Received Oct 10, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUAD) | SEQIRUS, INC. | N/A | 409166 | IM / RA |
Per local ER notes: 72yom with PMHx including HTN, HLD, OSA, CVA, anxiety, asthma/O2 dependent COPD (2.5 L), atrial fibrillation on Eliquis presents for evaluation of shortness of breath Patient states he had a flu shot yesterday and feels his breathing worsened a few hours after he received it EMS reports patient was 89% on his baseline 2.5 L upon their arrival, improved SpO2 when O2 increased to 3 L Patient reports dyspnea on exertion and chronic cough that is unchanged No associated chest pain and denies fever/chills
Code Description M54.50 Low back pain (SCT 279039007) R73.03 Prediabetes (SCT 714628002) Z77.29 Exposure to potentially hazardous substance (SCT 133261000119105) J44.9 Chronic obstructive lung disease (SCT 13645005) I48.20 Atrial fibrillation (SCT 49436004) I10. Essential hypertension (SCT 59621000) J30.2 Allergic rhinitis (SCT 61582004) R06.83 Snoring (SCT 72863001) E78.5 Hyperlipidemia (SCT 55822004) Z59.01 Housing lack (SCT 266935003) K40.90 Inguinal hernia (SCT 396232000) I63.9 Cerebrovascular accident (SCT 230690007) G43.909 Migraine (SCT 37796009) R91.1 Solitary nodule of lung (SCT 427359005) Z79.01 H/O: anticoagulant therapy (SCT 161647008)
Drug Name ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3ML Issue Date 10/06/2025 SIG INHALE 1 VIAL [3ML] BY NEBULIZER FOUR TIMES A DAY AS NEEDED FOR BRONCHI MUSCLE SPASM FROM COPD Facility: (withheld name) ================
Crab
10/10/25: MDM Detail: Nontoxic-appearing 72-year-old male for evaluation of shortness of breath which he feels worsened after receiving his flu shot yesterday, mildly hypoxic for EMS. EKG: NSR @ 60bpm, no ST elevation/depression, nonspecific ST-wave changes, normal intervals, no significant change from prior Labs reviewed and significant for leukopenia WBC count 3.3 which has been noted previously, hemoglobin 12.8 which appears to be near patient's baseline, platelets 149, decreased from previous, creatinine 0.82 with otherwise normal electrolytes and LFTs, troponin negative, BNP normal, Fluvid negative, VBG shows normal pH 7.33, mildly elevated pCO2 55 CXR clear Patient received multiple nebulizer treatments and Solu-Medrol in ED, subsequently feeling much better, ambulatory without developing shortness of breath or hypoxia when using his baseline oxygen. Comfortable discharge home at this time and will return to ED if new or worsening symptoms arise. Discharged home in stable condition.