Détails du rapport Vaer
Âge: 65 ans
Région : Kentucky
- Patient décédé?
- Renseignements sur les vaccins
Nom: COVID19 (COVID19 (MODERNA))
Type : Coronavirus 2019 vaccine
Nom: COVID19 (COVID19 (MODERNA))
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
1/26/22-66 yr/o male with no significant past medical history presenting for evaluation of respiratory distress. patient states he has been feeling increasingly unwell for approximately 1 week. he notes increasing dyspnea. associated with a productive cough. he does have sharp pain in the center of his chest. does not radiate. he notes body aches as well. he has been exposed to covid. he is vaccinated for covid. ems reports room air sats in the seventies. improved to the mid eighties on a nonrebreather review of systems constitutional: negative for chills and fever. hent: negative for congestion, ear pain and sore throat. eyes: negative for discharge. respiratory: positive for cough and shortness of breath. neg review of systems, respiratory: positive for cough and shortness of breath. negative for wheezing. cardiovascular: positive for chest pain. negative for palpitations. gastrointestinal: negative for abdominal pain, constipation, nausea and vomiting. endocrine: negative for polydipsia. genitourinary: negative for dysuria and urgency. musculoskeletal: positive for myalgias. negative for back pain and neck pain. skin: negative for rash. neurological: positive for headaches. negative for dizziness, seizures and weakness. hematological: does not bruise/bleed easily. all other systems reviewed and are negative. plan: 1. acute respiratory failure-placed on bipap. admitted to icu. ct of chest noted above. therapeutic lovenox, iv antibiotics and decadron initiated in ed. pending covid test. pulmonary consulted for further evaluation. contact precautions per protocol. 2. elevated troponin-ekg without ischemic changes. continue to monitor on telemetry. 3. hypokalemia-replace per potassium protocol. 4
- Données de laboratoire
1/26/22 covid-19 result detected abnormal, dvt prophylaxis-lovenox. cbc w/diff, collection time: 01/26/22 6:24 am, result value ref range, white blood count 24.36 (h) 4.5 - 11.0 10*3/ul, red blood count 4.77 4.5 - 5.9 10*6/ul, hemoglobin 15.1 13.5 - 17.5 g/dl, hematocrit 42.1 41.0 - 53.0 %, mean corpuscular volume 88.3 80.0 - 100.0 fl. mean corpuscular hemoglobin 31.7 26.0 - 34.0 pg, mean corpuscular hgb conc 35.9 31.0 - 37.0 g/dl, red cell distribution width-cv 12.2 12.0 - 16.8 %, platelet count 195 140 - 440 10*3/ul, mean platelet volume 9.6 8.4 - 12.4 fl, diff type hospital cbc w/autodiff (arb'u), neutrophils % 71.9 45 - 80 %, lymphocyte % 17.7 15 - 50 %, monocyte % 5.1 0 - 15 %, eosinophil% 1.1 0 - 7 %, baso% 0.6 0 - 2 %, nucleated rbc % 0 0 /100 (wbc), neutrophil abs 17.49 (h) 2.0 - 8.8 10*3/ul, lymphocyte-absolute 4.32 0.7 - 5.5 10*3/ul, monocyte absolute 1.25 0.0 - 1.7 10*3/ul, eos-absolute 0.27 0.0 - 0.8 10*3/ul, basophil abs 0.15 0.0 - 0.2 10*3/ul, polychromasia 1+ (a) none seen (arb'u), platelet estimate adequate adequate (arb'u), immature granulocyte% 3.6 (h) 0.0 - 1.0 %, immature granulocyte abs 0.88 (h) 0.00 - 0.10 10*3/ul, comprehensive metabolic panel (cmp), collection time: 01/26/22 6:24 am, result value ref range, sodium 129 (l) 136 - 145 mmol/l, potassium 3.4 (l) 3.5 - 5.1 mmol/l, chloride 89 (l) 98 - 107 mmol/l, carbon dioxide 30 (h) 22 - 29 mmol/l, anion gap 10 5 - 13 (arb'u), glucose 124 (h) 74 - 99 mg/dl, blood urea nitrogen (bun) 9 8 - 26 mg/dl, creatinine-blood 0.63 (l) 0.73 - 1.18 mg/dl, bun/creatinine ratio 14.3 ratio, estimated gfr >60 >60 /1.73 m2, estimated gfr if african-american >60 >60 /1.73 m2, total protein 6.3 6.2 - 8.0 g/dl, albumin 2.8 (l) 3.2 - 4.6 g/dl, globulin 3.5 1.5 - 4.5 g/dl, albumin/globulin ratio 0.8 (l) 1.1 - 2.5 ratio, calcium 8.7 8.4 - 10.2 mg/dl, total bilirubin 1.0 0.2 - 1.2 mg/dl, ast/sgot 49 (h) 5 - 34 u/l, alt/sgpt 25 0 - 55 u/l, alkaline phosphatase 79 40 - 150 u/l, b-type natriuretic peptide, collection time: 01/26/22 6:24 am, result value ref range, b-type natriuretic peptide 57.1 3 - 160 pg/ml, troponin, collection time: 01/26/22 6:24 am, result value ref range, troponin 0.765 (hh) 0.000 - 0.034 ng/ml, magnesium, collection time: 01/26/22 6:24 am, result value ref range, magnesium 1.6 1.6 - 2.6 mg/dl, arterial blood gas, collection time: 01/26/22 6:52 am, result value ref range, allen test positive (arb'u), ph-abg 7.54 (h) 7.35 - 7.45 ph, pco2-abg 37 35 - 48 mm(hg), po2-abg 64 (l) 83 - 108 mm(hg), hco3-abg 32 (h) 18 - 23 mmol/l, tc02-abg 33 (h) 19 - 24 mmol/l, base excess-abg 8.4 (h) 0.0 - 3.0 mmol/l, o2 sat-abg 93.1 (l) 95.0 - 98.0 %, fio2-abg 100.0 20 - 100 %, lactic acid, collection time: 01/26/22 7:04 am, result value ref range, lactic acid 2.3 (h) 0.7 - 2.0 mmol/l, xr chest 1 vw impression: multifocal areas of ground glass and airspace consolidation. the findings are nonspecific but may indicate manifestations of covid 19 pneumonia. ta of chest: 1. multifocal bilateral ground glass infiltrates which could reflect atypical/viral pneumonitis versus multifocal edema. 2. acute thrombus within the left upper lobe apical segmental artery 66-year-old patient who presented with shortness of breath was noted to have acute respiratory failure with hypoxia secondary to covid-19 pneumonia, ct of the chest was consistent also with acute bilateral pulmonary embolisms for which patient was started right away on full dose of anticoagulation. in regard to covid-19 pneumonia he was placed on appropriate treatment he did require to be on air vo for extensive period of time until hopefully over the last 48 hours we were able to titrate his oxygen down and by today and after 6-minute exercise pulse ox he qualified for home o2 however required only 2 l, he finished the course of remdesivir, decadron during his hospital stay. patient was vaccinated however he did not get the booster dose of the vaccine. in regard to patient was initiated on lovenox he will be going on eliquis 5 mg p.o. twice daily i do not believe we need the 7 days of 10 mg p.o. twice daily as the patient has been on full dose of anticoagulation for 11 days so far. duration of anticoagulation to be determined later on by dr. upon upcoming follow-up in the outpatient settings. noted to have elevated troponin which i believe is secondary to old above the findings, echocardiogram was grossly normal, no rv strain. tte procedure: echo doppler 2d mmode spect color complete. start date time: 1/26/2022, blood pressure: 122 / 77 mmhg, clinical indications pulmonary embolus's and shortness of breath. physician conclusions any valve disease noted in the report is non-rheumatic unless otherwise specifically noted. summary: the ejection fraction biplane was calculated at 56%. left ventricle size is normal. borderline left ventricular hypertrophy. overall left ventricular function is normal. mitral valve tissue doppler e/e'' ratio consistent with normal left atrial pressures. the right ventricular chamber size and systolic function are within normal limits. there is a small localized, anteriorly by right ventricle/right atrium, pericardial effusion noted. no evidence of tamponade. mild dilation of the aortic root 3.9 cm. findings left ventricle: the ejection fraction biplane was calculated at 56%. left ventricle size is normal. borderline left ventricular hypertrophy. overall left ventricular function is normal. mitral valve tissue doppler e/e'' ratio consistent with normal left atrial pressures. left atrium: left atrium is of normal size. right ventricle: the right ventricular chamber size and systolic function are within normal limits. right atrium: the right atrial chamber size appears normal. aortic valve: mild aortic leaflet calcification. aortic valve appears to be trileaflet. there is no evidence of aortic stenosis noted. mitral valve: there is no evidence of mitral valve stenosis noted. tricuspid valve: no evidence of tricuspid stenosis. there is inadequate tricuspid insufficiency to calculate accurate right ventricular systolic pressure. pulmonic valve: no evidence of pulmonic stenosis. pericardium: there is a small localized, anteriorly by right ventricle/right atrium, pericardial effusion noted. no evidence of tamponade. aorta/great vessels: mild dilation of the aortic root 3.9 cm. there is no dilatation of the ascending aorta
- Liste des symptômes
fraction of inspired oxygen echocardiogram normal aspartate aminotransferase normal po2 decreased allen's test malaise white blood cell count increased headache chest pain pain productive cough cough hypokalaemia pericardial effusion dyspnoea globulins increased myalgia neutrophil count increased blood chloride decreased chest x-ray abnormal blood creatinine normal respiratory distress blood sodium decreased full blood count blood urea decreased carbon dioxide decreased pulmonary embolism blood albumin decreased blood lactic acid differential white blood cell count blood potassium decreased covid-19 electrocardiogram normal lymphocyte percentage decreased sars-cov-2 test positive monocyte count increased lung opacity platelet count normal lung infiltration echocardiogram granulocyte percentage blood gases computerised tomogram thorax blood calcium decreased metabolic function test troponin increased lung consolidation neutrophil percentage increased blood glucose normal blood urea nitrogen/creatinine ratio mean platelet volume normal monocyte percentage angiogram pulmonary abnormal intensive care blood magnesium normal mean cell haemoglobin concentration normal basophil percentage blood bilirubin normal haemoglobin normal red blood cell nucleated morphology blood bicarbonate increased albumin globulin ratio covid-19 pneumonia brain natriuretic peptide glomerular filtration rate protein total normal carbon dioxide normal eosinophil count alanine aminotransferase normal mean cell volume normal eosinophil percentage anion gap cardiac telemetry exposure to sars-cov-2 blood alkaline phosphatase normal haematocrit normal red blood cell count normal red cell distribution width normal anticoagulant therapy basophil count increased acute respiratory failure aortic dilatation mean cell haemoglobin increased tricuspid valve incompetence lymphocyte count increased blood ph increased left ventricular hypertrophy immature granulocyte count polychromasia pco2 normal base excess pulmonary thrombosis aortic valve calcification positive airway pressure therapy
- 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?
- Maladie actuelle