outpatient treatment for pneumonia patient will be brought in for further evaluation and management of pneumonia, sepsis. 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 Hemodynamics Neurologic Patient Weight Patient Height None Reported Constitutional: No acute distress, well-nourished Eyes: PEERL, EOMI, normal conjunctiva, no scleral icterus ENMT: Moist oral mucosa Neck: Supple, non-tender, intact range of motion Respiratory: Lungs crackles and exp wheezing 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 Assessment/Plan 1. Sepsis A41.9 Sepsis order set in place ? Due to pneumonia failed outpatient treatment ? We will start vancomycin pharmacy dosing, cefepime and doxycycline ? Pending labs respiratory culture, procalcitonin, strep and MRSA PCR ? De-escalate antibiotic therapy as warranted as labs return 2. Pneumonia J18.9 Requiring oxygen at this time at increased flow within baseline. ? Chronic O2 use of 2 to 4 L at home, now on 5l nc ? RT protocol ? See plan above -CXR 5/29 Worsening multifocal airspace disease, likely infectious. 3. Hypoxia R09.02 Continue O2 as needed 4. Failure of outpatient treatment Z78.9 Meets inpatient criteria 5. GERD (gastroesophageal reflux disease) K21.9 Resume PPI 6. SOB (shortness of breath) R06.02 As above pneumonia plus?minus COPD exacerbation 7. Hypokalemia E87.6 replacement protocol Chronic back pain M54.9 Resume home meds COPD exacerbation J44.1 RT protocol continue Breo, Mucinex, doxycycline and IV steroids -Pt does not smoke , no hx of smoking, no work place exposures -Pt is a RT Hypertension I10 resume home meds Sleep apnea G47.30 RT routine evaluation and protocol -pt wears cpap at 8 ???????Patient is a full code ? DVT''s prophylaxis with Lovenox Orders: acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 05/29/23 17:25:00 albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, PRN, Shortness of Breath/Wheezing, 05/29/23 17:24:00 RT Care Assessment and Protocol per Policy albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, 05/29/23 19:00:00 RT Care Assessment and Protocol per Policy calcium carbonate, 750 mg, Orally, Tab, Chewable, 4 Times Daily, PRN, Indigestion, 05/29/23 17:25:00 cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 05/29/23 18:00:00 for 5 Days, 06/03/23 10:00:00 EDT, Total Volume (mL) = 50 docusate-senna, 2 Tablet, Orally, Tablet, BID, 05/29/23 21:00:00 doxycycline, 100 mg, Orally, Capsule, BID, Indication: COPD Exacerbation, 05/29/23 22:00:00 for 5 Days, 06/03/23 10:00:00 enoxaparin, 40 mg, Subcutaneous, Injection, Q24H, 05/30/23 6:00:00 guaifenesin, 600 mg, Orally, Tab, Extended Rel, BID, 05/29/23 21:00:00 hydrocodone-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain, Moderate (4-6 out of 10), 05/29/23 17:25:00 labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 05/29/23 17:25:00 magnesium sulfate, 4 GM, IVPB, Injection, Q12H, PRN, Lab (Details Required), 05/29/23 17:26:00 methylPREDNISolone, 40 mg, IV Push, Injection, Q12H, 05/29/23 18:00:00 ocular lubricant, 1 App, Eyes, Both, Ophthalmic OINT, Q4H, PRN, Dry Eyes, 05/29/23 17:25:00 ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 05/29/23 17:25:00 polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 05/29/23 17:25:00 potassium chloride, 30 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00 potassium chloride, 40 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00 potassium phosphate-sodium phosphate, 1 Packet, Orally, Powder, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00 potassium phosphate-sodium phosphate, 1 Packet, Orally, Powder, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00 umeclidinium-vilanterol, 1 Puff, Inhalation, MDI/DPI Inhaler Treatment, Daily, 05/30/23 9:00:00 vancomycin, 1,750 mg, IVPB, Injection, ONCE, Indication: Pneumonia - HAP/VAP, NOW, 05/29/23 17:25:00 EDT, 05/29/23 17:25:00, 250 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 500 Admit to Inpatient CAH 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 CBC w/Differential Collect Specimen Collect Specimen Collect Specimen Comp Metabolic Panel COPD Education per Respiratory Care CPAP Nocturnal CPAP Nocturnal with NAPs DC SIRS Alert and Sepsis Screen Do Not (Specify) Heating Pad Initiate IV Care Protocols As Appropriate Initiate Mobility Protocol Initiate Skin and Wound Care Protocol Level of Care Message to Nursing MRSA PCR Nasal Cannula Notify Provider Notify Provider Notify Provider Notify Provider Peripheral IV Insertion Procalcitonin PT Evaluation and Treatment Regular Diet Resp CX + Stn Resp Evaluation or Assessment Resp Evaluation or Assessment Resuscitation Status Strep pneumoniae Ag Urine Titrate FiO2 to Keep O2 Sat Troponin-I High Sensitivity Vancomycin Pharmacy Dosing Consult Vital Signs Vital Signs Weight Code Status None Recorded Chronic Problem List Anemia B12 deficiency Bariatric surgery status Bilateral shoulder pain Chronic back pain Chronic fatigue COPD exacerbation Depression Encounter for long-term (current) use of medications Failure of outpatient treatment Fibromyalgia GERD (gastroesophageal reflux disease) History of total knee arthroplasty Hypertension Hypoxia IBS (irritable bowel syndrome) Laryngopharyngeal reflux Left knee pain Migraine headache Neuropathy Osteoarthritis of right shoulder Osteoarthritis of shoulders, bilateral Pneumonia Polypharmacy Pre-diabetes Restrictive lung disease Sepsis Sleep apnea SOB (shortness of breath) Total knee replacement status Urinary frequency Vocal cord leukoplakia Vocal cord nodules Wellness examination Procedure/Surgical History nerve block in lower back (03/29/2023) Total knee replacement (11/27/2017) Colonoscopy (2015) EGD (2015) Mammogram (07/07/2014) Cataract Extraction (2012) Hernia repair (2009) Total hysterectomy (1997) Cholecystectomy Laparoscopic (1993) Appendectomy BONE SPUR REMOVAL Carpal tunnel release Laminectomy lap band removal LAP-BAND surgery status left eye Release of trigger finger Scleral buckle procedure Thoracotomy Total replacement of right knee joint TUMOR REMOVED Surgical History Internal 08/31/2018 Retinal Detachment Repair (Left) MD 11/27/2017 Knee Arthroplasty (Left) MD 10/21/2016 Gastric Band Revision Lapscpy MD 01/12/2016 Bronchoscopy Diagnostic w Fluoro MD Medications Home Medications (24) Active Advair Diskus 250 mCg-50 mCg inhalation powder 1 Puff, Inhalation, BID, Refills must be obtained from PCPrinse mouth and throat after use albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Inhalation, Q6H albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, 4 Times Daily amitriptyline 25 mg oral tablet 25 mg = 1 Tablet, Orally, At Bedtime, for migraine prevention busPIRone 10 mg oral tablet 10 mg = 1 Tablet, Orally, BID cycloBENZaprine 10 mg oral tablet 10 mg = 1 Tablet, Orally, TID Cymbalta 60 mg oral delayed release capsule 60 mg = 1 Capsule, Orally, Daily, (do not crush or chew) Ester-C 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, Daily famotidine 20 mg oral tablet 20 mg = 1 Tablet, PRN, Orally, Daily ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, BID gabapentin 300 mg oral capsule 600 mg = 2 Capsule, Orally, TID hydroCHLOROthiazide 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily hyoscyamine 0.375 mg oral tablet, extended release 0.375 mg = 1 Tablet, PRN, Orally, Q12H ibuprofen 200 mg oral tablet 600 mg = 3 Tablet, Orally, TID Imitrex 100 mg oral tablet 100 mg = 1 Tablet, PRN, Orally, ONCE lansoprazole 15 mg oral delayed release capsule 15 mg = 1 Capsule, Orally, At Bedtime loperamide 2 mg oral tablet 2 mg = 1 Tablet, PRN, Orally, Q4H losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily lysine 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, TID Norco 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q4H Os-Cal 500 , Orally Singulair 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily Super B Complex 1 Tablet, Orally, Daily Vitamin D3 10 mCg (400 intl units) oral capsule 10 mCg = 1 Capsule, Orally Active Scheduled Inpatient Medications albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 2.5 mg, Neb Inhal, Q6H, Start: 05/29/23 19:00:00 One-Time Medications Given 05/28/23 00:00:00 TO 05/29/23 17:25:09 None Reported PRN Medications (0600 - 0559) from 05/28 - 05/29 None Reported Allergies Diflucan (severe itching) Stadol NS (Itching) Ventolin HFA (shortness of breath) Topamax (Tingling in extremities) Social History Alcohol Current, Wine, 1-2 times per week, Previous treatment: None. Electronic Cigarette/Vaping E-Cigarette Use Never. Employment/School disability Exercise Exercise duration: 0. Home/Environment MARRIED - two children - disability, Lives with Spouse. Nutrition/Health Diet: Regular. Substance Abuse Denies Tobacco Tobacco Use: Never (less than 100 in lifetime). Family History Alcohol abuse: Aunt. Autoimmune disease..: Mother. Coronary artery disease..: Mother. DM (diabetes mellitus)..: Father. Heart disease..: Father. Hypertension..: Mother. Multiple sclerosis..: Mother and Aunt. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 12.2 k/cumm High (05/29/23 14:27:00) RBC: 3.6 million/cumm Low (05/29/23 14:27:00) Hgb: 10.7 GM/dL Low (05/29/23 14:27:00) Hct: 32.1 % Low (05/29/23 14:27:00) MCV: 89 fL (05/29/23 14:27:00) MCH: 29.7 pg (05/29/23 14:27:00) MCHC: 33.3 GM/dL (05/29/23 14:27:00) RDW: 13.6 % (05/29/23 14:27:00) Platelet: 253 k/cumm (05/29/23 14:27:00) MPV: 8 fL (05/29/23 14:27:00) Neutrophils %: 87 % (05/29/23 14:27:00) Lymphocytes %: 8 % (05/29/23 14:27:00) Monocytes %: 4 % (05/29/23 14:27:00) Eosinophils %: 1 % (05/29/23 14:27:00) Basophils %: 0 % (05/29/23 14:27:00) Absolute Neutrophil: 10.6 k/cumm High (05/29/23 14:27:00) Absolute Lymphocyte: 1 k/cumm (05/29/23 14:27:00) Absolute Monocyte: 0.5 k/cumm (05/29/23 14:27:00) Absolute Eosinophil: 0.1 k/cumm (05/29/23 14:27:00) Absolute Basophil: 0 k/cumm (05/29/23 14:27:00) Chemistry: Sodium SerPl QN: 135 mmol/L (05/29/23 14:27:00) Potassium SerPl QN: 3.3 mmol/L Low (05/29/23 14:27:00) Chloride SerPl QN: 97 mmol/L Low (05/29/23 14:27:00) Carbon Dioxide SerPl QN: 27 mmol/L (05/29/23 14:27:00) Anion Gap: 11 mmol/L (05/29/23 14:27:00) BUN SerPl QN: 12 mg/dL (05/29/23 14:27:00) Creatinine SerPl QN: 0.66 mg/dL (05/29/23 14:27:00) Estimated GFR (CKD-EPI, no race): $g90 (05/29/23 14:27:00) Estimated CRCL (CG): 107 mL/min (05/29/23 14:27:00) Glucose SerPl QN: 97 mg/dL (05/29/23 14:27:00) Calcium Total SerPl QN: 8.6 mg/dL (05/29/23 14:27:00) Troponin-I High Sensitivity: 27 ng/L High (05/29/23 14:27:00) BNP Pl QN: 56 pg/mL (05/29/23 14:27:00) Lactate Venous Pl QN: 1.2 mmol/L (05/29/23 14:27:00) pH Bld Venous QN: 7.48 High (05/29/23 14:27:00) PCO2 Bld Venous QN: 40 mmHg (05/29/23 14:27:00) PO2 Bld Venous QN: 42 mmHg (05/29/23 14:27:00) Base Excess Bld Venous: 6 mmol/L High (05/29/23 14:27:00) Bicarb Bld Venous Calc: 30 mmol/L High (05/29/23 14:27:00) O2 Sat Bld Venous Calc: 82 % (05/29/23 14:27:00) Patient Temperature: 37 DegC (05/29/23 14:27:00) All Other Labs: COVID 19 Specimen Source: Nasal (05/29/23 14:27:00) Coronavirus SARS-CoV2 Rapid: Not Detected (05/29/23 14:27:00) Diagnostics Radiology Results - Last 24 hours Across Visits 05/29/2023 15:16 - XR Chest PA or AP Portable IMPRESSION:Worsening multifocal airspace disease, likely infectious.Thank you for consulting our team of subspecialty radiologists Radiology. Please contact with any questions. Signature Line Electronically Signed on 05/29/23 17:25 ________________________________________________________ NP Electronically Signed on 05/29/23 17:27 ________________________________________________________ NP Addendum by MD on May 29, 2023 17:35:31 (Verified) I saw and evaluated the patient in addition to NP. 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. Constitutional: No acute distress, well-nourished Eyes: no scleral icterus ENMT: Moist oral mucosa Respiratory: Increased WOB Cardiovascular: Regular rate and rhythm Gastrointestinal: non-distended Musculoskeletal: intact ROM Integumentary: no rashes Neurologic: no focal deficits Psychiatric: Cooperative, appropriate mood and affect MD, FACP Signature Line Electronically Signed on 05/29/23 17:35 ________________________________________________________ MD

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain lower, Alanine aminotransferase normal, Ammonia, Anion gap, Aspartate aminotransferase normal, Asthenia, Auscultation, Back pain, Bacterial test positive, Basophil count decreased, Basophil percentage decreased, Bilirubin urine, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin increased, Blood calcium normal, Blood chloride normal, Blood creatine phosphokinase normal, Blood creatinine, Blood creatinine normal, Blood glucose normal, Blood lactic acid normal, Blood potassium normal, Blood sodium normal, Blood urea increased, Brain natriuretic peptide normal, Carbon dioxide decreased, Cerebral atrophy, Chest X-ray normal, Chromaturia, Chronic kidney disease, Coagulation test abnormal, Computerised tomogram abdomen abnormal, Computerised tomogram head abnormal, Condition aggravated, Creatinine renal clearance decreased, Eosinophil count decreased, Eosinophil percentage decreased, Fungal test positive, Gait inability, Gastrooesophageal reflux disease, Glomerular filtration rate normal, Glucose urine, Glycosylated haemoglobin normal, Haemangioma of liver, Haematocrit normal, Haematology test abnormal, Haemoglobin normal, Haemoglobin urine present, Headache, Hepatic steatosis, Hyperlipidaemia, Hypertension, International normalised ratio increased, Laboratory test abnormal, Leukocytosis, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Mesenteric arteriosclerosis, Micturition urgency, Monocyte count increased, Monocyte percentage increased, Muscular weakness, Neck pain, Neutrophil count increased, Neutrophil percentage increased, Nitrite urine absent, Percussion test normal, Platelet count normal, Pollakiuria, Protein total normal, Protein urine, Prothrombin time prolonged, Red blood cell count normal, Red blood cells urine positive, Red cell distribution width increased, SARS-CoV-2 test, Scan with contrast abnormal, Specific gravity urine normal, Troponin I, Urinary sediment present, Urinary tract infection, Urine abnormality, Urine analysis abnormal, Urine ketone body present, Urine leukocyte esterase positive, Urobilinogen urine, White blood cell count increased, White blood cells urine positive, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Liver neoplasms, benign (incl cysts and polyps) (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Liver-related coagulation and bleeding disturbances (narrow), Haemolytic disorders (narrow), Acute pancreatitis (broad), Dyslipidaemia (narrow), Haematopoietic leukopenia (narrow), Peripheral neuropathy (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Dystonia (broad), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Lipodystrophy (broad), Chronic kidney disease (narrow), Arthritis (broad), Tumour lysis syndrome (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Document Type: History and Physical Document Subject: History & Physical Note Performed By: MD on June 05, 2023 21:34 Verified By: MD on June 05, 2023 21:34 Encounter Info: Hospital, Inpatient, 06/05/23 - * Final Report * Document Has Been Revised History of Present Illness/Subjective Chief complaint: Generalized weakness History of present illness: 82-year-old female with past medical history of hypertension, diabetes mellitus, hyperlipidemia presented with generalized weakness. Family is at bedside assisting with history Patient is fairly active for her age, she works in the garden and is very independent of her ADLs. She was doing fine until the last 2 days when she started to have generalized weakness. Initially she had headache and neck pain and then felt very weak and was not able to walk. Today when family came from outside the found her sitting in the chair and was not able to move or use the bathroom. She was wearing a diaper which is very unusual for her. Patient complains of lower abdominal pain, low back pain without any radiation. This is better now She denies shortness of breath or cough. No fever or chills No vomiting or diarrhea She denies dysuria but has some urgency and frequency In the ED, she was given amlodipine 5 mg for uncontrolled hypertension and ceftriaxone Review of Systems Pertinent positives/negatives as noted in HPI. All other systems were reviewed and are negative. Physical Exam/Objective Vitals & Measurements most recent past 24 hours Hemodynamics Neurologic Patient Weight Patient Height None Reported 06/05/23 16:48 (L) 36.1 DegC 75 bpm 15 br/min 97 % 4 (H) 157 mmHg 67 mmHg 97 mmHg 55 kg Stand up General: Alert, in no acute cardiopulmonary distress. Mental Status: Oriented to person, place and time. Normal affect. Head: Normocephalic. Eyes: Pupils are equal, round and reactive to light. Extraocular muscles intact. Throat: Oropharynx clear, mucous membranes moist. Neck: Supple, Full range of motion. Respiratory: Clear to auscultation and percussion. No wheezing, rales or rhonchi. Cardiovascular: Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops. Gastrointestinal: Abdomen soft, non-tender, non-distended. Normal bowel sounds. No pulsatile mass. No hepatosplenomegaly. Genitourinary: No costovertebral angle tenderness. Neurologic: Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Flexor plantar response. Moves all extremities spontaneously. Sensation intact bilaterally. Skin: No rashes or lesions. No petechiae or purpura. No edema. Musculoskeletal: No cyanosis or clubbing. No gross deformities. Normal range of motion. Assessment/Plan 82-year-old female with past medical history of hypertension, diabetes mellitus, hyperlipidemia presented with generalized weakness 1. Generalized weakness R53.1 PT/OT -Likely from UTI -Check TSH and B12 -COVID-19 is pending -CT head showed generalized cerebral atrophy without acute intracranial abnormality ? Chest x-ray showed no acute findings ? CT abdomen/pelvis showed no acute findings, liver hemangiomas, proximal SMA atherosclerotic narrowing, mild fatty liver -Her weakness is more in the lower legs but she does not have any weakness in the upper extremities or facial droop/dysphagia or dysarthria. We will hold off on MRI of the brain. She denies having any trauma to her back. Denies any fall 2. Acute UTI N39.0 UA showed WBC of 21-50 and moderate leukocyte esterase -Continue ceftriaxone and follow urine cultures 3. Leukocytosis D72.829 Leukocytosis with WBC of 12.6. Patient does not have sepsis. No tachycardia or tachypnea -Chest x-ray and CT abdomen/pelvis showed no acute issues 4. Chronic kidney disease (CKD) N18.9 stage 3. Baseline creatinine is less than 1. Monitor 5. Diabetes mellitus E11.9 Hold metformin due to recent contrast exposure and start on low sliding scale insulin. Her A1c''s have been less than 7 6. Gastroesophageal reflux disease K21.9 Awaiting reconciliation. Plan to continue Protonix 7. Hypertension I10 On hydralazine as needed. She received amlodipine 5 mg in ED 8. Liver hemangioma D18.03 Noted and stable from previous CT scans 9. Hyperlipidemia E78.5 On statin 10. On deep vein thrombosis (DVT) prophylaxis Z79.899 On Lovenox Orders: Status Order Acknowledgement Code Status None Recorded Chronic Problem List Anxiety Atrophic vaginitis B12 deficiency Chronic kidney disease (CKD) Cognitive decline Dementia Diabetes mellitus Encounter for vitamin deficiency screening Encounter for vitamin deficiency screening Foot pain, left Gastroesophageal reflux disease Hypertension Hypokalemia Insomnia Liver hemangioma Long term use of drug Annual wellness visit, subsequent Pain of left lower leg Procedure/Surgical History ?Diabetic retinal eye exam (11/22/2021) ?colonoscopy (10/12/2016) ?CT of abdomen and pelvis (10/19/2015) ?Appendectomy ?Cesarean section ?Cystocele ?Hysterectomy Surgical History Internal 10/12/2016 Colonscpy Diagnostic/Screen MD Medications Home Medications (12) Active amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID Blood Glucose Test Strips See Instructions, Test Blood Sugar once a day Dx: DM E11.9 Claritin 10 mg oral tablet 10 mg, Orally, Daily lancets See Instructions, use to test blood sugar once daily.Dx: E11.9 Lancets See Instructions, use to check blood sugar once dailywhat brand ins covers dx E11.9 Melatonin 10 mg, Orally, At Bedtime metFORMIN 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID multivitamin , Orally, Daily pravastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily Strips - Glucose Test See Instructions, use to check blood sugar once daily dx: E11.9 Systane Ultra Preservative Free 1 Drop, Eyes, Both, BID Active Scheduled Inpatient Medications None Reported One-Time Medications Given 06/04/23 00:00:00 TO 06/05/23 21:32:05 None Reported PRN Medications (0600 - 0559) from 06/04 - 06/05 None Reported Allergies Centrum Silver (unknown) Fish (unknown) Premarin (unknown) Tagamet (unknown) aspirin (unknown) penicillins (unknown) terfenadine derivatives (unknown) Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Substance Abuse Denies Tobacco Tobacco Use: Never (less than 100 in lifetime). Family History Asthma: Mother. Depression: Sister. Diabetes...: Father. Heart disease..: Grandmother (M). Hypertension..: Father. Stroke: Grandmother (M). Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 12.6 k/cumm High (06/05/23 18:04:00) RBC: 4.75 million/cumm (06/05/23 18:04:00) Hgb: 13.4 GM/dL (06/05/23 18:04:00) Hct: 40.7 % (06/05/23 18:04:00) MCV: 86 fL (06/05/23 18:04:00) MCH: 28.3 pg (06/05/23 18:04:00) MCHC: 33 GM/dL (06/05/23 18:04:00) RDW: 14.6 % High (06/05/23 18:04:00) Platelet: 395 k/cumm (06/05/23 18:04:00) MPV: 7.6 fL (06/05/23 18:04:00) Neutrophils %: 83 % (06/05/23 18:04:00) Lymphocytes %: 8 % (06/05/23 18:04:00) Monocytes %: 10 % (06/05/23 18:04:00) Eosinophils %: 0 % (06/05/23 18:04:00) Basophils %: 0 % (06/05/23 18:04:00) Absolute Neutrophil: 10.4 k/cumm High (06/05/23 18:04:00) Absolute Lymphocyte: 0.9 k/cumm Low (06/05/23 18:04:00) Absolute Monocyte: 1.2 k/cumm (06/05/23 18:04:00) Absolute Eosinophil: 0 k/cumm (06/05/23 18:04:00) Absolute Basophil: 0 k/cumm (06/05/23 18:04:00) Chemistry: Sodium SerPl QN: 138 mmol/L (06/05/23 18:04:00) Potassium SerPl QN: 3.6 mmol/L (06/05/23 18:04:00) Chloride SerPl QN: 101 mmol/L (06/05/23 18:04:00) Carbon Dioxide SerPl QN: 22 mmol/L (06/05/23 18:04:00) Anion Gap: 15 mmol/L High (06/05/23 18:04:00) BUN SerPl QN: 30 mg/dL High (06/05/23 18:04:00) Creatinine SerPl QN: 0.92 mg/dL (06/05/23 18:04:00) Estimated GFR (CKD-EPI, no race): 62 mL/min/1.73m2 (06/05/23 18:04:00) Estimated CRCL (CG): 41 mL/min Low (06/05/23 18:04:00) Glucose SerPl QN: 169 mg/dL High (06/05/23 18:04:00) Calcium Total SerPl QN: 10.1 mg/dL (06/05/23 18:04:00) Alkaline Phos SerPl QN: 66 Units/L (06/05/23 18:04:00) ALT SerPl QN: 12 Units/L (06/05/23 18:04:00) AST SerPl QN: 15 Units/L (06/05/23 18:04:00) Bilirubin Total SerPl QN: 1.2 mg/dL High (06/05/23 18:04:00) Total Protein SerPl QN: 8.2 GM/dL High (06/05/23 18:04:00) Albumin SerPl QN: 4.4 GM/dL (06/05/23 18:04:00) CK SerPl QN: 124 Units/L (06/05/23 18:04:00) Troponin-I High Sensitivity: 10 ng/L (06/05/23 18:04:00) BNP Pl QN: 67 pg/mL (06/05/23 18:04:00) Ammonia Pl QN: 32 mCmol/L (06/05/23 18:04:00) Lactate Venous Pl QN: 1.4 mmol/L (06/05/23 18:04:00) Coagulation: PT: 13.1 seconds (06/05/23 18:04:00) INR: 1.14 (06/05/23 18:04:00) Urine Studies: Color: Yellow (06/05/23 18:33:00) Clarity: Slightly Cloudy (06/05/23 18:33:00) Specific Gravity: 1.027 (06/05/23 18:33:00) pH: 5.5 (06/05/23 18:33:00) Protein: 200 Abnormal (06/05/23 18:33:00) Glucose: 50 Abnormal (06/05/23 18:33:00) Ketones: 20 Abnormal (06/05/23 18:33:00) Bilirubin: NEGATIVE (06/05/23 18:33:00) Hgb Ur: Small 1+ Abnormal (06/05/23 18:33:00) Nitrite: NEGATIVE (06/05/23 18:33:00) Urobilinogen: Normal (06/05/23 18:33:00) Leukocyte Esterase Ur: Moderate250 Abnormal (06/05/23 18:33:00) WBC: 21-50 Abnormal (06/05/23 18:33:00) RBC: 6-10 Abnormal (06/05/23 18:33:00) Bacteria: TRACE. (06/05/23 18:33:00) Yeast Ur: PRESENT. Abnormal (06/05/23 18:33:00) Squamous Epithelial: Few (06/05/23 18:33:00) Mucous: PRESENT. (06/05/23 18:33:00) Diagnostics Radiology Results - Last 24 hours Across Visits 06/05/2023 18:08 - XR Chest PA or AP Portable IMPRESSION:1. No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions. 06/05/2023 19:58 - CT Abd/Pelvis W/IV Contrast IMPRESSION:1. No acute findings in the abdomen or pelvis.2. Multiple hypoechoic liver lesions are similar to decreased insize from the patient''s prior study and are compatible withhemangiomas.3. Mild to moderate atherosclerotic narrowing of the proximal SMAfor 2.5 cm.4. Mild fatty liver.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions. 06/05/2023 19:58 - CT Head W/o IV Contrast IMPRESSION: 1. Stable generalized cerebral atrophy without CT evidence of acuteintracranial abnormalities.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions. Signature Line Electronically Signed on 06/05/23 21:34 ________________________________________________________ MD Electronically Signed on 06/05/23 23:19 ________________________________________________________ MD Reviewed by MD

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain upper, Alanine aminotransferase increased, Alcohol use, Amylase normal, Anion gap, Aspartate aminotransferase increased, Auscultation, Back pain, Bacterial test negative, Bilirubin conjugated normal, Bilirubin urine, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium normal, Blood chloride decreased, Blood creatinine, Blood glucose normal, Blood potassium normal, Blood sodium normal, Blood urea normal, Carbon dioxide normal, Chest X-ray normal, Chromaturia, Cold sweat, Coma scale, Computerised tomogram abdomen abnormal, Creatinine renal clearance, Glomerular filtration rate, Glucose urine absent, Haematocrit increased, Haematology test, Haemoglobin increased, Haemoglobin urine absent, Hepatic steatosis, Laboratory test, Laboratory test abnormal, Lipase increased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume normal, Nausea, Nitrite urine absent, Pain, Pancreatitis, Platelet count normal, Protein total normal, Protein urine present, Red blood cell count normal, Red blood cells urine, Red cell distribution width normal, Sleep disorder, Specific gravity urine normal, Troponin I, Urinary sediment present, Urine analysis abnormal, Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine, White blood cell count increased, White blood cells urine, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 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): $g90 (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

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Injection site pain, Loss of consciousness, Paraesthesia
SMQs:, Torsade de pointes/QT prolongation (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt said they felt pain in left arm upon needle insertion like it "hit a nerve". She reports that her fingers were tingly but she felt well enough to leave the immunization room. Upon walking to the waiting area, she then felt faint and lowered herself to the ground where her spouse said she lost consciousness for about 5 seconds. She was given a cold pack and cold water and recovered after about 10 minutes.

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Small intestinal obstruction
SMQs:, Gastrointestinal obstruction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: ER - chest pain, ER - small bowel obstruction. Hospital admission. These visits were within 6 weeks of receiving the COVID vaccine.

Administered by: Pharmacy       Purchased by: ?
Symptoms: Loss of consciousness, Road traffic accident, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt reported fainting "blackout" 1.5hrs after vaccination. Pt was driving at the time, resulted in minor car accident. No injuries reported.

Administered by: Private       Purchased by: ?
Symptoms: Dysphagia, Facial paralysis
SMQs:, Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hearing impairment (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lexapro Ferrous sulfate Heparin Lidoderm patch Vit-B-1 Lasix Tylenol Flomax Lipitor
Current Illness:
Preexisting Conditions: ? Aortic atherosclerosis ? Arthritis of knee Prior cortisone injections ? Gastric ulcer 2002 Associated with UGI hemorrhage, syncope; related to NSAID use. ? Insomnia ? Sciatica
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Right facial droop, unable to swallow, steroids given and eyes drops instilled. Patient became better over time.

Administered by: Private       Purchased by: ?
Symptoms: Stomatitis
SMQs:, Severe cutaneous adverse reactions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed an oral mucositis two days after vaccination. Resolved a few days later.

Administered by: Private       Purchased by: ?
Symptoms: Hypoaesthesia, Paraesthesia
SMQs:, Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Numbness and tingling in both hands. ED visit and hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Private       Purchased by: ?
Symptoms: Bipolar I disorder, Mania, Psychotic disorder
SMQs:, Systemic lupus erythematosus (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 40 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Bipolar I disorder, single manic episode, severe, with psychosis. ED visit and hospital admission. This visit was within 6 weeks of receiving COVID vaccine.

Administered by: Unknown       Purchased by: ?
Symptoms: Nausea, Vertigo, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: vertigo, extreme nausea and vomiting

Administered by: Private       Purchased by: ?
Symptoms: Diverticulitis intestinal haemorrhagic
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal haemorrhage (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Diverticular hemorrhage. ED visit and hospital admission. This visit was within 6 weeks of receiving the COVID vaccine.

Administered by: Senior Living       Purchased by: ?
Symptoms: Extra dose administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received 2 doses of seasonal influenza vaccine. One high dose and one standard dose.

Administered by: School       Purchased by: ?
Symptoms: Visual impairment
SMQs:, Anticholinergic syndrome (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: A student complaining that he started having vision problems the night of receiving flu and COVID shots on 9/25/23. He has already been checked out in the ER and by an eye doctor. Outcome unknown.

Administered by: Unknown       Purchased by: ?
Symptoms: Testicular pain
SMQs:, Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: got booster and next day my testicals felt like i got kicked in them. coincidently after initially receiving my 1st and 2nd dose i had a thrombus in my right spermatic cord which led to me having a denervation of the right groin in june. Initially, my doctors chalked up the first incident to coincidence. after talking with my urologist, he had me do 2 weeks of nsaids, with only an increase in pain. now currently on 600mg gabapentin 3x a day with moderate relief. currently continuing to follow with urologist.

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Infection
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Breakthrough COVID

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Positive COVID-19