|
| VAERS ID: |
1028247 (history) |
| Form: |
Version 2.0 |
| Age: |
17.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2021-02-12 |
| Onset: | 2021-02-13 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Immune thrombocytopenia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Petichae ITP |
|
| VAERS ID: |
1206421 (history) |
| Form: |
Version 2.0 |
| Age: |
17.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-03-11 |
| Onset: | 2021-03-14 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-04-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EN6204 / 1 |
RA / SYR |
Administered by: Other Purchased by: ?
Symptoms: Blood test abnormal,
Deep vein thrombosis,
Nodule,
Pain in extremity,
SARS-CoV-2 test negative,
Thrombosis,
Ultrasound scan abnormal
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Thrombophlebitis (broad), Tendinopathies and ligament disorders (broad), COVID-19 (broad)
Life Threatening? Yes
Birth Defect? Yes
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: melatonin,
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: Ultrasound on 3/18 showed DVT in right calf, and blood panels were also done, covid test was negative. Blood work showed he was positive for heterozygous positivity for Factor11 (prothrombin) gene mutation
CDC Split Type:
Write-up: Blood clot in right calf. Noticed pain and knot in calf on Sunday 3/14/2021. It worsened over the next few days. Went to Urgent care on 3/18 and they sent us straight to ER for Ultrasound. In hospital they found it was a clot identified as deep vein thrombosis, and started a treatment of blood thinner and pain medication. |
|
| VAERS ID: |
1225942 (history) |
| Form: |
Version 2.0 |
| Age: |
16.0 |
| Sex: |
Female |
| Location: |
Wisconsin |
| Vaccinated: | 2021-03-19 |
| Onset: | 2021-03-28 |
| Days after vaccination: | 9 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-04-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
UNKNOWN / 1 |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Cardiac arrest,
Death,
Laboratory test,
Lung assist device therapy,
Oral contraception,
Pulmonary embolism,
Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-30
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Reported to be on Drospirenone-Ethinyl Estradiol 3-0.02 MG per tab
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient was a 16yr female who received Pfizer vaccine 3/19/21 at vaccine clinic and presented with ongoing CPR to the ED 3/28/21 after cardiac arrest at home. Patient placed on ECMO and imaging revealed bilateral large pulmonary embolism as likely etiology of arrest. Risk factors included oral contraceptive use. Labs have since confirmed absence of Factor V leiden or prothrombin gene mutation. Patient declared dead by neurologic criteria 3/30/21. |
|
| VAERS ID: |
1234443 (history) |
| Form: |
Version 2.0 |
| Age: |
16.0 |
| Sex: |
Female |
| Location: |
Colorado |
| Vaccinated: | 2021-03-31 |
| Onset: | 2021-03-31 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-04-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
ER8734 / 1 |
RA / IM |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EW0161 / 2 |
RA / IM |
Administered by: Pharmacy Purchased by: ?
Symptoms: Blood thromboplastin,
Epistaxis,
Full blood count normal,
Thrombosis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Methotrexate
Current Illness:
Preexisting Conditions: JIA and Sjogrens
Allergies:
Diagnostic Lab Data: After dose #1 CBC (normal) and Urinalysis (abnormal- clarity and elevated pH) after dose #2 CBC (normal) PTT and PT. Pediatrician consulting a hematologist
CDC Split Type:
Write-up: After the first dose, mild dizziness and nausea followed by massive inflammation in joints and face, severe fatigue and loss of hearing in right ear. Hearing returned in 3 days, general malaise until a week before 2nd shot when she started having severe bloody noses and EXTREMELY heavy period. After the second dose, 45 minute nose bleed soaked through two wash cloths, so many blood clots it clogged the sink. |
|
| VAERS ID: |
1271027 (history) |
| Form: |
Version 2.0 |
| Age: |
16.0 |
| Sex: |
Male |
| Location: |
Illinois |
| Vaccinated: | 2021-04-25 |
| Onset: | 2021-04-28 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-04-29 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
ER8736 / 1 |
- / IM |
Administered by: Unknown Purchased by: ?
Symptoms: Full blood count,
Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune 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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Miralax, milk of magnesia, dextroamphetamine
Current Illness: being evaluated for persistent abdominal pain
Preexisting Conditions: ADHD
Allergies: lisdexamphetamine
Diagnostic Lab Data: as above, CBC obtained 4/28/21
CDC Split Type:
Write-up: Patient developed significant thrombocytopenia 3 days after vaccination (platelet count 35,000). Other counts normal, no clinical bleeding. Lab was ordered as part of a work up for persistent abdominal pain (which was present before the vaccine) |
|
| VAERS ID: |
1281631 (history) |
| Form: |
Version 2.0 |
| Age: |
17.0 |
| Sex: |
Male |
| Location: |
New Jersey |
| Vaccinated: | 2021-04-27 |
| Onset: | 2021-04-29 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-05-03 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EWO170 / 2 |
- / IM |
Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time normal,
Alanine aminotransferase increased,
Aspartate aminotransferase increased,
Blood albumin normal,
Blood alkaline phosphatase normal,
Blood bilirubin normal,
Blood chloride increased,
Blood creatinine normal,
Blood glucose normal,
Blood potassium normal,
Blood sodium increased,
Blood urea normal,
Carbon dioxide normal,
Fibrin D dimer,
Haematocrit decreased,
Haemoglobin decreased,
International normalised ratio normal,
Petechiae,
Protein total normal,
Prothrombin time normal,
SARS-CoV-2 test negative,
Urine analysis normal,
White blood cell count normal
SMQs:, Liver related investigations, signs and symptoms (narrow), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (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? No
Previous Vaccinations:
Other Medications: (RECEIVED FIRST COVID VACCINATION 4/6/21
Current Illness:
Preexisting Conditions: MIGRAINES ASTHMA HX OF MALNUTRITION (OPPOSITION TO FOOD)
Allergies: AMOXICILLIN
Diagnostic Lab Data: 4/30 cbc: normal wbc5.3, hbg-13, hct-38.6, plt- 181 Pt/INR/PTT- normal- pt 12.2, inr 1.07, ptt -30 ua - normal d-dimer - <150 SARS COVID RNA - NEG CMP: Na-147, potassium - 4.2, cl-107, co2-30, bun -12, cr-0.8, glucose-74, t protein-7.8, alb-4.6, t bili 0.7, ast-54, alt 53, alk phos 139,
CDC Split Type:
Write-up: Petechial rash noted to dorsal aspect of b/l feet, not including legs/calves or soles of feet. nontender, nonswollen |
|
| VAERS ID: |
1290426 (history) |
| Form: |
Version 2.0 |
| Age: |
17.0 |
| Sex: |
Male |
| Location: |
Utah |
| Vaccinated: | 2021-04-21 |
| Onset: | 2021-04-21 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-05-05 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
RA / IM |
Administered by: Private Purchased by: ?
Symptoms: Activated partial thromboplastin time,
Angiogram cerebral abnormal,
Anticoagulant therapy,
Arteriogram carotid abnormal,
Blood fibrinogen,
Body temperature increased,
C-reactive protein normal,
Computerised tomogram abnormal,
Computerised tomogram head abnormal,
Computerised tomogram neck,
Deep vein thrombosis,
Epstein-Barr virus antibody,
Full blood count,
Gene mutation identification test,
Headache,
Influenza A virus test,
Influenza virus test,
Intensive care,
International normalised ratio normal,
Localised oedema,
Lymphadenitis bacterial,
Malaise,
Metabolic function test,
Neck pain,
Prothrombin time normal,
SARS-CoV-2 test negative,
Scan with contrast,
Thrombophlebitis,
Transverse sinus thrombosis
SMQs:, Angioedema (broad), Neuroleptic malignant syndrome (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Central nervous system vascular disorders, not specified as haemorrhagic or ischaemic (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypersensitivity (broad), Arthritis (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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lexapro, Gabapentin
Current Illness: Previously healthy
Preexisting Conditions: Previously healthy
Allergies: NKDA
Diagnostic Lab Data: CT Head and Neck - 4/26: Significant diffuse right-sided deep spatial neck edema. Right-sided adenopathy is present and there is a right level 2 1.8 cm suppurative lymph node or abscess. CTA Head and Neck - 5/4: 1. Deep venous thrombosis involving the left internal jugular vein from the skull base to approximately the level of the hyoid bone. Of note CT of the brain performed the same day shows extension of this thrombus into the transverse sinus. 2. Suppurative lymphadenopathy in the right side of the neck. This was present on the previous study and has decreased slightly in size. 3. No evidence of embolic disease in the visualized portions of the lungs on today?s study. CBC, BMP, PTT, PT, INR, CRP, covid-19, RSV and influenza A+B PCR, EBV Ab, Fibrinogen, Factor V liden, Prothrombin 20210 G/A mutation Neurology Consult Hematology Consult Admitted to ICU
CDC Split Type:
Write-up: 17-year-old male who presents with 8 days of headache. He received his first dose of the Pfizer vaccine on 4/21. He felt like he had the flu after getting the vaccine and developed right-sided neck pain and a temperature to 100. The patient did endorse being elbowed in the neck playing basketball during this time as well, as he played in a basketball tournament in right after this. He got his Covid vaccine in his right deltoid. He saw his pediatrician on 4/26 and a CT scan of his neck with IV contrast was done and this showed significant diffuse right-sided deep spatial neck edema and right-sided adenopathy. The pediatrician discussed the findings with ENT who recommended augmentin and a medrol dosepak. The patient developed a headache several days after this and went to urgent care for evaluation. There was concern that the augmentin and steroids had caused the headache, so the steroids were stopped and he was switched to keflex on 4/30. He was given phenergan and toradol at Urgent Care and discharged home. His mom notes that several days ago he had fevers of 101-104. He has not had a fever for several days now. His headache continued and he felt unwell at basketball practice so he returned to urgent care on 5/4. A CT scan of his head was done which showed right sigmoid and transverse sinus thrombosis as well as thrombophlebitis of the right IJ. He was sent to ED for further management at that time. In the ED, the patient was hemodynamically stable and well-appearing. The CTs were overread by our radiologists here. The patient had some labs done at the outside urgent care but PT/PTT/INR and a CRP were drawn here, which were unremarkable. A Covid PCR is negative. Neurosurgery, neurology, and hematology were consulted. Neurology recommended heparin and a hypercoagulable workup and hematology agreed with this plan. The patient was admitted to the ICU for neuro checks and monitoring during initiation of heparin. |
|
| VAERS ID: |
1293709 (history) |
| Form: |
Version 2.0 |
| Age: |
16.0 |
| Sex: |
Female |
| Location: |
Ohio |
| Vaccinated: | 2021-05-02 |
| Onset: | 2021-05-06 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-05-06 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Petechiae
SMQs:, Haemorrhage terms (excl laboratory terms) (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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Petechiae present on the chin and increasing in severity 4 days after vaccination. Started 5/6/21 at 5pm. No prior trauma to area. Spontaneous presentation. |
|
| VAERS ID: |
1300698 (history) |
| Form: |
Version 2.0 |
| Age: |
17.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-04-17 |
| Onset: | 2021-05-06 |
| Days after vaccination: | 19 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-05-09 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: C-reactive protein,
Full blood count,
Metabolic function test,
Pyrexia,
Rash,
Thrombocytopenia
SMQs:, Anaphylactic reaction (broad), Haematopoietic thrombocytopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Immune-mediated/autoimmune 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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: History of ITP
Allergies:
Diagnostic Lab Data: CBC, CMP, CRP
CDC Split Type:
Write-up: Fever, rash, and thrombocytopenia |
|
| VAERS ID: |
1307924 (history) |
| Form: |
Version 2.0 |
| Age: |
16.0 |
| Sex: |
Male |
| Location: |
Wisconsin |
| Vaccinated: | 2021-04-29 |
| Onset: | 2021-05-10 |
| Days after vaccination: | 11 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-05-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Abdominal pain upper,
Activated partial thromboplastin time normal,
Alanine aminotransferase increased,
Albumin globulin ratio normal,
Anaemia,
Anion gap normal,
Aspartate aminotransferase normal,
Blood albumin normal,
Blood alkaline phosphatase increased,
Blood bilirubin normal,
Blood calcium normal,
Blood chloride normal,
Blood creatinine normal,
Blood glucose increased,
Blood potassium normal,
Blood sodium normal,
Blood urea normal,
Carbon dioxide decreased,
Contusion,
Full blood count,
Gingival bleeding,
Globulin,
Glomerular filtration rate,
Haematocrit decreased,
Haemoglobin decreased,
International normalised ratio increased,
Mean cell haemoglobin concentration normal,
Mean cell haemoglobin normal,
Mean cell volume normal,
Mean platelet volume increased,
Metabolic function test,
Oropharyngeal pain,
Petechiae,
Pharyngeal haemorrhage,
Platelet count decreased,
Protein total normal,
Prothrombin time prolonged,
Red blood cell count decreased,
Red cell distribution width increased,
Thrombocytopenia,
White blood cell count normal
SMQs:, Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Acute pancreatitis (broad), Haematopoietic erythropenia (narrow), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Systemic lupus erythematosus (broad), Gingival disorders (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Biliary system related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune 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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: This is your record. Keep this with you and show to your community pharmacist(s) and physician(s) at each visit. Allergies: No Known Allergies Medications Valid as of: May 11, 2021 - 4:41 PM Generic Name Brand Name Tablet Size Instruct
Current Illness: 4/16/21 ED visit N/V/D diagnosed with viral gastroenteritis COVID-19 antigen negative 4/25/21 ED visit fever, sore throat, earache, dizziness, shortness of breath. Rapid strep negative, COVID-19 antigen and Influenza negative diagnosised with otitis media 4/28/21 Ed Visit Sore Throat diangosed with viral syndrome
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data: Diagnostics: Results for orders placed or performed during the hospital encounter of 05/10/21 CBC WITH DIFFERENTIAL Result Value Ref Range White Blood Cells 7.72 4.0 - 13.0 K/uL Red Blood Cells 3.48 (L) 4.15 - 5.30 M/uL Hemoglobin 10.8 (L) 11.8 - 15.4 g/dL Hematocrit 30.5 (L) 35.5 - 46.5 % MCV 87.7 77 - 94 fL MCH 31.0 25.0 - 32.3 pg MCHC 35.4 31.9 - 35.9 g/dL RDW 16.2 (H) 11.5 - 14.8 % Platelet Count 9 (LL) 160 - 424 K/uL MPV 11.4 (H) 6.8 - 10.5 fL Neutrophil % Pending % Lymphocyte % Pending % Monocyte % Pending % Eosinophil % Pending % Basophil % Pending % Absolute Neutrophils Pending 1.6 - 7.5 K/uL Absolute Lymphocytes Pending 1.2 - 4.9 K/uL Absolute Monocytes Pending 0.1 - 0.9 K/uL Absolute Eosinophils Pending 0.0 - 0.6 K/uL Absolute Basophils Pending 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range Sodium 138 133 - 144 mEq/L Potassium 4.4 3.5 - 5.0 mEq/L Chloride 101 95 - 107 mEq/L Carbon Dioxide 22 22 - 32 mEq/L Anion Gap 15 6 - 15 mEq/L BUN 14 8 - 24 mg/dL Creatinine 0.81 0.69 - 1.20 mg/dL Glomerular Filt Rate NOT CALCULATED due to age less than 18 years. mL/min Glucose 110 (H) 70 - 100 mg/dL Albumin 4.9 3.5 - 5.2 g/dL Calcium 10.0 8.6 - 10.4 mg/dL AST 23 11 - 41 IU/L ALT 28 (H) 0 - 19 IU/L Alkaline Phosphatase 142 90 - 366 IU/L Bilirubin, Total 0.4 <1.5 mg/dL Total Protein 7.7 5.9 - 7.8 g/dL Globulin 2.8 1.8 - 3.7 g/dL A:G Ratio 1.8 1.2 - 2.7 PROTHROMBIN TIME Result Value Ref Range Prothrombin Time 18.4 (H) 12.0 - 14.6 sec INR 1.5 (H) 0.9 - 1.1 PTT, PARTIAL THROMBOPLASTIN Result Value Ref Range PTT 32 23 - 36 sec CRITICAL VALUE HEME Result Value Ref Range Critical Value Result called to and read back by: RN Test(s) Reported: PLT COUNT 5/10/2021 @ 11:27 N
CDC Split Type:
Write-up: HPI: Patient is a 16-year-old male who was upgraded to our emergency department after blood work showed a significant thrombocytopenia. Please see walk-in clinic provider NP for presenting history and physical exam. Patient reports to me development of sore throat as well as blood from the throat last Thursday. Patient also began to notice development of bruising to his legs without any injury approximately a week ago. Denies any pain. Denies any blood in the urine or stool. No other medical complaints at this time. Chief Complaint Patient presents with ? Sore Throat was seen a few weeks ago for ear infection, also had sore throat at that time that never went away. School nurse wanted him swabbed for strep and covid PCR ? Bleeding/Bruising has large bruising to right leg for about a week, no injury. also states bruise to upper left thigh and right shoulder and scattered small bruises. School nurse wants his platelets checked. Denies pain. States mild bleeding in gums and states notices blood in back of throat ROS: See HPI above. All other 12 review systems negative otherwise specified in HPI above. ROS PMH: Past Medical History Past Medical History: Diagnosis Date ? Asthma ? GI symptoms 10/2018 with pharyngitis ? Headache ? Strep throat ? Tonsillar and adenoid hypertrophy nasal scope Past Surgical History Past Surgical History: Procedure Laterality Date ? COLONOSCOPY 12/07/2018 with biopsies ? ESOPHAGOGASTRODUODENOSCOPY 12/07/2018 with biopsies ? TONSILLECTOMY & ADENOIDECTOMY 2011 Family History Family History Problem Relation Age of Onset ? Hypertension Father ? Diabetes Mellitus Father Social History Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used ? Tobacco comment: no second hand smoke exposure Substance Use Topics ? Alcohol use: No Allergies: No Known Allergies Meds: No current facility-administered medications on file prior to encounter. Current Outpatient Medications on File Prior to Encounter Medication Sig Dispense Refill ? albuterol HFA 108 (90 Base) MCG/ACT inhaler Inhale 2 puffs every 4 hours as needed. 1 inhaler 1 ? Aspirin-Acetaminophen-Caffeine (EXCEDRIN PO) ? acetaminophen (TYLENOL) 325 MG tablet Take 975 mg by mouth every 6 hours as needed for Pain. ? naproxen (NAPROSYN) 220 MG tablet Take 440 mg by mouth twice daily - with breakfast and supper. Physical Exam: Blood pressure (!) 148/93, pulse 107, temperature 98.6 ?F (37 ?C), resp. rate 20, height 6'' 5" (1.956 m), weight (!) 348 lb 8 oz (158.1 kg), SpO2 96 %. O2 flow: Physical Exam Constitutional: He is well-developed, well-nourished, and in no distress. No distress. HENT: Head: Normocephalic. Right Ear: External ear normal. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Mild erythema in the posterior pharynx with some bleeding. No posterior pharynx edema. Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Cardiovascular: Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal. No stridor. No respiratory distress. He has no wheezes. He has no rales. Abdominal: Soft. Left upper quadrant tenderness. Musculoskeletal: General: No tenderness, deformity or edema. Cervical back: Normal range of motion. Neurological: He is alert. Gait normal. GCS score is 15. Skin: Skin is warm. He is not diaphoretic. Multiple baseball to softball size bruises to the bilateral lower extremities worse on the right than left. Mild petechiae. Psychiatric: Mood, memory, affect and judgment normal. Diagnostics: Results for orders placed or performed during the hospital encounter of 05/10/21 CBC WITH DIFFERENTIAL Result Value Ref Range White Blood Cells 7.72 4.0 - 13.0 K/uL Red Blood Cells 3.48 (L) 4.15 - 5.30 M/uL Hemoglobin 10.8 (L) 11.8 - 15.4 g/dL Hematocrit 30.5 (L) 35.5 - 46.5 % MCV 87.7 77 - 94 fL MCH 31.0 25.0 - 32.3 pg MCHC 35.4 31.9 - 35.9 g/dL RDW 16.2 (H) 11.5 - 14.8 % Platelet Count 9 (LL) 160 - 424 K/uL MPV 11.4 (H) 6.8 - 10.5 fL Neutrophil % Pending % Lymphocyte % Pending % Monocyte % Pending % Eosinophil % Pending % Basophil % Pending % Absolute Neutrophils Pending 1.6 - 7.5 K/uL Absolute Lymphocytes Pending 1.2 - 4.9 K/uL Absolute Monocytes Pending 0.1 - 0.9 K/uL Absolute Eosinophils Pending 0.0 - 0.6 K/uL Absolute Basophils Pending 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range Sodium 138 133 - 144 mEq/L Potassium 4.4 3.5 - 5.0 mEq/L Chloride 101 95 - 107 mEq/L Carbon Dioxide 22 22 - 32 mEq/L Anion Gap 15 6 - 15 mEq/L BUN 14 8 - 24 mg/dL Creatinine 0.81 0.69 - 1.20 mg/dL Glomerular Filt Rate NOT CALCULATED due to age less than 18 years. mL/min Glucose 110 (H) 70 - 100 mg/dL Albumin 4.9 3.5 - 5.2 g/dL Calcium 10.0 8.6 - 10.4 mg/dL AST 23 11 - 41 IU/L ALT 28 (H) 0 - 19 IU/L Alkaline Phosphatase 142 90 - 366 IU/L Bilirubin, Total 0.4 <1.5 mg/dL Total Protein 7.7 5.9 - 7.8 g/dL Globulin 2.8 1.8 - 3.7 g/dL A:G Ratio 1.8 1.2 - 2.7 PROTHROMBIN TIME Result Value Ref Range Prothrombin Time 18.4 (H) 12.0 - 14.6 sec INR 1.5 (H) 0.9 - 1.1 PTT, PARTIAL THROMBOPLASTIN Result Value Ref Range PTT 32 23 - 36 sec CRITICAL VALUE HEME Result Value Ref Range Critical Value ED Course: Patient was upgraded to the emergency department after he was noted to have significant thrombocytopenia. Patient is pleasant he has no active complaints other than some throat irritation bleeding in the throat and bruising that was nontraumatic to the legs. My physical examination reveals multiple rather large bruises to the bilateral lower extremities up to softball size worse on the right than left. Patient had some mild left upper quadrant discomfort. Very minimal bleeding in the posterior pharynx. I personally reviewed the labs and CBC revealed an anemia at 10.830.5 hemoglobin hematocrit respectively. Most notably a 9000 thrombocytopenia. CMP essentially unremarkable. INR 1.5 PTT normal. I added on Lyme disease and tick-borne illness as well as a Monospot type and screen. Patient did receive his 1st visor vaccine for COVID-19 on April 29, 2021. IV was established in the emergency department in consultation made to Pediatric Oncology. I spoke with pediatric oncology in regards to patient''s history and present illness. He does agree that the patient should in fact be transferred under the pediatric care but recommended under the general hospitalist service. He did not advise to proceed with any active treatment in our emergency department such as gamma globulin, platelets or steroids. Awaited call back from pediatric hospitalist and spoke with Dr. She has agreed to accept the patient in transfer. Patient and family are comfortable disposition plan no further questions at this time. Impression: 1. ITP Disposition: Transfer ED on 5/10/2021 Revision History Detailed Report Note shared with patient Note filed date Mon May 10, 2021 12:24 PM |
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