chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Abdominal X-ray, Abdominal pain, Acquired diaphragmatic eventration, Aortic arteriosclerosis, Ascites
Clinical narrative: Patient is a 79 year old male with a past medical history of hypertension, type-2 diabetes & obstructive sleep apnea who presented to ED on 4/19/22 with concerns related to sharp right-sided abdominal pain that began that same morning. Radiologic evaluation revealed a duodenal perforation. General surgery was consulted for evaluation & Patient was boarded/consented for a laparoscopic omental repair of perforated duodenal ulcer & repair of umbilical hernia. The operation went well without complication 7 a 19F Blake drain was placed in the right upper quadrant for post-surgical drainage. Patient was sent to the general medical floor in stable condition afterwards with an NG tube in place & a strict NPO order. He remained NPO throughout the day 4/20/22 & progressed well clinically. An Upper GI study was ordered 4/21/22 (POD#2) for evaluation of a leak at the repair site which did not identify any evidence of a leak. He was started on a clear liquid diet after this & his NG tube was removed. He continued to progress well & his diet was advanced to soft foods on 4/22/22 which he tolerated well throughout the day. At the end of the day 4/22/22 Patient was having consistent bowel function, tolerating a diet well & his pain was well-controlled. His right upper quadrant drain was pulled at the bedside & dressed. It was decided at this time that Patient could discharge home with instructions to follow up in the emergency general surgery clinic in 2 weeks for an in-person appointment. He was discharged on Robaxin PRN Q6H for 5 days for muscle spasm as a new medication. He was instructed to no longer take his NSAID medications from home (Naproxen & Aspirin) due to his duodenal ulcer perforation.   Physical therapy & occupational therapy teams worked with Patient throughout the entirety of his hospital stay when clinically appropriate who recommended he get discharged home when clinically appropriate with home health services. Care management assisted in the coordination of this for him at home.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Bacterial test negative, Blood culture negative, COVID-19, Candida test positive, Chest X-ray abnormal
Clinical narrative: Patient is a 79 year old male with a past medical history of hypertension, type-2 diabetes & obstructive sleep apnea who presented to ED on 4/19/22 with concerns related to sharp right-sided abdominal pain that began that same morning. Radiologic evaluation revealed a duodenal perforation. General surgery was consulted for evaluation & Patient was boarded/consented for a laparoscopic omental repair of perforated duodenal ulcer & repair of umbilical hernia. The operation went well without complication 7 a 19F Blake drain was placed in the right upper quadrant for post-surgical drainage. Patient was sent to the general medical floor in stable condition afterwards with an NG tube in place & a strict NPO order. He remained NPO throughout the day 4/20/22 & progressed well clinically. An Upper GI study was ordered 4/21/22 (POD#2) for evaluation of a leak at the repair site which did not identify any evidence of a leak. He was started on a clear liquid diet after this & his NG tube was removed. He continued to progress well & his diet was advanced to soft foods on 4/22/22 which he tolerated well throughout the day. At the end of the day 4/22/22 Patient was having consistent bowel function, tolerating a diet well & his pain was well-controlled. His right upper quadrant drain was pulled at the bedside & dressed. It was decided at this time that Patient could discharge home with instructions to follow up in the emergency general surgery clinic in 2 weeks for an in-person appointment. He was discharged on Robaxin PRN Q6H for 5 days for muscle spasm as a new medication. He was instructed to no longer take his NSAID medications from home (Naproxen & Aspirin) due to his duodenal ulcer perforation.   Physical therapy & occupational therapy teams worked with Patient throughout the entirety of his hospital stay when clinically appropriate who recommended he get discharged home when clinically appropriate with home health services. Care management assisted in the coordination of this for him at home.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen abnormal, Diverticulum intestinal, Drain placement, Duodenal perforation, Duodenal stenosis
Clinical narrative: Patient is a 79 year old male with a past medical history of hypertension, type-2 diabetes & obstructive sleep apnea who presented to ED on 4/19/22 with concerns related to sharp right-sided abdominal pain that began that same morning. Radiologic evaluation revealed a duodenal perforation. General surgery was consulted for evaluation & Patient was boarded/consented for a laparoscopic omental repair of perforated duodenal ulcer & repair of umbilical hernia. The operation went well without complication 7 a 19F Blake drain was placed in the right upper quadrant for post-surgical drainage. Patient was sent to the general medical floor in stable condition afterwards with an NG tube in place & a strict NPO order. He remained NPO throughout the day 4/20/22 & progressed well clinically. An Upper GI study was ordered 4/21/22 (POD#2) for evaluation of a leak at the repair site which did not identify any evidence of a leak. He was started on a clear liquid diet after this & his NG tube was removed. He continued to progress well & his diet was advanced to soft foods on 4/22/22 which he tolerated well throughout the day. At the end of the day 4/22/22 Patient was having consistent bowel function, tolerating a diet well & his pain was well-controlled. His right upper quadrant drain was pulled at the bedside & dressed. It was decided at this time that Patient could discharge home with instructions to follow up in the emergency general surgery clinic in 2 weeks for an in-person appointment. He was discharged on Robaxin PRN Q6H for 5 days for muscle spasm as a new medication. He was instructed to no longer take his NSAID medications from home (Naproxen & Aspirin) due to his duodenal ulcer perforation.   Physical therapy & occupational therapy teams worked with Patient throughout the entirety of his hospital stay when clinically appropriate who recommended he get discharged home when clinically appropriate with home health services. Care management assisted in the coordination of this for him at home.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Duodenal ulcer perforation, Duodenal ulcer repair, Fungal test positive, Gastric dilatation, Gastrointestinal tube insertion
Clinical narrative: Patient is a 79 year old male with a past medical history of hypertension, type-2 diabetes & obstructive sleep apnea who presented to ED on 4/19/22 with concerns related to sharp right-sided abdominal pain that began that same morning. Radiologic evaluation revealed a duodenal perforation. General surgery was consulted for evaluation & Patient was boarded/consented for a laparoscopic omental repair of perforated duodenal ulcer & repair of umbilical hernia. The operation went well without complication 7 a 19F Blake drain was placed in the right upper quadrant for post-surgical drainage. Patient was sent to the general medical floor in stable condition afterwards with an NG tube in place & a strict NPO order. He remained NPO throughout the day 4/20/22 & progressed well clinically. An Upper GI study was ordered 4/21/22 (POD#2) for evaluation of a leak at the repair site which did not identify any evidence of a leak. He was started on a clear liquid diet after this & his NG tube was removed. He continued to progress well & his diet was advanced to soft foods on 4/22/22 which he tolerated well throughout the day. At the end of the day 4/22/22 Patient was having consistent bowel function, tolerating a diet well & his pain was well-controlled. His right upper quadrant drain was pulled at the bedside & dressed. It was decided at this time that Patient could discharge home with instructions to follow up in the emergency general surgery clinic in 2 weeks for an in-person appointment. He was discharged on Robaxin PRN Q6H for 5 days for muscle spasm as a new medication. He was instructed to no longer take his NSAID medications from home (Naproxen & Aspirin) due to his duodenal ulcer perforation.   Physical therapy & occupational therapy teams worked with Patient throughout the entirety of his hospital stay when clinically appropriate who recommended he get discharged home when clinically appropriate with home health services. Care management assisted in the coordination of this for him at home.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Gram stain positive, Hiatus hernia, Influenza A virus test negative, Influenza B virus test, Laparoscopic surgery
Clinical narrative: Patient is a 79 year old male with a past medical history of hypertension, type-2 diabetes & obstructive sleep apnea who presented to ED on 4/19/22 with concerns related to sharp right-sided abdominal pain that began that same morning. Radiologic evaluation revealed a duodenal perforation. General surgery was consulted for evaluation & Patient was boarded/consented for a laparoscopic omental repair of perforated duodenal ulcer & repair of umbilical hernia. The operation went well without complication 7 a 19F Blake drain was placed in the right upper quadrant for post-surgical drainage. Patient was sent to the general medical floor in stable condition afterwards with an NG tube in place & a strict NPO order. He remained NPO throughout the day 4/20/22 & progressed well clinically. An Upper GI study was ordered 4/21/22 (POD#2) for evaluation of a leak at the repair site which did not identify any evidence of a leak. He was started on a clear liquid diet after this & his NG tube was removed. He continued to progress well & his diet was advanced to soft foods on 4/22/22 which he tolerated well throughout the day. At the end of the day 4/22/22 Patient was having consistent bowel function, tolerating a diet well & his pain was well-controlled. His right upper quadrant drain was pulled at the bedside & dressed. It was decided at this time that Patient could discharge home with instructions to follow up in the emergency general surgery clinic in 2 weeks for an in-person appointment. He was discharged on Robaxin PRN Q6H for 5 days for muscle spasm as a new medication. He was instructed to no longer take his NSAID medications from home (Naproxen & Aspirin) due to his duodenal ulcer perforation.   Physical therapy & occupational therapy teams worked with Patient throughout the entirety of his hospital stay when clinically appropriate who recommended he get discharged home when clinically appropriate with home health services. Care management assisted in the coordination of this for him at home.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Muscle spasms, Pneumoperitoneum, Pulmonary granuloma, Respiratory syncytial virus test negative, SARS-CoV-2 test positive
Clinical narrative: Patient is a 79 year old male with a past medical history of hypertension, type-2 diabetes & obstructive sleep apnea who presented to ED on 4/19/22 with concerns related to sharp right-sided abdominal pain that began that same morning. Radiologic evaluation revealed a duodenal perforation. General surgery was consulted for evaluation & Patient was boarded/consented for a laparoscopic omental repair of perforated duodenal ulcer & repair of umbilical hernia. The operation went well without complication 7 a 19F Blake drain was placed in the right upper quadrant for post-surgical drainage. Patient was sent to the general medical floor in stable condition afterwards with an NG tube in place & a strict NPO order. He remained NPO throughout the day 4/20/22 & progressed well clinically. An Upper GI study was ordered 4/21/22 (POD#2) for evaluation of a leak at the repair site which did not identify any evidence of a leak. He was started on a clear liquid diet after this & his NG tube was removed. He continued to progress well & his diet was advanced to soft foods on 4/22/22 which he tolerated well throughout the day. At the end of the day 4/22/22 Patient was having consistent bowel function, tolerating a diet well & his pain was well-controlled. His right upper quadrant drain was pulled at the bedside & dressed. It was decided at this time that Patient could discharge home with instructions to follow up in the emergency general surgery clinic in 2 weeks for an in-person appointment. He was discharged on Robaxin PRN Q6H for 5 days for muscle spasm as a new medication. He was instructed to no longer take his NSAID medications from home (Naproxen & Aspirin) due to his duodenal ulcer perforation.   Physical therapy & occupational therapy teams worked with Patient throughout the entirety of his hospital stay when clinically appropriate who recommended he get discharged home when clinically appropriate with home health services. Care management assisted in the coordination of this for him at home.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Scan with contrast abnormal, Umbilical hernia repair, White blood cell count abnormal, X-ray
Clinical narrative: Patient is a 79 year old male with a past medical history of hypertension, type-2 diabetes & obstructive sleep apnea who presented to ED on 4/19/22 with concerns related to sharp right-sided abdominal pain that began that same morning. Radiologic evaluation revealed a duodenal perforation. General surgery was consulted for evaluation & Patient was boarded/consented for a laparoscopic omental repair of perforated duodenal ulcer & repair of umbilical hernia. The operation went well without complication 7 a 19F Blake drain was placed in the right upper quadrant for post-surgical drainage. Patient was sent to the general medical floor in stable condition afterwards with an NG tube in place & a strict NPO order. He remained NPO throughout the day 4/20/22 & progressed well clinically. An Upper GI study was ordered 4/21/22 (POD#2) for evaluation of a leak at the repair site which did not identify any evidence of a leak. He was started on a clear liquid diet after this & his NG tube was removed. He continued to progress well & his diet was advanced to soft foods on 4/22/22 which he tolerated well throughout the day. At the end of the day 4/22/22 Patient was having consistent bowel function, tolerating a diet well & his pain was well-controlled. His right upper quadrant drain was pulled at the bedside & dressed. It was decided at this time that Patient could discharge home with instructions to follow up in the emergency general surgery clinic in 2 weeks for an in-person appointment. He was discharged on Robaxin PRN Q6H for 5 days for muscle spasm as a new medication. He was instructed to no longer take his NSAID medications from home (Naproxen & Aspirin) due to his duodenal ulcer perforation.   Physical therapy & occupational therapy teams worked with Patient throughout the entirety of his hospital stay when clinically appropriate who recommended he get discharged home when clinically appropriate with home health services. Care management assisted in the coordination of this for him at home.
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect dose administered
Clinical narrative: Non - IC patient received Moderna full dose 0.5mL as B1 in error as indicated in this report - Incident happened 11/08/21, discovered 04/28/22
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Feeling hot, Gait disturbance, Malaise, Panic attack
Clinical narrative: A few days after receiving the vaccine, I had gone to the mall and went up to the second floor and started walking when I began to feel over heated and was suddenly not feeling well. It felt like I was having a panic attack. I started to become dizzy and felt like I was going to pass out so I grabbed on to the railing near by and knelt down a bit and waited for it to subside. I had tunnel vision for a while and it started to get better. It felt as though it lasted a long time but was most likely only 10 minutes or so. I eventually was able to get down stairs and back to my car to get home. I called my doctor the next day to see what was going on because everywhere I went, I would feel dizzy and unsteady on my feet. I was concerned about an inner ear issue but the doctor implied that it my be due to my vaccine. She prescribed a steroid Z pack and everything seemed to get better.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Tunnel vision
Clinical narrative: A few days after receiving the vaccine, I had gone to the mall and went up to the second floor and started walking when I began to feel over heated and was suddenly not feeling well. It felt like I was having a panic attack. I started to become dizzy and felt like I was going to pass out so I grabbed on to the railing near by and knelt down a bit and waited for it to subside. I had tunnel vision for a while and it started to get better. It felt as though it lasted a long time but was most likely only 10 minutes or so. I eventually was able to get down stairs and back to my car to get home. I called my doctor the next day to see what was going on because everywhere I went, I would feel dizzy and unsteady on my feet. I was concerned about an inner ear issue but the doctor implied that it my be due to my vaccine. She prescribed a steroid Z pack and everything seemed to get better.
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect dose administered
Clinical narrative: NON - IC patient received Moderna full dose 0.5mL for B1 in error. Vaccination happened on 09/21/21 and discovered today as indicated in this report.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Adenovirus test, Bladder catheterisation, Blood culture negative, Blood lactic acid, Bordetella test negative
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Central venous catheterisation, Cerebral small vessel ischaemic disease, Chest X-ray abnormal, Chlamydia test negative
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Computerised tomogram head abnormal, Coronavirus test positive, Depressed level of consciousness, Encephalomalacia, Enterovirus test negative
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Fibrin D dimer increased, Human metapneumovirus test, Human rhinovirus test, Hypotension, Hypoxia
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Influenza A virus test negative, Influenza B virus test, Intensive care, Interstitial lung disease, Lacunar infarction
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Legionella test, Lethargy, Lung opacity, Meningioma, Mental status changes
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Mucosal hypertrophy, Mycoplasma test negative, Pleural effusion, Pneumonia, Poverty of speech
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Pyrexia, Respiratory syncytial virus test negative, Respirovirus test, SARS-CoV-2 test positive, Seizure
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Sepsis, Shift to the left, Staphylococcus test negative, Ultrasound Doppler normal, Urine analysis normal
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: White blood cell count normal
Clinical narrative: Patient is a 76 y.o. male nursing home resident patient with history of dementia who presents today with witnessed seizure and decreased level of consciousness.  Patient was hypotensive and febrile and hypoxic on arrival.  Patient is responsive to IVF's with improved MAP of 70 with a heart rate of 84 (sinus rhythm).   His code status is DNR, but his wife (who is his MDPOA) said do not intubate, no CPR, but okay to place CVC for IVF resuscitation and possible need for pressors.  The CVC was placed via US guidance successfully with CXR confirming placement with no pneumothorax.  The CXR is consistent with bilateral lower lobe interstitial pneumonia consistent with his COVID 19 positivity.  Patient doesn't seem to have labored breathing at this time on a NRB mask which will be converted to HFNC on the floor.  His Sa)2 is 100%.     He is lethargic at this time, but woke up and took my hand away when I looked at his ears.  At baseline he can answer yes/no questions and speaks in one word sentences.  Per the ER RN, the patient is a resident at a nursing facility related to his advanced dementia.     He is being admitted for Severe Sepsis with the following sepsis criteria:  T 38.5, HR 98, BP 73/44, RR 22, NRB mask w/ SaO2 94-96%, WBC 9.38 w/ a L shift, lactic acid 3.4.  Source is lungs.  UA is negative with good urine output with foley catheter in place.     Unfortunately, he tested positive for COVID 19, but he is fully vaccinated with the 1st booster completed on 12/3/21.  He is overdue for his 2nd booster.     He will be admitted to CCU for Severe sepsis secondary to bilateral interstitial pneumonia.  Will rule out bacterial and other viral etiologies.   Asbestos related cancer to lung with mets to brain.  He had a partial lobectomy of the tumor, had surgical removal from brain as well.  He has a recurrence to the brain, after being in remission since 2016.  He had gamma knife surgery for the 2nd brain lesion.
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Asthenia, C-reactive protein increased, COVID-19, Comminuted fracture, Computerised tomogram abnormal
Clinical narrative: his is a 92-year-old male with a past medical history significant for coronary artery disease, DVT, GERD, subdural hemorrhage and craniotomy and cholecystectomy, who presents to the emergency department with complaints of progressive symptoms of cough, shortness of breath and altered mentation for approximately 1-1/2 days.  This occurs in the setting of a recent fall.  Patient was seen in the emergency department on 4/22/2022 for fall when he tripped while using his walker.  The patient suffered a comminuted impacted fracture of the neck of the right humerus.  Patient's radiographic studies in the emergency department on that day were x-rays of the shoulder as well as CT scans of the shoulder.  He did not have any other scans of the head neck as he had denied any head injury no loss of consciousness.  Patient has presently a nonproductive cough shortness of breath and increased dyspnea on exertion and per the son is more confused
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Computerised tomogram head normal, Confusional state, Cough, Dehydration, Dyspnoea
Clinical narrative: his is a 92-year-old male with a past medical history significant for coronary artery disease, DVT, GERD, subdural hemorrhage and craniotomy and cholecystectomy, who presents to the emergency department with complaints of progressive symptoms of cough, shortness of breath and altered mentation for approximately 1-1/2 days.  This occurs in the setting of a recent fall.  Patient was seen in the emergency department on 4/22/2022 for fall when he tripped while using his walker.  The patient suffered a comminuted impacted fracture of the neck of the right humerus.  Patient's radiographic studies in the emergency department on that day were x-rays of the shoulder as well as CT scans of the shoulder.  He did not have any other scans of the head neck as he had denied any head injury no loss of consciousness.  Patient has presently a nonproductive cough shortness of breath and increased dyspnea on exertion and per the son is more confused
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Dyspnoea exertional, Fall, Gait disturbance, Humerus fracture, Hypophagia
Clinical narrative: his is a 92-year-old male with a past medical history significant for coronary artery disease, DVT, GERD, subdural hemorrhage and craniotomy and cholecystectomy, who presents to the emergency department with complaints of progressive symptoms of cough, shortness of breath and altered mentation for approximately 1-1/2 days.  This occurs in the setting of a recent fall.  Patient was seen in the emergency department on 4/22/2022 for fall when he tripped while using his walker.  The patient suffered a comminuted impacted fracture of the neck of the right humerus.  Patient's radiographic studies in the emergency department on that day were x-rays of the shoulder as well as CT scans of the shoulder.  He did not have any other scans of the head neck as he had denied any head injury no loss of consciousness.  Patient has presently a nonproductive cough shortness of breath and increased dyspnea on exertion and per the son is more confused
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Impacted fracture, Mental status changes, Myalgia, Positive airway pressure therapy, Red blood cell sedimentation rate increased
Clinical narrative: his is a 92-year-old male with a past medical history significant for coronary artery disease, DVT, GERD, subdural hemorrhage and craniotomy and cholecystectomy, who presents to the emergency department with complaints of progressive symptoms of cough, shortness of breath and altered mentation for approximately 1-1/2 days.  This occurs in the setting of a recent fall.  Patient was seen in the emergency department on 4/22/2022 for fall when he tripped while using his walker.  The patient suffered a comminuted impacted fracture of the neck of the right humerus.  Patient's radiographic studies in the emergency department on that day were x-rays of the shoulder as well as CT scans of the shoulder.  He did not have any other scans of the head neck as he had denied any head injury no loss of consciousness.  Patient has presently a nonproductive cough shortness of breath and increased dyspnea on exertion and per the son is more confused
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Viral infection, Walking aid user, X-ray limb abnormal
Clinical narrative: his is a 92-year-old male with a past medical history significant for coronary artery disease, DVT, GERD, subdural hemorrhage and craniotomy and cholecystectomy, who presents to the emergency department with complaints of progressive symptoms of cough, shortness of breath and altered mentation for approximately 1-1/2 days.  This occurs in the setting of a recent fall.  Patient was seen in the emergency department on 4/22/2022 for fall when he tripped while using his walker.  The patient suffered a comminuted impacted fracture of the neck of the right humerus.  Patient's radiographic studies in the emergency department on that day were x-rays of the shoulder as well as CT scans of the shoulder.  He did not have any other scans of the head neck as he had denied any head injury no loss of consciousness.  Patient has presently a nonproductive cough shortness of breath and increased dyspnea on exertion and per the son is more confused
Age: 53.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiac stress test normal, Chest pain, Echocardiogram, Electric shock sensation, Electrocardiogram
Clinical narrative: 13 days following the first booster, had pain in left chest beginning sporadically around approximately 3pm.  By 6pm the pain was continuous.  It felt like a charley horse or electrical shock in my heart. I went to an ER. The last thing I remember was being given morphine. I was hospitalized until Monday November 22nd. I underwent numerous tests including a stress test and GI related tests. All results were inconclusive.  An electrophysiologist recommended implanting a loop recorder.  I chose to do this on an outpatient basis.  Had the procedure done on February.  Had the device explanted a week later because the incision opened and the device began backing itself out of the open incision area.  Am now recording my symptoms with the Kardiamobile device and patiently waiting for someone to figure out the solution to the ongoing cardiac symptoms I?m experiencing since (probably) having Covid.
Age: 53.0
Sex: F
Vaccine: COVID19
Symptoms: Gastrointestinal scan, Implantable cardiac monitor insertion, Implantable cardiac monitor removal, Postoperative wound complication
Clinical narrative: 13 days following the first booster, had pain in left chest beginning sporadically around approximately 3pm.  By 6pm the pain was continuous.  It felt like a charley horse or electrical shock in my heart. I went to an ER. The last thing I remember was being given morphine. I was hospitalized until Monday November 22nd. I underwent numerous tests including a stress test and GI related tests. All results were inconclusive.  An electrophysiologist recommended implanting a loop recorder.  I chose to do this on an outpatient basis.  Had the procedure done on February.  Had the device explanted a week later because the incision opened and the device began backing itself out of the open incision area.  Am now recording my symptoms with the Kardiamobile device and patiently waiting for someone to figure out the solution to the ongoing cardiac symptoms I?m experiencing since (probably) having Covid.
Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Acoustic stimulation tests abnormal, Balance disorder, Deafness neurosensory, Deafness unilateral, Sudden hearing loss
Clinical narrative: Awoke on 12/13 with Sudden Neurosnsory Hearing Loss.  Loss of balance, loss of hearing in one ear.  Treatment was steroid treatment and injections.  Hearing loss in right ear is permanent, requiring hearing aids.
Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Dizziness, Dyspnoea, Hypotension, Inappropriate schedule of product administration
Clinical narrative: Client presented at vaccination site on 01.13.22. Client reported she received first dose of Moderna COVID vaccine on 03/23/21 (lot #: 008B21A) with no issues. Client reported she received second dose of Moderna COVID vaccine on 04/24/21 (lot #: 014C21A), she stated within 10 minutes after the shot, she had dizziness, lightheadedness, weakness, and shortness of breath (breathing hard and feeling like she was going to faint but didn?t faint). Client reported the MD at the vaccination site took her BP and told her BP was low and she was experiencing a panic attack. Client denied any history of panic attacks or anxiety. She stated she didn?t follow-up with her PCP. She reported she didn?t have any chronic illnesses, not on any medications, or have any known allergy. Client reports she takes iron pills when she gets her period as needed. Client reports she has a fear of blood draw and injection. Today, PHN took client?s vitals: BP 129/93, HR 93, O2 Sat. 100 %. Client is requesting for the booster dose of Moderna COVID vaccine today. PHN submitted a medical consult via text message to clinical project coordinator, requesting to proceed with the booster dose of Moderna COVID vaccine. Per the doctor, approval to proceed with the booster dose of Moderna COVID vaccine was obtained via text message from clinical project coordinator. Client received the booster dose of Moderna COVID vaccine, LOT#: 084J21A on 01/13/22 at 1509 by LVN. The client did not report any symptoms during the 30-minute observation period. PHN educated client on possible adverse reactions and when to seek EMS. Client verbalized understanding. Client left vaccination site at 1539 unassisted and with a steady gait.