chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 50.0
Sex: M
Vaccine: COVID19
Symptoms: Tinnitus
Clinical narrative: Tinnitus in either ear, but predominately in left ear, occurring and resolving multiple times a day since the week of vaccination
Sex: U
Vaccine: COVID19, COVID19
Symptoms: Acute myocardial infarction, Acute respiratory failure, COVID-19, COVID-19 pneumonia, Cardiac failure acute
Clinical narrative: Pt. is a 92 year old male who resides at an assisted living facility for the past 2 months.  He has dementia but reportedly is oriented to self and place at baseline.  He is not currently able to give a reliable history.  Per ER report, the patient developed lethargy and shortness of breath and tested positive for COVID yesterday.  He worsened fairly quickly and was found to be hypoxic today, and was transferred to the ER.  He had an O2 sat in the low 80s on room air, and was on NRB when he arrived with sat of 95%.  Oxygen has since been turned down to 4L with sat in the low 90s.  Patient is having a productive cough.  He has received his primary COVID vaccine series less than 6 months ago, therefore has not had a booster yet.  He is not complaining of any chest pain.  His troponin is elevated but EKG without acute ischemic changes.  His pro-BNP is also markedly elevated at 29K.  He was administered 40 mg IV Lasix in the ER, and admission requested.    I contacted his daughter at the number provided on the ace sheet.  We discussed treatment plans, and she confirmed patient has DNR orders.  Her husband passed away yesterday, and she requests that we contact her brother as the primary contact for her dad during the remainder of the admission.  1/20/2022: DISCHARGE: Acute hypoxic respiratory failure -Initially requiring supplemental oxygen, now keeping sat >90 on room air -MAT protocol    Pneumonia due to COVID-19 -Continue dexamethasone (may have started yesterday) 1/10 - on remdesivir day 4/5. Will need to monitor renal function and LFTs closely. Both mildly abnormal but do not meet criteria for withholding the medication at this time -Considered tocilizumab or baricitinib if worsening, but down to 2 L and now room air  -OK to truncate RDSV when improved and no longer requires Dex off oxygen    Acute on chronic diastolic heart failure  CXR looks more PNA    CKD stage III -Monitor renal function closely with meds as above    Elevated troponin, type 2 NSTEMI CAD -started aspirin and statin -Echo noted -Per family, no invasive procedures    Hypertension -Continue home metoprolol, amlodipine, ramipril    Hypothyroidism -Continue home levothyroxine    Dementia -Complicates care -Pt's daughter is POA but she requests we contact her brother to provide updates, as her husband passed away 1/16       Dysphagia, high risk for aspiration, made NPO - son describes this as a chronic issue, he thinks they WOULD want a feeding tube if felt he could survive this and get stronger -NPO for most of 1/18, repeat eval indicates swallowing ok, diet ordered       Son updated 1/19  He agrees needs to get back asap and will arrange that today
Sex: U
Vaccine: COVID19, COVID19
Symptoms: Chest X-ray abnormal, Chronic kidney disease, Coronary artery disease, Dementia, Dysphagia
Clinical narrative: Pt. is a 92 year old male who resides at an assisted living facility for the past 2 months.  He has dementia but reportedly is oriented to self and place at baseline.  He is not currently able to give a reliable history.  Per ER report, the patient developed lethargy and shortness of breath and tested positive for COVID yesterday.  He worsened fairly quickly and was found to be hypoxic today, and was transferred to the ER.  He had an O2 sat in the low 80s on room air, and was on NRB when he arrived with sat of 95%.  Oxygen has since been turned down to 4L with sat in the low 90s.  Patient is having a productive cough.  He has received his primary COVID vaccine series less than 6 months ago, therefore has not had a booster yet.  He is not complaining of any chest pain.  His troponin is elevated but EKG without acute ischemic changes.  His pro-BNP is also markedly elevated at 29K.  He was administered 40 mg IV Lasix in the ER, and admission requested.    I contacted his daughter at the number provided on the ace sheet.  We discussed treatment plans, and she confirmed patient has DNR orders.  Her husband passed away yesterday, and she requests that we contact her brother as the primary contact for her dad during the remainder of the admission.  1/20/2022: DISCHARGE: Acute hypoxic respiratory failure -Initially requiring supplemental oxygen, now keeping sat >90 on room air -MAT protocol    Pneumonia due to COVID-19 -Continue dexamethasone (may have started yesterday) 1/10 - on remdesivir day 4/5. Will need to monitor renal function and LFTs closely. Both mildly abnormal but do not meet criteria for withholding the medication at this time -Considered tocilizumab or baricitinib if worsening, but down to 2 L and now room air  -OK to truncate RDSV when improved and no longer requires Dex off oxygen    Acute on chronic diastolic heart failure  CXR looks more PNA    CKD stage III -Monitor renal function closely with meds as above    Elevated troponin, type 2 NSTEMI CAD -started aspirin and statin -Echo noted -Per family, no invasive procedures    Hypertension -Continue home metoprolol, amlodipine, ramipril    Hypothyroidism -Continue home levothyroxine    Dementia -Complicates care -Pt's daughter is POA but she requests we contact her brother to provide updates, as her husband passed away 1/16       Dysphagia, high risk for aspiration, made NPO - son describes this as a chronic issue, he thinks they WOULD want a feeding tube if felt he could survive this and get stronger -NPO for most of 1/18, repeat eval indicates swallowing ok, diet ordered       Son updated 1/19  He agrees needs to get back asap and will arrange that today
Sex: U
Vaccine: COVID19, COVID19
Symptoms: Dyspnoea, Echocardiogram, Electrocardiogram normal, General physical health deterioration, Hypertension
Clinical narrative: Pt. is a 92 year old male who resides at an assisted living facility for the past 2 months.  He has dementia but reportedly is oriented to self and place at baseline.  He is not currently able to give a reliable history.  Per ER report, the patient developed lethargy and shortness of breath and tested positive for COVID yesterday.  He worsened fairly quickly and was found to be hypoxic today, and was transferred to the ER.  He had an O2 sat in the low 80s on room air, and was on NRB when he arrived with sat of 95%.  Oxygen has since been turned down to 4L with sat in the low 90s.  Patient is having a productive cough.  He has received his primary COVID vaccine series less than 6 months ago, therefore has not had a booster yet.  He is not complaining of any chest pain.  His troponin is elevated but EKG without acute ischemic changes.  His pro-BNP is also markedly elevated at 29K.  He was administered 40 mg IV Lasix in the ER, and admission requested.    I contacted his daughter at the number provided on the ace sheet.  We discussed treatment plans, and she confirmed patient has DNR orders.  Her husband passed away yesterday, and she requests that we contact her brother as the primary contact for her dad during the remainder of the admission.  1/20/2022: DISCHARGE: Acute hypoxic respiratory failure -Initially requiring supplemental oxygen, now keeping sat >90 on room air -MAT protocol    Pneumonia due to COVID-19 -Continue dexamethasone (may have started yesterday) 1/10 - on remdesivir day 4/5. Will need to monitor renal function and LFTs closely. Both mildly abnormal but do not meet criteria for withholding the medication at this time -Considered tocilizumab or baricitinib if worsening, but down to 2 L and now room air  -OK to truncate RDSV when improved and no longer requires Dex off oxygen    Acute on chronic diastolic heart failure  CXR looks more PNA    CKD stage III -Monitor renal function closely with meds as above    Elevated troponin, type 2 NSTEMI CAD -started aspirin and statin -Echo noted -Per family, no invasive procedures    Hypertension -Continue home metoprolol, amlodipine, ramipril    Hypothyroidism -Continue home levothyroxine    Dementia -Complicates care -Pt's daughter is POA but she requests we contact her brother to provide updates, as her husband passed away 1/16       Dysphagia, high risk for aspiration, made NPO - son describes this as a chronic issue, he thinks they WOULD want a feeding tube if felt he could survive this and get stronger -NPO for most of 1/18, repeat eval indicates swallowing ok, diet ordered       Son updated 1/19  He agrees needs to get back asap and will arrange that today
Sex: U
Vaccine: COVID19, COVID19
Symptoms: Hypothyroidism, Hypoxia, Left ventricular failure, Lethargy, Liver function test abnormal
Clinical narrative: Pt. is a 92 year old male who resides at an assisted living facility for the past 2 months.  He has dementia but reportedly is oriented to self and place at baseline.  He is not currently able to give a reliable history.  Per ER report, the patient developed lethargy and shortness of breath and tested positive for COVID yesterday.  He worsened fairly quickly and was found to be hypoxic today, and was transferred to the ER.  He had an O2 sat in the low 80s on room air, and was on NRB when he arrived with sat of 95%.  Oxygen has since been turned down to 4L with sat in the low 90s.  Patient is having a productive cough.  He has received his primary COVID vaccine series less than 6 months ago, therefore has not had a booster yet.  He is not complaining of any chest pain.  His troponin is elevated but EKG without acute ischemic changes.  His pro-BNP is also markedly elevated at 29K.  He was administered 40 mg IV Lasix in the ER, and admission requested.    I contacted his daughter at the number provided on the ace sheet.  We discussed treatment plans, and she confirmed patient has DNR orders.  Her husband passed away yesterday, and she requests that we contact her brother as the primary contact for her dad during the remainder of the admission.  1/20/2022: DISCHARGE: Acute hypoxic respiratory failure -Initially requiring supplemental oxygen, now keeping sat >90 on room air -MAT protocol    Pneumonia due to COVID-19 -Continue dexamethasone (may have started yesterday) 1/10 - on remdesivir day 4/5. Will need to monitor renal function and LFTs closely. Both mildly abnormal but do not meet criteria for withholding the medication at this time -Considered tocilizumab or baricitinib if worsening, but down to 2 L and now room air  -OK to truncate RDSV when improved and no longer requires Dex off oxygen    Acute on chronic diastolic heart failure  CXR looks more PNA    CKD stage III -Monitor renal function closely with meds as above    Elevated troponin, type 2 NSTEMI CAD -started aspirin and statin -Echo noted -Per family, no invasive procedures    Hypertension -Continue home metoprolol, amlodipine, ramipril    Hypothyroidism -Continue home levothyroxine    Dementia -Complicates care -Pt's daughter is POA but she requests we contact her brother to provide updates, as her husband passed away 1/16       Dysphagia, high risk for aspiration, made NPO - son describes this as a chronic issue, he thinks they WOULD want a feeding tube if felt he could survive this and get stronger -NPO for most of 1/18, repeat eval indicates swallowing ok, diet ordered       Son updated 1/19  He agrees needs to get back asap and will arrange that today
Sex: U
Vaccine: COVID19, COVID19
Symptoms: N-terminal prohormone brain natriuretic peptide increased, Nothing by mouth order, Oxygen saturation decreased, Productive cough, Renal impairment
Clinical narrative: Pt. is a 92 year old male who resides at an assisted living facility for the past 2 months.  He has dementia but reportedly is oriented to self and place at baseline.  He is not currently able to give a reliable history.  Per ER report, the patient developed lethargy and shortness of breath and tested positive for COVID yesterday.  He worsened fairly quickly and was found to be hypoxic today, and was transferred to the ER.  He had an O2 sat in the low 80s on room air, and was on NRB when he arrived with sat of 95%.  Oxygen has since been turned down to 4L with sat in the low 90s.  Patient is having a productive cough.  He has received his primary COVID vaccine series less than 6 months ago, therefore has not had a booster yet.  He is not complaining of any chest pain.  His troponin is elevated but EKG without acute ischemic changes.  His pro-BNP is also markedly elevated at 29K.  He was administered 40 mg IV Lasix in the ER, and admission requested.    I contacted his daughter at the number provided on the ace sheet.  We discussed treatment plans, and she confirmed patient has DNR orders.  Her husband passed away yesterday, and she requests that we contact her brother as the primary contact for her dad during the remainder of the admission.  1/20/2022: DISCHARGE: Acute hypoxic respiratory failure -Initially requiring supplemental oxygen, now keeping sat >90 on room air -MAT protocol    Pneumonia due to COVID-19 -Continue dexamethasone (may have started yesterday) 1/10 - on remdesivir day 4/5. Will need to monitor renal function and LFTs closely. Both mildly abnormal but do not meet criteria for withholding the medication at this time -Considered tocilizumab or baricitinib if worsening, but down to 2 L and now room air  -OK to truncate RDSV when improved and no longer requires Dex off oxygen    Acute on chronic diastolic heart failure  CXR looks more PNA    CKD stage III -Monitor renal function closely with meds as above    Elevated troponin, type 2 NSTEMI CAD -started aspirin and statin -Echo noted -Per family, no invasive procedures    Hypertension -Continue home metoprolol, amlodipine, ramipril    Hypothyroidism -Continue home levothyroxine    Dementia -Complicates care -Pt's daughter is POA but she requests we contact her brother to provide updates, as her husband passed away 1/16       Dysphagia, high risk for aspiration, made NPO - son describes this as a chronic issue, he thinks they WOULD want a feeding tube if felt he could survive this and get stronger -NPO for most of 1/18, repeat eval indicates swallowing ok, diet ordered       Son updated 1/19  He agrees needs to get back asap and will arrange that today
Sex: U
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Troponin increased
Clinical narrative: Pt. is a 92 year old male who resides at an assisted living facility for the past 2 months.  He has dementia but reportedly is oriented to self and place at baseline.  He is not currently able to give a reliable history.  Per ER report, the patient developed lethargy and shortness of breath and tested positive for COVID yesterday.  He worsened fairly quickly and was found to be hypoxic today, and was transferred to the ER.  He had an O2 sat in the low 80s on room air, and was on NRB when he arrived with sat of 95%.  Oxygen has since been turned down to 4L with sat in the low 90s.  Patient is having a productive cough.  He has received his primary COVID vaccine series less than 6 months ago, therefore has not had a booster yet.  He is not complaining of any chest pain.  His troponin is elevated but EKG without acute ischemic changes.  His pro-BNP is also markedly elevated at 29K.  He was administered 40 mg IV Lasix in the ER, and admission requested.    I contacted his daughter at the number provided on the ace sheet.  We discussed treatment plans, and she confirmed patient has DNR orders.  Her husband passed away yesterday, and she requests that we contact her brother as the primary contact for her dad during the remainder of the admission.  1/20/2022: DISCHARGE: Acute hypoxic respiratory failure -Initially requiring supplemental oxygen, now keeping sat >90 on room air -MAT protocol    Pneumonia due to COVID-19 -Continue dexamethasone (may have started yesterday) 1/10 - on remdesivir day 4/5. Will need to monitor renal function and LFTs closely. Both mildly abnormal but do not meet criteria for withholding the medication at this time -Considered tocilizumab or baricitinib if worsening, but down to 2 L and now room air  -OK to truncate RDSV when improved and no longer requires Dex off oxygen    Acute on chronic diastolic heart failure  CXR looks more PNA    CKD stage III -Monitor renal function closely with meds as above    Elevated troponin, type 2 NSTEMI CAD -started aspirin and statin -Echo noted -Per family, no invasive procedures    Hypertension -Continue home metoprolol, amlodipine, ramipril    Hypothyroidism -Continue home levothyroxine    Dementia -Complicates care -Pt's daughter is POA but she requests we contact her brother to provide updates, as her husband passed away 1/16       Dysphagia, high risk for aspiration, made NPO - son describes this as a chronic issue, he thinks they WOULD want a feeding tube if felt he could survive this and get stronger -NPO for most of 1/18, repeat eval indicates swallowing ok, diet ordered       Son updated 1/19  He agrees needs to get back asap and will arrange that today
Age: 30.0
Sex: F
Vaccine: COVID19
Symptoms: Erythema, Mechanical urticaria, Pruritus, Rash pruritic, Urticaria
Clinical narrative: Received booster (3rd Moderna dose) 12/10/21.  Evening of 12/21/21 began to feel itchy. Had raised red welts/hives. Clothes and heat irritated skin.  Condition, diagnosed dermatographia, has continued since 12/21/21. If skin is scratched or irritated it will begin to produce raised red hives/bumps that itch.   Taking two antihistamines daily to prevent symptoms since 1/6/2022
Age: 27.0
Sex: M
Vaccine: COVID19
Symptoms: Hyperaesthesia, Mechanical urticaria, Pruritus, Sensitive skin, Skin irritation
Clinical narrative: Dermatographia on all parts of the body. There is a consistent trend in those who have pre-existing allergy conditions related to the skin or other parts of the body to develop severe skin reactions after receiving their 2nd or 3rd doses. My condition is best described by skin hypersensitivity. Regular clothing that used to cause no issues now irritates the skin, causing itching sensations, which leads to worsening of the condition if scratched. After scratching a location, wheals raise from the skin like hives and the itching gets worse. The severe sensations are tempered by taking daily allergy pills and using copious amounts of lotion and ointment. "Skin Writing" is the layman's term for Dermatographia, meaning that if I run my fingernail along my skin lightly, that contact points will redden and rise off the body as described above. The itching sensations come and go every 20-30 minutes in different places.
Age: 27.0
Sex: M
Vaccine: COVID19
Symptoms: Urticaria
Clinical narrative: Dermatographia on all parts of the body. There is a consistent trend in those who have pre-existing allergy conditions related to the skin or other parts of the body to develop severe skin reactions after receiving their 2nd or 3rd doses. My condition is best described by skin hypersensitivity. Regular clothing that used to cause no issues now irritates the skin, causing itching sensations, which leads to worsening of the condition if scratched. After scratching a location, wheals raise from the skin like hives and the itching gets worse. The severe sensations are tempered by taking daily allergy pills and using copious amounts of lotion and ointment. "Skin Writing" is the layman's term for Dermatographia, meaning that if I run my fingernail along my skin lightly, that contact points will redden and rise off the body as described above. The itching sensations come and go every 20-30 minutes in different places.
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Chest X-ray normal, Confusional state, Exposure to SARS-CoV-2, Fall
Clinical narrative: This patient is an 89-year-old man with dementia.  He comes from dementia unit.  He had some exposure to COVID, had some mild upper respiratory symptoms, and was diagnosed with COVID about 5 days ago.  He is fully vaccinated.  The daughter is at bedside and gives history.  Apparently, he has been having increased falls this year for about the last 2 weeks.  He was brought to the emergency room today after he fell and had laceration to his face that required suturing.  He apparently has gotten up and walked to the nurse's station while here because he is confused, but not far from baseline that he has unsteady gait, we have been asked to admit him to the hospital.  Appears that he had been started on dexamethasone at his dementia unit, it looks like he may be started a couple of days ago.   DISCHARGED 01/18/2022: This patient is an 89-year-old man with dementia.  He comes from dementia unit.  He had some exposure to COVID, had some mild upper respiratory symptoms, and was diagnosed with COVID about 5 days ago.  He is fully vaccinated.  The daughter is at bedside and gives history.  Apparently, he has been having increased falls this year for about the last 2 weeks.  He was brought to the emergency room today after he fell and had laceration to his face that required suturing.  He apparently has gotten up and walked to the nurse's station while here because he is confused, but not far from baseline that he has unsteady gait, we have been asked to admit him to the hospital.  Appears that he had been started on dexamethasone at his dementia unit, it looks like he may be started a couple of days ago.   Did well with PT, vitals stable, on room air and CXR w/o infiltrates.  Daughter agreeable with return to Facility, in fact would prefer he go back today as his dementia worsens when out of  his usual environment.
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Gait disturbance, Respiratory symptom, Skin laceration, Suture insertion
Clinical narrative: This patient is an 89-year-old man with dementia.  He comes from dementia unit.  He had some exposure to COVID, had some mild upper respiratory symptoms, and was diagnosed with COVID about 5 days ago.  He is fully vaccinated.  The daughter is at bedside and gives history.  Apparently, he has been having increased falls this year for about the last 2 weeks.  He was brought to the emergency room today after he fell and had laceration to his face that required suturing.  He apparently has gotten up and walked to the nurse's station while here because he is confused, but not far from baseline that he has unsteady gait, we have been asked to admit him to the hospital.  Appears that he had been started on dexamethasone at his dementia unit, it looks like he may be started a couple of days ago.   DISCHARGED 01/18/2022: This patient is an 89-year-old man with dementia.  He comes from dementia unit.  He had some exposure to COVID, had some mild upper respiratory symptoms, and was diagnosed with COVID about 5 days ago.  He is fully vaccinated.  The daughter is at bedside and gives history.  Apparently, he has been having increased falls this year for about the last 2 weeks.  He was brought to the emergency room today after he fell and had laceration to his face that required suturing.  He apparently has gotten up and walked to the nurse's station while here because he is confused, but not far from baseline that he has unsteady gait, we have been asked to admit him to the hospital.  Appears that he had been started on dexamethasone at his dementia unit, it looks like he may be started a couple of days ago.   Did well with PT, vitals stable, on room air and CXR w/o infiltrates.  Daughter agreeable with return to Facility, in fact would prefer he go back today as his dementia worsens when out of  his usual environment.
Age: 64.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Asthenia, Atrial fibrillation, Blood creatinine increased
Clinical narrative: 65-year-old male with past medical history of AFib on Eliquis, asthma, hypertension, diabetes type 2 and diastolic CHF presents to medical center with complaints of weakness.  Patient's reports he has had intermittent weakness and swelling in his lower extremities for approximately 1 week.  Also admits to chills, mild shortness of breath, 1 episode of nonbloody diarrhea.  Due to weakness patient has had 1 fall yesterday denies any head trauma loss of consciousness.  Patient does not require any assistance with ambulation.  Takes Eliquis for chronic atrial fibrillation, last dose was day prior to admission.  Otherwise stated above denies any fever, cough, nausea, abdominal pain.  Reports friend's daughter recently tested positive for COVID but has not been in close contact with the daughter however has been in close contact with his friend.  Received 2 doses of Pfizer vaccine in June has not received Brewster.  Chronic history of asthma on Symbicort, denies any tobacco use, does not require supplemental oxygen at home. Of note patient was flushed and tremulous on exam did admit to feeling cold.  Denies any history of essential tremors, Parkinson's disease, alcohol abuse.  Reports he only drinks 1 6 pack per week.  ED course: VS:  SpO2 90% on room air, improved to 94% on 2 L nasal cannula  Labs:  BUN/creatinine 30/1.6, glucose 324, AST/ALT 45/40, troponin chin 540.3, ABG 7.44//27//58//18.6 Imaging:  EKG:  Atrial fibrillation with heart rate 97, CXR:  Increase interstitial opacities with patchy infiltrates Received 2 L NS in the ER PMHx:   DISCHARGED 01/20/2022:  DISCHARGE SUMMARY NOT PREPARED AT THIS TIME.
Age: 64.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood gases, Blood glucose increased, Blood urea increased, Chest X-ray abnormal, Chills
Clinical narrative: 65-year-old male with past medical history of AFib on Eliquis, asthma, hypertension, diabetes type 2 and diastolic CHF presents to medical center with complaints of weakness.  Patient's reports he has had intermittent weakness and swelling in his lower extremities for approximately 1 week.  Also admits to chills, mild shortness of breath, 1 episode of nonbloody diarrhea.  Due to weakness patient has had 1 fall yesterday denies any head trauma loss of consciousness.  Patient does not require any assistance with ambulation.  Takes Eliquis for chronic atrial fibrillation, last dose was day prior to admission.  Otherwise stated above denies any fever, cough, nausea, abdominal pain.  Reports friend's daughter recently tested positive for COVID but has not been in close contact with the daughter however has been in close contact with his friend.  Received 2 doses of Pfizer vaccine in June has not received Brewster.  Chronic history of asthma on Symbicort, denies any tobacco use, does not require supplemental oxygen at home. Of note patient was flushed and tremulous on exam did admit to feeling cold.  Denies any history of essential tremors, Parkinson's disease, alcohol abuse.  Reports he only drinks 1 6 pack per week.  ED course: VS:  SpO2 90% on room air, improved to 94% on 2 L nasal cannula  Labs:  BUN/creatinine 30/1.6, glucose 324, AST/ALT 45/40, troponin chin 540.3, ABG 7.44//27//58//18.6 Imaging:  EKG:  Atrial fibrillation with heart rate 97, CXR:  Increase interstitial opacities with patchy infiltrates Received 2 L NS in the ER PMHx:   DISCHARGED 01/20/2022:  DISCHARGE SUMMARY NOT PREPARED AT THIS TIME.
Age: 64.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Condition aggravated, Diarrhoea, Dyspnoea, Electrocardiogram abnormal, Fall
Clinical narrative: 65-year-old male with past medical history of AFib on Eliquis, asthma, hypertension, diabetes type 2 and diastolic CHF presents to medical center with complaints of weakness.  Patient's reports he has had intermittent weakness and swelling in his lower extremities for approximately 1 week.  Also admits to chills, mild shortness of breath, 1 episode of nonbloody diarrhea.  Due to weakness patient has had 1 fall yesterday denies any head trauma loss of consciousness.  Patient does not require any assistance with ambulation.  Takes Eliquis for chronic atrial fibrillation, last dose was day prior to admission.  Otherwise stated above denies any fever, cough, nausea, abdominal pain.  Reports friend's daughter recently tested positive for COVID but has not been in close contact with the daughter however has been in close contact with his friend.  Received 2 doses of Pfizer vaccine in June has not received Brewster.  Chronic history of asthma on Symbicort, denies any tobacco use, does not require supplemental oxygen at home. Of note patient was flushed and tremulous on exam did admit to feeling cold.  Denies any history of essential tremors, Parkinson's disease, alcohol abuse.  Reports he only drinks 1 6 pack per week.  ED course: VS:  SpO2 90% on room air, improved to 94% on 2 L nasal cannula  Labs:  BUN/creatinine 30/1.6, glucose 324, AST/ALT 45/40, troponin chin 540.3, ABG 7.44//27//58//18.6 Imaging:  EKG:  Atrial fibrillation with heart rate 97, CXR:  Increase interstitial opacities with patchy infiltrates Received 2 L NS in the ER PMHx:   DISCHARGED 01/20/2022:  DISCHARGE SUMMARY NOT PREPARED AT THIS TIME.
Age: 64.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Feeling cold, Flushing, Lung infiltration, Lung opacity, Peripheral swelling
Clinical narrative: 65-year-old male with past medical history of AFib on Eliquis, asthma, hypertension, diabetes type 2 and diastolic CHF presents to medical center with complaints of weakness.  Patient's reports he has had intermittent weakness and swelling in his lower extremities for approximately 1 week.  Also admits to chills, mild shortness of breath, 1 episode of nonbloody diarrhea.  Due to weakness patient has had 1 fall yesterday denies any head trauma loss of consciousness.  Patient does not require any assistance with ambulation.  Takes Eliquis for chronic atrial fibrillation, last dose was day prior to admission.  Otherwise stated above denies any fever, cough, nausea, abdominal pain.  Reports friend's daughter recently tested positive for COVID but has not been in close contact with the daughter however has been in close contact with his friend.  Received 2 doses of Pfizer vaccine in June has not received Brewster.  Chronic history of asthma on Symbicort, denies any tobacco use, does not require supplemental oxygen at home. Of note patient was flushed and tremulous on exam did admit to feeling cold.  Denies any history of essential tremors, Parkinson's disease, alcohol abuse.  Reports he only drinks 1 6 pack per week.  ED course: VS:  SpO2 90% on room air, improved to 94% on 2 L nasal cannula  Labs:  BUN/creatinine 30/1.6, glucose 324, AST/ALT 45/40, troponin chin 540.3, ABG 7.44//27//58//18.6 Imaging:  EKG:  Atrial fibrillation with heart rate 97, CXR:  Increase interstitial opacities with patchy infiltrates Received 2 L NS in the ER PMHx:   DISCHARGED 01/20/2022:  DISCHARGE SUMMARY NOT PREPARED AT THIS TIME.
Age: 64.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Tremor, Troponin
Clinical narrative: 65-year-old male with past medical history of AFib on Eliquis, asthma, hypertension, diabetes type 2 and diastolic CHF presents to medical center with complaints of weakness.  Patient's reports he has had intermittent weakness and swelling in his lower extremities for approximately 1 week.  Also admits to chills, mild shortness of breath, 1 episode of nonbloody diarrhea.  Due to weakness patient has had 1 fall yesterday denies any head trauma loss of consciousness.  Patient does not require any assistance with ambulation.  Takes Eliquis for chronic atrial fibrillation, last dose was day prior to admission.  Otherwise stated above denies any fever, cough, nausea, abdominal pain.  Reports friend's daughter recently tested positive for COVID but has not been in close contact with the daughter however has been in close contact with his friend.  Received 2 doses of Pfizer vaccine in June has not received Brewster.  Chronic history of asthma on Symbicort, denies any tobacco use, does not require supplemental oxygen at home. Of note patient was flushed and tremulous on exam did admit to feeling cold.  Denies any history of essential tremors, Parkinson's disease, alcohol abuse.  Reports he only drinks 1 6 pack per week.  ED course: VS:  SpO2 90% on room air, improved to 94% on 2 L nasal cannula  Labs:  BUN/creatinine 30/1.6, glucose 324, AST/ALT 45/40, troponin chin 540.3, ABG 7.44//27//58//18.6 Imaging:  EKG:  Atrial fibrillation with heart rate 97, CXR:  Increase interstitial opacities with patchy infiltrates Received 2 L NS in the ER PMHx:   DISCHARGED 01/20/2022:  DISCHARGE SUMMARY NOT PREPARED AT THIS TIME.
Age: 80.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Aspiration, Chills, Dyspnoea, Influenza virus test negative, Lip discolouration
Clinical narrative: Patient is a 81-year-old male with a past medical history of dementia and Parkinson's disease who presents to the ED coming from another facility with fever, chills, and witnessed aspiration event.  Patient is a resident of another facility who has dementia and Parkinson's disease with baseline mental status of alert and oriented to self only rarely speaks, uses wheelchair at baseline.  During time of exam patient is clearance and oriented to self only.  Attempted to contact patient's son but was unable to reach him.  Perceived patient history from ER physician and facility Nursing staff.  Over last few days patient has been having fevers with temperature of 100° Fahrenheit receiving Tylenol t.i.d..They also state patient has had chills.  Patient also had witnessed aspiration event today at lunch, afterwards had increased work of breathing.  There is no documented oxygen saturation, but night nurse had report of discolored lips.  ER physician reported son stated SpO2 in the 60% with this colored lives after aspiration event.  Patient was swabbed for COVID and flu over the weekend and negative.  Upon asking if facility had any COVID her flu going around they stated 1 patient at their facility was tested positive for flu today.  Will repeat COVID and flu swab today. PT REMAINS INPATIENT.
Age: 80.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Pyrexia, SARS-CoV-2 test negative
Clinical narrative: Patient is a 81-year-old male with a past medical history of dementia and Parkinson's disease who presents to the ED coming from another facility with fever, chills, and witnessed aspiration event.  Patient is a resident of another facility who has dementia and Parkinson's disease with baseline mental status of alert and oriented to self only rarely speaks, uses wheelchair at baseline.  During time of exam patient is clearance and oriented to self only.  Attempted to contact patient's son but was unable to reach him.  Perceived patient history from ER physician and facility Nursing staff.  Over last few days patient has been having fevers with temperature of 100° Fahrenheit receiving Tylenol t.i.d..They also state patient has had chills.  Patient also had witnessed aspiration event today at lunch, afterwards had increased work of breathing.  There is no documented oxygen saturation, but night nurse had report of discolored lips.  ER physician reported son stated SpO2 in the 60% with this colored lives after aspiration event.  Patient was swabbed for COVID and flu over the weekend and negative.  Upon asking if facility had any COVID her flu going around they stated 1 patient at their facility was tested positive for flu today.  Will repeat COVID and flu swab today. PT REMAINS INPATIENT.
Age: 79.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Asthenia, COVID-19, Cough, Dehydration, Dyspnoea
Clinical narrative: This patient is an 80-year-old man, followed by Dr.  He was exposed to his wife with COVID.  He was not having any symptoms, but was tested on January 12th and was positive for COVID.  He started developing some COVID symptoms on January 14th.  He is fully vaccinated.  His symptoms have been fever, cough.  He started developing shortness of breath and weakness.  He was actually in the emergency room on January 16th, main complaints were weakness, had some dehydration at that time. He was able to be discharged home.  He started having worsening weakness and shortness of breath.  He was found to have a pulse ox of 84% at home and was brought here for further evaluation.  I asked the patient if he had been started on any treatment for COVID and he admitted to taking doxycycline.  Pharmacy on the med reconciliation though notes that he is taking 4/5 days of Molnupiravir for COVID.   DISCHARGE SUMMARY HAS NOT BEEN COMPLETED AT THIS TIME.
Age: 79.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Exposure to SARS-CoV-2, Malaise, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: This patient is an 80-year-old man, followed by Dr.  He was exposed to his wife with COVID.  He was not having any symptoms, but was tested on January 12th and was positive for COVID.  He started developing some COVID symptoms on January 14th.  He is fully vaccinated.  His symptoms have been fever, cough.  He started developing shortness of breath and weakness.  He was actually in the emergency room on January 16th, main complaints were weakness, had some dehydration at that time. He was able to be discharged home.  He started having worsening weakness and shortness of breath.  He was found to have a pulse ox of 84% at home and was brought here for further evaluation.  I asked the patient if he had been started on any treatment for COVID and he admitted to taking doxycycline.  Pharmacy on the med reconciliation though notes that he is taking 4/5 days of Molnupiravir for COVID.   DISCHARGE SUMMARY HAS NOT BEEN COMPLETED AT THIS TIME.
Age: 32.0
Sex: F
Vaccine: COVID19, PPV, TDAP
Symptoms: Arthralgia, Burning sensation, Chills, Dizziness, Hyperhidrosis
Clinical narrative: Started feeling a little dizzy and pain on my right shoulder, then the pain in the right shoulder had become severe by the following day, on the third day I couldn?t even lift my arm and was in severe pain had severe migraines, had body aches, excessive sweating, chills and tingling burning sensation on the right side of my body, red almost rash like extending from below the injection site down my  bicep to elbow. I currently still have the redness covering my bicep and still experiencing muscle weakness. It will be a week tomorrow since the injection.
Age: 32.0
Sex: F
Vaccine: COVID19, PPV, TDAP
Symptoms: Injection site erythema, Migraine, Mobility decreased, Muscular weakness, Pain
Clinical narrative: Started feeling a little dizzy and pain on my right shoulder, then the pain in the right shoulder had become severe by the following day, on the third day I couldn?t even lift my arm and was in severe pain had severe migraines, had body aches, excessive sweating, chills and tingling burning sensation on the right side of my body, red almost rash like extending from below the injection site down my  bicep to elbow. I currently still have the redness covering my bicep and still experiencing muscle weakness. It will be a week tomorrow since the injection.
Age: 32.0
Sex: F
Vaccine: COVID19, PPV, TDAP
Symptoms: Paraesthesia
Clinical narrative: Started feeling a little dizzy and pain on my right shoulder, then the pain in the right shoulder had become severe by the following day, on the third day I couldn?t even lift my arm and was in severe pain had severe migraines, had body aches, excessive sweating, chills and tingling burning sensation on the right side of my body, red almost rash like extending from below the injection site down my  bicep to elbow. I currently still have the redness covering my bicep and still experiencing muscle weakness. It will be a week tomorrow since the injection.
Age: 74.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Anal incontinence, Blood bicarbonate decreased, Blood creatinine increased, Blood gases abnormal, Blood glucose normal
Clinical narrative: Patient is a 75 y/o male with hx of DMII, HTN, HLD who presented to the ED after a fall. Patient reports he has had some difficulty urinating recently and reports hematuria as well as dysuria recently. Today he reports he was in his usual state of health and he went to his bank today to transfer some money over. He recalls entering the bank and approaching the teller, and remembers nothing after that until awakening in the ED. Per ED physician, patient was noted to fall backward, striking the back of his head. There was no report of any seizure activity and no tongue bite; however, it was reported patient did lose control of bowels. Patient denies any history of seizure activity. He is currently alert and oriented x 3 but seems to be having some difficulty with comprehension. He otherwise denies complaints at this time.   In the ED, patient is noted to be borderline hypotensive with SBP 80s-100s and otherwise hemodynamically stable. Laboratory studies are significant for WBC 1, platelets 109, sodium 130, bicarbonate 19, BUN 17, creatinine 1.3, glucose 56, lactic 4.5, procalcitonin 6.6. COVID-19 is positive. ABG reveals pH 7.39, pCO2 30, pO2 90 on room air. CT Head reveals several hyperdense foci which are felt 2/2 hemorrhagic foci vs underlying tumor as well as questionable SAH vs SDH. MRI brain is recommended. CT Chest/Abdomen/Pelvis reveals no acute abnormality. Patient has been given an amp of D50 for hypoglycemia. Neurosurgery has been consulted from the ED and hospitalist service is asked for admission. Neurology was alerted of patient and is available for consult if needed pending results of MRI.  PT IS CURRENTLY INPATIENT.
Age: 74.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Blood lactic acid, Blood pH normal, Blood sodium decreased, Blood urea normal, Brain neoplasm
Clinical narrative: Patient is a 75 y/o male with hx of DMII, HTN, HLD who presented to the ED after a fall. Patient reports he has had some difficulty urinating recently and reports hematuria as well as dysuria recently. Today he reports he was in his usual state of health and he went to his bank today to transfer some money over. He recalls entering the bank and approaching the teller, and remembers nothing after that until awakening in the ED. Per ED physician, patient was noted to fall backward, striking the back of his head. There was no report of any seizure activity and no tongue bite; however, it was reported patient did lose control of bowels. Patient denies any history of seizure activity. He is currently alert and oriented x 3 but seems to be having some difficulty with comprehension. He otherwise denies complaints at this time.   In the ED, patient is noted to be borderline hypotensive with SBP 80s-100s and otherwise hemodynamically stable. Laboratory studies are significant for WBC 1, platelets 109, sodium 130, bicarbonate 19, BUN 17, creatinine 1.3, glucose 56, lactic 4.5, procalcitonin 6.6. COVID-19 is positive. ABG reveals pH 7.39, pCO2 30, pO2 90 on room air. CT Head reveals several hyperdense foci which are felt 2/2 hemorrhagic foci vs underlying tumor as well as questionable SAH vs SDH. MRI brain is recommended. CT Chest/Abdomen/Pelvis reveals no acute abnormality. Patient has been given an amp of D50 for hypoglycemia. Neurosurgery has been consulted from the ED and hospitalist service is asked for admission. Neurology was alerted of patient and is available for consult if needed pending results of MRI.  PT IS CURRENTLY INPATIENT.
Age: 74.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Cognitive disorder, Computerised tomogram abdomen normal, Computerised tomogram head abnormal, Computerised tomogram thorax normal
Clinical narrative: Patient is a 75 y/o male with hx of DMII, HTN, HLD who presented to the ED after a fall. Patient reports he has had some difficulty urinating recently and reports hematuria as well as dysuria recently. Today he reports he was in his usual state of health and he went to his bank today to transfer some money over. He recalls entering the bank and approaching the teller, and remembers nothing after that until awakening in the ED. Per ED physician, patient was noted to fall backward, striking the back of his head. There was no report of any seizure activity and no tongue bite; however, it was reported patient did lose control of bowels. Patient denies any history of seizure activity. He is currently alert and oriented x 3 but seems to be having some difficulty with comprehension. He otherwise denies complaints at this time.   In the ED, patient is noted to be borderline hypotensive with SBP 80s-100s and otherwise hemodynamically stable. Laboratory studies are significant for WBC 1, platelets 109, sodium 130, bicarbonate 19, BUN 17, creatinine 1.3, glucose 56, lactic 4.5, procalcitonin 6.6. COVID-19 is positive. ABG reveals pH 7.39, pCO2 30, pO2 90 on room air. CT Head reveals several hyperdense foci which are felt 2/2 hemorrhagic foci vs underlying tumor as well as questionable SAH vs SDH. MRI brain is recommended. CT Chest/Abdomen/Pelvis reveals no acute abnormality. Patient has been given an amp of D50 for hypoglycemia. Neurosurgery has been consulted from the ED and hospitalist service is asked for admission. Neurology was alerted of patient and is available for consult if needed pending results of MRI.  PT IS CURRENTLY INPATIENT.
Age: 74.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Dysuria, Fall, Haematuria, Head injury, Hypoglycaemia
Clinical narrative: Patient is a 75 y/o male with hx of DMII, HTN, HLD who presented to the ED after a fall. Patient reports he has had some difficulty urinating recently and reports hematuria as well as dysuria recently. Today he reports he was in his usual state of health and he went to his bank today to transfer some money over. He recalls entering the bank and approaching the teller, and remembers nothing after that until awakening in the ED. Per ED physician, patient was noted to fall backward, striking the back of his head. There was no report of any seizure activity and no tongue bite; however, it was reported patient did lose control of bowels. Patient denies any history of seizure activity. He is currently alert and oriented x 3 but seems to be having some difficulty with comprehension. He otherwise denies complaints at this time.   In the ED, patient is noted to be borderline hypotensive with SBP 80s-100s and otherwise hemodynamically stable. Laboratory studies are significant for WBC 1, platelets 109, sodium 130, bicarbonate 19, BUN 17, creatinine 1.3, glucose 56, lactic 4.5, procalcitonin 6.6. COVID-19 is positive. ABG reveals pH 7.39, pCO2 30, pO2 90 on room air. CT Head reveals several hyperdense foci which are felt 2/2 hemorrhagic foci vs underlying tumor as well as questionable SAH vs SDH. MRI brain is recommended. CT Chest/Abdomen/Pelvis reveals no acute abnormality. Patient has been given an amp of D50 for hypoglycemia. Neurosurgery has been consulted from the ED and hospitalist service is asked for admission. Neurology was alerted of patient and is available for consult if needed pending results of MRI.  PT IS CURRENTLY INPATIENT.
Age: 74.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Hypotension, Laboratory test abnormal, PCO2 decreased, PO2 normal, Platelet count decreased
Clinical narrative: Patient is a 75 y/o male with hx of DMII, HTN, HLD who presented to the ED after a fall. Patient reports he has had some difficulty urinating recently and reports hematuria as well as dysuria recently. Today he reports he was in his usual state of health and he went to his bank today to transfer some money over. He recalls entering the bank and approaching the teller, and remembers nothing after that until awakening in the ED. Per ED physician, patient was noted to fall backward, striking the back of his head. There was no report of any seizure activity and no tongue bite; however, it was reported patient did lose control of bowels. Patient denies any history of seizure activity. He is currently alert and oriented x 3 but seems to be having some difficulty with comprehension. He otherwise denies complaints at this time.   In the ED, patient is noted to be borderline hypotensive with SBP 80s-100s and otherwise hemodynamically stable. Laboratory studies are significant for WBC 1, platelets 109, sodium 130, bicarbonate 19, BUN 17, creatinine 1.3, glucose 56, lactic 4.5, procalcitonin 6.6. COVID-19 is positive. ABG reveals pH 7.39, pCO2 30, pO2 90 on room air. CT Head reveals several hyperdense foci which are felt 2/2 hemorrhagic foci vs underlying tumor as well as questionable SAH vs SDH. MRI brain is recommended. CT Chest/Abdomen/Pelvis reveals no acute abnormality. Patient has been given an amp of D50 for hypoglycemia. Neurosurgery has been consulted from the ED and hospitalist service is asked for admission. Neurology was alerted of patient and is available for consult if needed pending results of MRI.  PT IS CURRENTLY INPATIENT.