Détails du rapport Vaer
Âge: 82 ans
Région : Minnesota
- Patient décédé?
- Renseignements sur les vaccins
Nom: COVID19 (COVID19 (PFIZER-BIONTECH))
Type : Coronavirus 2019 vaccine
- Date de réception du rapport
- Date à laquelle le formulaire est complèté
- Date de vaccination
- Date d’apparition
- Nombre de jours (date d’apparition – date de vaccination)
- Description de l’événement indésirable
progress note 02/07/2021 the patient is an 82-year-old woman with complicated past medical history including chronic systolic heart failure (ef 40-45%), history of bilateral ureteral obstruction and bladder outlet obstruction s/p bilateral ureteral stent exchange 12/20/2021, stage i cll taking ibrutinib, history of limited stage renal cancer s/p partial left nephrectomy in 2009, ckd stage iv (baseline creatinine around 1.7), essential hypertension, type 2 diabetes, mild dementia with agitation and behavioral disturbances, gout, neuropathy, and recent positive covid test 1/23/2022 who was admitted to hospitalist medicine service from emergency department 2/3/2022 with mild to moderate covid-19, covid pneumonia. #. covid pneumonia #. moderate covid 19: recovering. the patient tested positive for covid-19 1/23/2022 as a patient was screened due to recent covid exposure. covid symptoms began 1/27/2022 (harsh, nonproductive cough with associated fatigue). portable chest x-ray on admission demonstrating vascular congestion with increased opacification to right lung field concerning for infection. the patient's resting room air spo2 was transiently 89%, but acute hypoxemic respiratory failure not present. procalcitonin 0.04; however white count more elevated and more focal opacity to right perihilar lung field concerning for superimposed bacterial pneumonia. -empiric dexamethasone 6 mg p.o. daily, discontinue 2/7/2022 as patient appears to be recovering -taking apixaban (also for atrial fibrillation - see below) -continuing empiric iv ceftriaxone + oral doxycycline through 2/10/2022 -trending inflammatory markers -as needed antitussives #. acute kidney injury on ckd stage iii-iv: patient's baseline creatinine is 1.7, and the patient's creatinine was 2 on admission. the patient's acute kidney injury most likely prerenal due to dehydration; however, mild cardiorenal syndrome can't be ruled out. cr of 2 might be patient's new baseline. bladder outlet obstruction ruled out. protein/creatine ratio > 9, nephrotic range proteinuria. less likely cardiorenal syndrome (acute chf) but will continue to watch closely. -ginger diuresis w/ iv lasix 2/7/2022 -holding pta oral lasix -trending gfr #. chronic systolic heart failure: acute chf less likely as lung findings thought to be mainly 2/2 viral and bacterial pneumonia. edw 225 lbs, and admission weight 233 lbs. would benefit from fluid de resuscitation since oral held since admission. -20 mg iv lasix every 6 hours x 3 doses -daily weights -strict is and os #. asymptomatic bradycardia: the patient's daughter reported that the patient has had low heart rates for at least 3 weeks. twelve-lead ekg demonstrating atrial fibrillation with slow response perhaps related to sick sinus syndrome. no immediate need for pacemaer -cardiology following, recommendations much appreciated -holding pta metoprolol indefinitely -telemetry #. newly diagnosed atrial fibrillation: 2/3/2022 twelve-lead ekg demonstrating slow atrial fibrillation. the patient does not have a known history of atrial fibrillation. chads2vasc of at least 4. -cardiology following -apixaban 2.5 mg po bid (renally dosed), initiated 2/4/2022 #. hx of bladder outlet obstruction and bilateral ureteral obstruction: s/p bilateral ureteral stent placement 12/20/2021 and patient's daughter was told that patient's left ureteral stent high risk for occluding. 2/4/2022 renal us only demonstrating mild hydronephrosis bilaterally, acute ureteral obstruction and bladder outlet obstruction ruled out. #. gross hematuria: starting 2/7/2022, more red urine observed in foley bag. will re evaluate for uti. gross hematuria most likely exacerbated by taking apixaban. -continue to monitor -consider urology consult #. cll: diagnosed stage i 6/30/2021. patient follows w/ dr. through health center. restarting pta ibrutinib after discussing case w/ dr. igg level wnl, no ivig needed. #. complex lesion to left kidney, incidental finding: was present on previous us 8/21/2020, actually decreased in size. did not discuss findings with patient. #. essential htn: -pta hydralazine and imdur -holding pta metoprolol xl due to bradycardia #. leukocytosis: hx of cll further exacerbated by dexamethasone. -dexamethasone discontinued 2/7/2022 #. dementia w/ agitation and behavioral disturbances: -prn seroquel, prn haldol if not tolerating po #. copd: -pta inhalers #. gout: -pta allopurinol #. depression: -pta cymbalta #. morbid obesity: bmi 44.99
- Données de laboratoire
covid positive home test 1/23/2021
- Liste des symptômes
urine protein/creatinine ratio bradycardia polyuria atrial fibrillation malaise fatigue blood creatinine increased white blood cell count increased leukocytosis cough haematuria dehydration electrocardiogram abnormal hydronephrosis pulmonary congestion chest x-ray abnormal proteinuria covid-19 sars-cov-2 test positive acute kidney injury lung opacity chromaturia heart rate decreased chronic obstructive pulmonary disease blood immunoglobulin g normal pneumonia viral covid-19 pneumonia glomerular filtration rate cardiac telemetry exposure to sars-cov-2 ultrasound kidney abnormal pneumonia bacterial bladder catheterisation procalcitonin ureteral stent insertion inflammatory marker test
- Patient décédé?
- Date de décès
- Anomalie congénitale
- Vaccin administré par :
- Vaccin acheté par :
- Visite d’un patient à l’urgence?
- Patient hospitalisé?
- Séjour à l’hôpital
- Nombre de jours à l’hôpital
- Non spécifié
- Invalidité permanente?
dilaudid [hydromorphone (bulk)], nsaids (non-steroidal anti-inflammatory drug), penicillins, and vicodin [hydrocodone-acetaminophen]
- Maladie actuelle