chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 34.0
Sex: M
Vaccine: COVID19
Symptoms: Chest discomfort, Flushing, Hypoaesthesia, Nausea
Clinical narrative: Patient received first dose of Pfizer COVID vaccine at a local pharmacy (Pharmacy).  He did not report symptoms experienced to that pharmacy, although he waited the requested 15 minutes there after vaccination.  Several weeks later, he reported post vaccination symptoms during an unrelated visit to the Co. Health Department.  He described sensations of chest tightness, facial and chest flushing, mild nausea and numbness in both hands which started ten minutes after vaccine administration.  He left the pharmacy without reporting these symptoms and reports they resolved without any intervention or medication, by two hours after receiving the vaccine.  During his subsequent visit to the Health Department he asked if he could complete vaccination for COVID.
Age: 17.0
Sex: F
Vaccine: COVID19
Symptoms: No adverse event, Product administered to patient of inappropriate age
Clinical narrative: No reactions.  Patient was under age of requirement for the Moderna Vaccine at the time of first dose vaccination.  Administered 2nd dose with parent's approval.
Age: 0.17
Sex: M
Vaccine: DTAPHEPBIP, HIBV, PNC13, RV1
Symptoms: Lacrimation increased, Swelling face
Clinical narrative: Mother states infant woke up at 10:00 am on 08/12/21 the day after immunizations w/ R side face swelling and watery R eye.  States no redness, no breathing difficulty, and no noted fever.  States infant smiling and appears to be in no distress.  Referred infant to ER.
Age: 14.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Rash, Rash maculo-papular
Clinical narrative: Maculopapular rash began on right arm and spread throughout the body 1-2 days after the second vaccination. No fevers, pain, itchy or joint pain was involved. Rash is asymptomatic.
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Ophthalmic vein thrombosis, Ophthalmological examination abnormal, Retinal vein occlusion, Visual impairment
Clinical narrative: Retinal Vein Occlusion. Blood clot in eye?
Age: 49.0
Sex: F
Vaccine: COVID19
Symptoms: Vitreous floaters
Clinical narrative: Sudden onset of eye floaters
Age: 26.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram, Ear discomfort, Headache, Hypertension, Migraine
Clinical narrative: Symptoms: blurred vision, clogged ears, migraine, fever, stiff neck, high blood pressure   Adverse effect of COVID-19 vaccine Acute nonintractable headache, unspecified headache type Trapezius muscle spasm Pseudotumor migraine  Migraine cocktail and CT scan performed  Symptoms were much better after
Age: 26.0
Sex: F
Vaccine: COVID19
Symptoms: Muscle spasms, Musculoskeletal stiffness, Vaccination complication, Vision blurred
Clinical narrative: Symptoms: blurred vision, clogged ears, migraine, fever, stiff neck, high blood pressure   Adverse effect of COVID-19 vaccine Acute nonintractable headache, unspecified headache type Trapezius muscle spasm Pseudotumor migraine  Migraine cocktail and CT scan performed  Symptoms were much better after
Age: 44.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Positive covid antigen test reported 9/5/21
Age: 51.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Bell's palsy, Eye irritation, Facial paralysis, Osteoarthritis
Clinical narrative: Bells Palsy onset 6/19/21 (began as eye irritation), noticed facial palsy 6/25/21. Noticeably better by July 2.  Fully resolved by July 16.   Also noticed onset of osteoarthritis in left index finger shortly after Bells Palsy. That has not resolved.  Not sure if related to vaccine or not.
Age: 36.0
Sex: F
Vaccine: COVID19
Symptoms: Ageusia, Anosmia, COVID-19, Diarrhoea, Dyspnoea
Clinical narrative: Pt. fully vaccinated with Pfizer vaccine: dose 1 on 12/22/20 and dose 2 on 1/12/21. Pt. reports COVID symptoms of Muscle aches, sore throat, fever, headache, loss of taste, loss of smell, diarrhea, shortness of breath, congestion  starting on 8/30/21. Pt. had 2 high risk community exposures to 2 non-vaccinated household members (children) prior to symptom onset.  Pt. was not able to separate from the COVID+ household members. Pt. tested COVID positive on 9/2/21
Age: 36.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Myalgia, Oropharyngeal pain, Pyrexia, Respiratory tract congestion
Clinical narrative: Pt. fully vaccinated with Pfizer vaccine: dose 1 on 12/22/20 and dose 2 on 1/12/21. Pt. reports COVID symptoms of Muscle aches, sore throat, fever, headache, loss of taste, loss of smell, diarrhea, shortness of breath, congestion  starting on 8/30/21. Pt. had 2 high risk community exposures to 2 non-vaccinated household members (children) prior to symptom onset.  Pt. was not able to separate from the COVID+ household members. Pt. tested COVID positive on 9/2/21
Age: 36.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: Pt. fully vaccinated with Pfizer vaccine: dose 1 on 12/22/20 and dose 2 on 1/12/21. Pt. reports COVID symptoms of Muscle aches, sore throat, fever, headache, loss of taste, loss of smell, diarrhea, shortness of breath, congestion  starting on 8/30/21. Pt. had 2 high risk community exposures to 2 non-vaccinated household members (children) prior to symptom onset.  Pt. was not able to separate from the COVID+ household members. Pt. tested COVID positive on 9/2/21
Age: 61.0
Sex: F
Vaccine: VARZOS
Symptoms: Chills, Cough, Pain, Pyrexia
Clinical narrative: Patient started to have body aches, chills, fever, and cough.  States symptoms are moderate in nature but started about 12 hours after the vaccination.
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Appetite disorder, Dyspepsia, Limb discomfort, Nausea, Neuropathy peripheral
Clinical narrative: Extreme tremors, lower legs became heavy, neuropathy, neurological disorders, vomiting for 4 day.  Still extremely nauseated effecting digestive tract.  Severe diet disorder.
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Tremor, Vomiting
Clinical narrative: Extreme tremors, lower legs became heavy, neuropathy, neurological disorders, vomiting for 4 day.  Still extremely nauseated effecting digestive tract.  Severe diet disorder.
Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Bone pain, Fatigue, Headache
Clinical narrative: headache, bone ache, fatigue; took tylenol; resolved in 4 days
Age: 37.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain upper, Diarrhoea, Headache, Myalgia, Nausea
Clinical narrative: Fever, Headache, Myalgias, Stomach Cramping, Nausea, Diarrhea
Age: 37.0
Sex: F
Vaccine: COVID19
Symptoms: Pyrexia
Clinical narrative: Fever, Headache, Myalgias, Stomach Cramping, Nausea, Diarrhea
Age: 34.0
Sex: F
Vaccine: COVID19
Symptoms: Intermenstrual bleeding
Clinical narrative: Patient called the pharmacy the day after the vaccination and reported break through bleeding in her menstrual cycle.  She usually is very regular and shouldn't cycle until the 26th of the month.  Patient will continue to monitor.
Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Back pain, Inflammation, Pain in extremity, Polymyalgia rheumatica
Clinical narrative: inflamation  pain in back, legs and joints, spinal stenosis
Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Spinal stenosis
Clinical narrative: inflamation  pain in back, legs and joints, spinal stenosis
Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Dyspnoea, Seizure, Speech disorder
Clinical narrative: CONVULSIONS. DIFFICULTY SPEAKING. DIFFICULTY BREATHING. WEAKNESS
Age: 68.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood test, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Cough, Dyspnoea
Clinical narrative: Patient stated that the day of the vaccine he was fine. The next day he had a cough and was getting shortness of breathe. His wife took him to the ER. They found two blood clots in his lungs.
Age: 68.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Pulmonary thrombosis
Clinical narrative: Patient stated that the day of the vaccine he was fine. The next day he had a cough and was getting shortness of breathe. His wife took him to the ER. They found two blood clots in his lungs.
Age: 66.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Chills, Cough, Oropharyngeal pain, Pain
Clinical narrative: Presents with multiple complaints including body aches, chills, cough, and sore throat.
Age: 66.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: Presents with multiple complaints including body aches, chills, cough, and sore throat.
Age: 33.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Pain, Pyrexia, Somnolence
Clinical narrative: Fever, whole body soreness, feeling drowsy and weak.
Age: 69.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Chills, Fatigue, Insomnia, Muscle spasms, Nausea
Clinical narrative: 9/2 - The first day arm pain, end of second day pt had nausea and chills.  Fatigue increased on the 3rd day. 9/7 patient reports leg cramps in bilateral legs to the point patient could not sleep. Pt reports that she is very active usually. Advised pt if she experienced leg pain or SOB to seek care with MD.
Age: 69.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Pain in extremity
Clinical narrative: 9/2 - The first day arm pain, end of second day pt had nausea and chills.  Fatigue increased on the 3rd day. 9/7 patient reports leg cramps in bilateral legs to the point patient could not sleep. Pt reports that she is very active usually. Advised pt if she experienced leg pain or SOB to seek care with MD.
Age: 35.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain, Chills, Fatigue, Headache, Myalgia
Clinical narrative: Chills, headache, fever, fatigue, muscle aches, abdominal pain, congestion beginning 2230 on 09/07/2021.
Age: 35.0
Sex: F
Vaccine: COVID19
Symptoms: Pyrexia, Respiratory tract congestion
Clinical narrative: Chills, headache, fever, fatigue, muscle aches, abdominal pain, congestion beginning 2230 on 09/07/2021.
Age: 29.0
Sex: F
Vaccine: UNK
Symptoms: Headache
Clinical narrative: Pounding headache
Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Hospitalization with COVID-19.  Positive test on 09/02/2021
Age: 46.0
Sex: M
Vaccine: COVID19
Symptoms: Blood pressure decreased, Dyspnoea, Face injury, Fatigue, Heart rate decreased
Clinical narrative: First five minutes seemed normal but suddenly passed out and hit my face on the floor.  paramedics were called and my blood pressure dropped and pulse was as low as 32 bpm.  I had a lot of sweat everywhere as well.  I was feeling tired as well.  I thought I was getting better then passed out again.  For about 10 seconds I couldn't get enough air and thought I was going to die.  I finally returned to normal after an hour.
Age: 46.0
Sex: M
Vaccine: COVID19
Symptoms: Hyperhidrosis, Loss of consciousness
Clinical narrative: First five minutes seemed normal but suddenly passed out and hit my face on the floor.  paramedics were called and my blood pressure dropped and pulse was as low as 32 bpm.  I had a lot of sweat everywhere as well.  I was feeling tired as well.  I thought I was getting better then passed out again.  For about 10 seconds I couldn't get enough air and thought I was going to die.  I finally returned to normal after an hour.
Age: 41.0
Sex: F
Vaccine: COVID19
Symptoms: Back pain, Blood test, Computerised tomogram abnormal, Discomfort, Gait disturbance
Clinical narrative: 8/31- shot given no side effects immediately                Evening, sore arm slightly warm 9/1-4:00am woke up extremely uncomfortable cramps in lower back couldn?t get comfortable. Took alive tried to go back to sleep           5:30 get up to make breakfast intense pain in lower back and hurting when I walked in my right leg Limped around to make breakfast took Tylenol layer back down tried to rest. Thinking it was body aches. Through the morning the pain increases to unbearable my right leg tingles like it?s asleep. Extremely painful to sit. We notice my back is swollen we do heating pad, ice more alieve. We call pharmacy to tell them and ask what to do they say they have never heard of this reaction. Tell us to call our dr. We call our insurance carrier and talk to nurse who advised us to go to ER where I was treated they did ct scan and I was diagnosis there was sciatica we were referred to orthopedic specialist. I was given meds I saw the orthopedic dr on Friday I believe. I was given a back brace and two injections and told to see a spinal specialist. To see a spinal specialist I needed to see a primary care provider which I saw this morning. We did blood work to check for autoimmune disease and I have a MRI scheduled tomorrow. I was also given another injection plus more pain meds. I did check disabled below because I can barely function  I?m not sure if this is going to resolve
Age: 41.0
Sex: F
Vaccine: COVID19
Symptoms: Mobility decreased, Muscle spasms, Pain, Pain in extremity, Paraesthesia
Clinical narrative: 8/31- shot given no side effects immediately                Evening, sore arm slightly warm 9/1-4:00am woke up extremely uncomfortable cramps in lower back couldn?t get comfortable. Took alive tried to go back to sleep           5:30 get up to make breakfast intense pain in lower back and hurting when I walked in my right leg Limped around to make breakfast took Tylenol layer back down tried to rest. Thinking it was body aches. Through the morning the pain increases to unbearable my right leg tingles like it?s asleep. Extremely painful to sit. We notice my back is swollen we do heating pad, ice more alieve. We call pharmacy to tell them and ask what to do they say they have never heard of this reaction. Tell us to call our dr. We call our insurance carrier and talk to nurse who advised us to go to ER where I was treated they did ct scan and I was diagnosis there was sciatica we were referred to orthopedic specialist. I was given meds I saw the orthopedic dr on Friday I believe. I was given a back brace and two injections and told to see a spinal specialist. To see a spinal specialist I needed to see a primary care provider which I saw this morning. We did blood work to check for autoimmune disease and I have a MRI scheduled tomorrow. I was also given another injection plus more pain meds. I did check disabled below because I can barely function  I?m not sure if this is going to resolve
Age: 41.0
Sex: F
Vaccine: COVID19
Symptoms: Sciatica, Skin warm, Sleep disorder, Swelling
Clinical narrative: 8/31- shot given no side effects immediately                Evening, sore arm slightly warm 9/1-4:00am woke up extremely uncomfortable cramps in lower back couldn?t get comfortable. Took alive tried to go back to sleep           5:30 get up to make breakfast intense pain in lower back and hurting when I walked in my right leg Limped around to make breakfast took Tylenol layer back down tried to rest. Thinking it was body aches. Through the morning the pain increases to unbearable my right leg tingles like it?s asleep. Extremely painful to sit. We notice my back is swollen we do heating pad, ice more alieve. We call pharmacy to tell them and ask what to do they say they have never heard of this reaction. Tell us to call our dr. We call our insurance carrier and talk to nurse who advised us to go to ER where I was treated they did ct scan and I was diagnosis there was sciatica we were referred to orthopedic specialist. I was given meds I saw the orthopedic dr on Friday I believe. I was given a back brace and two injections and told to see a spinal specialist. To see a spinal specialist I needed to see a primary care provider which I saw this morning. We did blood work to check for autoimmune disease and I have a MRI scheduled tomorrow. I was also given another injection plus more pain meds. I did check disabled below because I can barely function  I?m not sure if this is going to resolve
Age: 54.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Erythema, Pruritus, Skin discolouration, Skin lesion, Skin warm
Clinical narrative: Starting 2-3 days after 1st dose silver dollar sized lesion to right leg. Started off as red with itch then got darker and warm to touch lasting approx 14 days. Then another lesion appeared with similar course.  Thus far patient has had total of 10 lesions come and go to legs, arms.
Age: 34.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Chest pain, Chills, Fatigue, Hyperhidrosis
Clinical narrative: High fever (104F), severe body aches, weakness, chest pain, fatigue, sweating, chills. These items lasted from approximately 6pm on 9/7, until 5am 9/8 and have been beginning to subside since then.
Age: 34.0
Sex: F
Vaccine: COVID19
Symptoms: Pain, Pyrexia
Clinical narrative: High fever (104F), severe body aches, weakness, chest pain, fatigue, sweating, chills. These items lasted from approximately 6pm on 9/7, until 5am 9/8 and have been beginning to subside since then.
Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Audiogram, Immediate post-injection reaction, Tinnitus
Clinical narrative: The patient develop acute onset tinnitus in the immediate period of the second dose of the Moderna Covid vaccine. He had no prior ENT issues. He was having no ENT issues at the preceding the vaccine. The tinnitus has not resolved now going on 5 months since the vaccine.
Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Eyelid disorder, Eyelid pain, Headache
Clinical narrative: Left eyelid is heavy and aches, massive headache on left side
Age: 32.0
Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine normal, Chills, Myalgia
Clinical narrative: Fevers to 102 with chills, myalgias for 6 days. Responsive to Tylenol and ibuprofen.
Age: 32.0
Sex: M
Vaccine: COVID19
Symptoms: Platelet count decreased, Pyrexia, White blood cell count decreased
Clinical narrative: Fevers to 102 with chills, myalgias for 6 days. Responsive to Tylenol and ibuprofen.
Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Angiogram normal, Aphasia, Blood test normal, Computerised tomogram normal, Dizziness
Clinical narrative: Tues: dizziness, nausea, numb lips Wed: dizziness, nausea, numb face Thurs: dizziness, nausea, numb face and all extremities, aphasia
Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Echocardiogram normal, Hypoaesthesia, Hypoaesthesia oral, Laboratory test normal, Magnetic resonance imaging normal
Clinical narrative: Tues: dizziness, nausea, numb lips Wed: dizziness, nausea, numb face Thurs: dizziness, nausea, numb face and all extremities, aphasia
Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Nausea, SARS-CoV-2 test negative, Ultrasound Doppler, Venogram normal
Clinical narrative: Tues: dizziness, nausea, numb lips Wed: dizziness, nausea, numb face Thurs: dizziness, nausea, numb face and all extremities, aphasia
Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test
Clinical narrative: Started symptoms on 08/31/2021.
Age: 92.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Exposure to SARS-CoV-2, SARS-CoV-2 test positive
Clinical narrative: POSITIVE COVID RESULT 9/7/21. KNOWN EXPOSURE ON 9/2/21 FROM FAMILY MEMBER
Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Breast tenderness
Clinical narrative: Tenderness in left breast where lymph nodes were removed during a lumpectomy that occurred in January 2013. Tenderness still there as of this date. Although minor I wanted my information included with others how may have reported.
Age: 15.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Chills, Pain in extremity, Pyrexia
Clinical narrative: chills fever sore arm
Age: 15.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Interchange of vaccine products
Clinical narrative: chills fever sore arm
Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dyspnoea, Vaccination complication
Clinical narrative: EMERGENCY PHYSICIAN PROVIDER NOTE     FINAL IMPRESSION 1. Vaccine reaction, initial encounter      ED COURSE AND MEDICAL DECISION MAKING   48-year-old female with a history of diverticulitis persisting despite oral Augmentin who was admitted yesterday for IV antibiotics and received Covid 19 Johnson & Johnson vaccination presents with anxiety and shortness of breath.  She is scheduled to start IV ertapenem infusion today.  No evidence of anaphylaxis or severe reaction at this time.  She was treated with 1 g IV ertapenem as scheduled in the ER and monitored closely without evidence of serious reaction.  She was reassured and advised she can follow-up as scheduled in the infusion clinic tomorrow.   Return to ED instructions discussed and provided. Pt discharged from ED in stable condition.
Age: 85.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Pain in extremity
Clinical narrative: Left arm is extremely painful even after 6 months since vaccinations
Age: 15.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Feeling hot, Hypoacusis, Paraesthesia oral
Clinical narrative: Patient stated had difficulty hearing, tingling of lower lip, dizziness. Code white called (get members of management to area) as well as 911. Spoke with patient and she felt hot and dizzy. Patient felt OK sitting down and did not want to move. Father left to get a short sleeve shirt as she was wearing a sweatshirt. Kept patient talking while waiting for EMS to arrive. Patient was coherent and answered questions accurately. Was asked by management if she was thirsty but I would not let her get water in the event she passed out. EMS arrived and spoke to patient and father and she declined to go to the hospital and within 5 minutes of them arriving they left and patient left with father to go home. Spoke to  office @ 1:06pm and reported adverse reaction.
Age: 72.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Computerised tomogram, Thrombosis, Transient ischaemic attack
Clinical narrative: Blood Clots found after a Cat Scan and trip to emergency for a series of TIA's.
Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Balance disorder, Computerised tomogram normal, Concussion, Eye pain, Facial bones fracture
Clinical narrative: Started noticing some unsteadiness and lack of balance and that has been going on for at least four months - it may have started as soon as a month or may be two months after receiving the vaccine, I'm not completely sure. I have had headaches but that was after a fall when I hit my head. I started falling when I was in and didn't go to the doctor. I fell and hit my head on a cement floor - and broke me nose.  I did see the doctor after that and he said that I had had a concussion - that was my first fall that I had. The first fall was in May. The last fall was on August 24th and  I had second one on July 12th also - I miss judged my stairs in the dark and fell on head and neck. I went to the hospital ER - for the 2nd one. The doctors don't know the cause of my falls. I have seen the eye doctor yesterday and he said everything looked normal even though I had pain behind both of my eyes. I'm going to heart doctor end of this month. I am still having the unsteadiness and lack of balance at least once a day. I am still having the pain behind both of my eyes and I still have headaches.  No treatment at this time.
Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Fall, Head injury, Headache
Clinical narrative: Started noticing some unsteadiness and lack of balance and that has been going on for at least four months - it may have started as soon as a month or may be two months after receiving the vaccine, I'm not completely sure. I have had headaches but that was after a fall when I hit my head. I started falling when I was in and didn't go to the doctor. I fell and hit my head on a cement floor - and broke me nose.  I did see the doctor after that and he said that I had had a concussion - that was my first fall that I had. The first fall was in May. The last fall was on August 24th and  I had second one on July 12th also - I miss judged my stairs in the dark and fell on head and neck. I went to the hospital ER - for the 2nd one. The doctors don't know the cause of my falls. I have seen the eye doctor yesterday and he said everything looked normal even though I had pain behind both of my eyes. I'm going to heart doctor end of this month. I am still having the unsteadiness and lack of balance at least once a day. I am still having the pain behind both of my eyes and I still have headaches.  No treatment at this time.
Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Dysmenorrhoea, Gynaecological examination, Menstruation irregular, Polymenorrhoea, Ultrasound scan
Clinical narrative: irregular bleeding, shortened menstrual cycle, menstrual cramping throughout cycle period. prior to vaccine, very regular cycles with no intermittent bleeding.
Age: 23.0
Sex: F
Vaccine: COVID19
Symptoms: Carotid pulse increased, Dyspnoea, Echocardiogram, Hypoaesthesia, Ultrasound Doppler
Clinical narrative: Adverse Events: Carotid pulsating, lost feeling in left leg, lost feeling in face, hard to breathe. Loss of breath and carotid pulsating is still ongoing   Treatment: Heart echo and ultrasound of arteries   Outcome: unknown
Age: 17.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Covid confirmed on 9.4.2021
Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Chills, Headache, Pyrexia
Clinical narrative: extreme headache, body chills, fever
Age: 26.0
Sex: M
Vaccine: COVID19
Symptoms: Blindness, Eye movement disorder, Hyperhidrosis, Nausea
Clinical narrative: I started to feel nauseous about 10m after getting the shot. After the 15m I had convinced myself I was just low on energy and needed to get food, I got up to head to get bread and my vision started to black out... I eventually lost vision completely so I turned around and called for help. I was helped back to my chair and when sitting I was able to see again. An ex-doctor nearby told me my blood pressure dropped and the pharmacist said my eyes rolled back into my head during the time I said I couldn't see. I was covered in sweat that wasn't there before. I was given water and drank a bunch.. After waiting in the chair for about 30m I started to feel better so I went to get food and recovered completely after eating and resting.
Age: 52.0
Sex: F
Vaccine: COVID19
Symptoms: Pruritus
Clinical narrative: I have had an unusual amount of itchingaround my face and neck
Age: 39.0
Sex: M
Vaccine: COVID19
Symptoms: Abdominal pain upper, Intestinal obstruction
Clinical narrative: Patient presented to the ED 5/20/2021 and was subsequently hospitalized for partial intestinal obstruction within 6 weeks of receiving COVID vaccination. Patient also presented to the ED 6/7/2021 for upper abdominal pain and was subsequently hospitalized.
Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Heavy menstrual bleeding, Menstruation irregular, Polymenorrhoea
Clinical narrative: Following covid-vaccine menstrual cycle was due following week on 04/30/2021 as normal -- period was extremely heavy unlike normal, following 2nd dose of covid (05/20/2021) vaccine was extremely heavy  on 05/24/2021.  June cycle was somewhat more normal(shorter) and July 16 started menstrual cycle somewhat more normal. Since the end of 5 day period that started July 16 I have not had a cycle since -- about 55 days ago. The only change in life has been the vaccine.
Age: 4.0
Sex: F
Vaccine: DTAPIPV
Symptoms: Inappropriate schedule of product administration
Clinical narrative: The child was receiving a catch up vaccination schedule. RN reviewed the forecast and removed the vaccine from storage for administration. MA prepared and administered the dose. While the dose of Kinrix is age appropriate for the child it did not meet the minimum spacing interval for a DTaP catch up schedule of 6 months from dose #3 to dose #4.  The error was caught immediately after administration. The parent was assured while the dose was early is should not harm the child but may not count as valid and that the next dose is due in 6 months. The parent left abruptly and went to the clinic where she was seen by Dr. who contacted this clinic and was informed of the nature of the error.  Upon research the DTaP dose is valid and the child will need another dose of Kinrix in 6 months to complete her series (dose #5 of DTaP and valid dose #4 of IPV). Physician notified by email of the dose being valid and messages left by phone for mom who is not returning calls.
Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Benign neoplasm of thyroid gland, Biopsy thyroid gland normal, Goitre, Ultrasound scan abnormal
Clinical narrative: By examination it was determined that I had multinodular goiter. Ultrasound showed 1 3.3 mostly solid nodule. Then on July 21, 2021 I went back to DR to find it was a 3.3CM nodule.
Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Atrial fibrillation, Cardiac failure congestive, Cardiogenic shock, Dyspnoea, Electrocardiogram abnormal
Clinical narrative: SOB - Afib  - CHF leading to cardio genie shock.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Facial discomfort, Fatigue, Herpes zoster, Laboratory test, Migraine
Clinical narrative: The biggest effects from Dose 1 are the fatigue, migraines and shingles. I don't have a rash but I still can feel it all over my face and palm of my hands. I have been treated prescribed medication for shingles it hasn't helped.
Age: 17.0
Sex: M
Vaccine: COVID19
Symptoms: Chest pain, Pulmonary embolism, Vena cava thrombosis
Clinical narrative: Patient developed chest pain approximately 6 days after receiving first dose of Pfizer vaccine. He presented to the ER on 7/23/21 (11 days after vaccine) and was found to have a pulmonary embolism and deep venous thrombosis in his inferior vena cava (IVC).
Age: 23.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Hypotension
Clinical narrative: Pt waiting shot time; became dizzy and felt like she needed to lie down; no hives noted; no shob noted; hypotensive in the SBP 89/65;; pt was assisted to room and laid down flat; retook SBP 98/68 HR 67; pt reports feeling better; BS checked 98; pt was given Orange juice; awaiting d/c ; will monitor for symotoms
Age: 33.0
Sex: F
Vaccine: COVID19
Symptoms: Cold sweat, Dizziness, Flushing
Clinical narrative: Pt stated dizzy, lightheaded, flushed, clammy after receiving 2nd dose of Pfizer (EW0191).
Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site erythema, Injection site pruritus, Injection site rash
Clinical narrative: Patient reports itching and red rash around injection site starting 7 days post vaccination.
Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Deafness unilateral, Tinnitus, Vertigo
Clinical narrative: vertigo, tinnitus, loss of hearing right ear
Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Colonoscopy, Face and mouth X-ray abnormal, Headache, Precancerous cells present, Sinusitis
Clinical narrative: I experienced sever headaches and my doctor ordered X-rays that showed a severe sigmoid sinus infection. I also went back to the doctor on 05/07/2021 for a Colonoscopy which showed an increase number of precancerous cells (scheduled another appointment for next year) along with Gasterosteus. (prescribed medicine).
Age: 71.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Cough, Dyspnoea, SARS-CoV-2 test positive
Clinical narrative: Patient admitted with shortness of breath and cough, tested positive for COVID-19. Patient still receiving inpatient treatment.
Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Herpes zoster
Clinical narrative: Onset of shingles on the right forehead and eye being treated with valacyclovir.  Ocular evaluation indicates no optic nerve involvement at this time.  Treatment is ongoing.
Age: 38.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Back pain, Headache, Menstrual disorder, Palpitations
Clinical narrative: Changes in menstruation within 2 hours of 1st dose on 8/10/21. Cycle started 5 days early, went off after 4 days, and came back on the next week for 2 days. Headache on and off.  Most severe headache for 2 days after both vaccines. Lower back pain for 3 days with 1st dose. Heart palpitations on and off with both doses.   1st dose-8/10/2021 2nd dose-8/31/2021
Age: 38.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Asthenia, Chills, Feeling abnormal, Headache, Heavy menstrual bleeding
Clinical narrative: I had the most extreme head ache with nausea I have ever experienced in my whole life and I am used to having migraines, but this was much worse than my worst migraine, weakness in my body to the extent I couldn't get up from the bed, chills, all started 12h after the vaccine and lasted 24h. The following 7 days I felt several times a day a very localized severe pain on my left side of the brain, it felt like an aneurysm about to burst. Even now 7 months after the vaccine my menstrual cycles are still extremely irregular. Having my periods every 2 weeks sometimes, some other times every 6 weeks or 3 weeks or 4 weeks apart, I literally don?t know anymore when to expect my periods, also I had extremely high flow on several occasions, severe pain, and concerning big blood clots during my periods. Before taking the Covid vaccines I always had very normal periods, never had irregular times or flows.
Age: 38.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Menstruation irregular, Nausea, Pain, Thrombosis
Clinical narrative: I had the most extreme head ache with nausea I have ever experienced in my whole life and I am used to having migraines, but this was much worse than my worst migraine, weakness in my body to the extent I couldn't get up from the bed, chills, all started 12h after the vaccine and lasted 24h. The following 7 days I felt several times a day a very localized severe pain on my left side of the brain, it felt like an aneurysm about to burst. Even now 7 months after the vaccine my menstrual cycles are still extremely irregular. Having my periods every 2 weeks sometimes, some other times every 6 weeks or 3 weeks or 4 weeks apart, I literally don?t know anymore when to expect my periods, also I had extremely high flow on several occasions, severe pain, and concerning big blood clots during my periods. Before taking the Covid vaccines I always had very normal periods, never had irregular times or flows.
Age: 33.0
Sex: F
Vaccine: COVID19
Symptoms: Pleural effusion, Rash
Clinical narrative: Patient states w/in a week (can't remember number of days ) after receiving vaccine, she broke out in a rash around neck and felt like she had fluid in her lungs.
Age: 32.0
Sex: M
Vaccine: COVID19
Symptoms: Chest X-ray normal, Chest pain, Electrocardiogram normal
Clinical narrative: Approximately 1 hr after vaccine (1630), I began to have mild chest pain on the left side of my body. RHR was fairly steady around 70 bpm. Chest pain steadily became worse. Around 1930, RHR peaked at 117 bpm and remained above 90 bpm. Chest pain was at 7/10 and I went to the ER. ER conducted EKG and chest X-Ray, both normal. Given tramadol and aspirin which dulled pain. Prescribed Ibuprofen and released. Follow up with primary care, prescribed naproxen and acetaminophen. Chest pain still persists
Age: 14.0
Sex: F
Vaccine: COVID19
Symptoms: Vaginal ulceration
Clinical narrative: patient developed vaginal ulcers 4 days after 2nd vaccine for this series without evidence of illness or trauma
Sex: U
Vaccine: COVID19
Symptoms: Dizziness, Fatigue, Headache
Clinical narrative: On 9/2 started feeling lightheaded 2hrs after the shot, then the headaches came in. From this day 9/8, I still feel the headaches and feel fatigue.
Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Neuropathy peripheral
Clinical narrative: I have a nerve conditions in both feet. Doctor diagnostic me with having Neuropathy. I believed it to be arthritis.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal discomfort, Arthralgia, Breast tenderness, Dizziness, Headache
Clinical narrative: 1st Covid Vaccine: Pfizer 8/9/21 Symptoms: dizziness, headache, extreme nausea + digestive upset, congestion, muscle + joint aches, tender breasts and painful injection site   -Day after vaccine: unable to function, feeling extremely ill, in bed   -Headache, dizziness, nausea + digestive upset, muscle aches, tender breasts continue until 8/18   -Nausea + digestive upset and tender breasts continue until today   Question: Great concern in regard to receiving 2nd vaccine.  If yes, when?  If no, letter of exemption?   If yes: optimal wait time until 2nd shot, supporting body with second shot, teaching until receiving second shot?   If no: Exemption from vaccine, recommendation for medical leave?  Teaching without second vaccine? Safety measures?
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site pain, Loss of personal independence in daily activities, Malaise, Mobility decreased, Myalgia
Clinical narrative: 1st Covid Vaccine: Pfizer 8/9/21 Symptoms: dizziness, headache, extreme nausea + digestive upset, congestion, muscle + joint aches, tender breasts and painful injection site   -Day after vaccine: unable to function, feeling extremely ill, in bed   -Headache, dizziness, nausea + digestive upset, muscle aches, tender breasts continue until 8/18   -Nausea + digestive upset and tender breasts continue until today   Question: Great concern in regard to receiving 2nd vaccine.  If yes, when?  If no, letter of exemption?   If yes: optimal wait time until 2nd shot, supporting body with second shot, teaching until receiving second shot?   If no: Exemption from vaccine, recommendation for medical leave?  Teaching without second vaccine? Safety measures?
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Nausea, Respiratory tract congestion
Clinical narrative: 1st Covid Vaccine: Pfizer 8/9/21 Symptoms: dizziness, headache, extreme nausea + digestive upset, congestion, muscle + joint aches, tender breasts and painful injection site   -Day after vaccine: unable to function, feeling extremely ill, in bed   -Headache, dizziness, nausea + digestive upset, muscle aches, tender breasts continue until 8/18   -Nausea + digestive upset and tender breasts continue until today   Question: Great concern in regard to receiving 2nd vaccine.  If yes, when?  If no, letter of exemption?   If yes: optimal wait time until 2nd shot, supporting body with second shot, teaching until receiving second shot?   If no: Exemption from vaccine, recommendation for medical leave?  Teaching without second vaccine? Safety measures?
Age: 70.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19 pneumonia, Syncope
Clinical narrative: Patient presented to ED after having syncopal episode, denied shortness of breath of cough. Patient admitted for COVID PNA and is still undergoing inpatient treatment.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Decreased appetite, Fatigue, Headache, Mobility decreased
Clinical narrative: Moderna COVID-19 Vaccine EUA swelling arm, aching joints, muscle aches, fever, rolling headaches, terrible fatigue, no appetite, couldn't do anything except lie in bed
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Myalgia, Peripheral swelling, Pyrexia
Clinical narrative: Moderna COVID-19 Vaccine EUA swelling arm, aching joints, muscle aches, fever, rolling headaches, terrible fatigue, no appetite, couldn't do anything except lie in bed
Age: 19.0
Sex: U
Vaccine: COVID19
Symptoms: Dizziness, Tinnitus
Clinical narrative: Patient received the vaccine, shortly after receiving the vaccine (1-2 minutes), the patient begin to feel dizzy and started hearing a ringing sound in her ears.
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Herpes zoster
Clinical narrative: SHINGLES TO RIGHT FOREHEAD
Age: 47.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Extra dose administered, SARS-CoV-2 test positive
Clinical narrative: PT WAS VACCINATED USING PFIZER VACCINE ON 12/23/20 (ELO410) + 1/13/21 (ELO142) + 9/4/21 (FC3182). S/O BEGAN 9/05/21, TESTED + 9/06/21
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Candida infection, Fatigue, Herpes zoster, Hypersomnia, Laboratory test abnormal
Clinical narrative: I exp shingles pain it doesn't go away, thrush, horrible fatigue and a lot of sleeping. It is very painful on my skin.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Pain, Pain of skin
Clinical narrative: I exp shingles pain it doesn't go away, thrush, horrible fatigue and a lot of sleeping. It is very painful on my skin.
Age: 42.0
Sex: F
Vaccine: COVID19
Symptoms: Palpitations
Clinical narrative: Patient stated that she felt palpitations.  was given an extra bottle of water given, vital signs taken .  At 1:35 vitals taken again and was taken to ED and handed over to staff for further evaluation.
Age: 40.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Headache, Influenza like illness, Injection site pain, Pain
Clinical narrative: Flu like symptoms, body ache, fatigue, headache, persistent right deltoid pain.
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Condition aggravated, Nephrolithiasis
Clinical narrative: Adverse event had NOTHING to do with vaccination and everything to do with my propensity toward kidney stones. But because I reported that I had to visit an ER, apparently I have to report now.
Age: 63.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Chest X-ray normal, Laboratory test normal, Troponin I normal, Vaccination complication
Clinical narrative: 1. Adverse reaction to COVID-19 vaccine      PLAN Discharge Medication List as of 8/22/2021  6:12 AM         PATIENT INSTRUCTIONS   Discharge Instructions    Albuterol 2-4 puffs every 2 hours if needed for chest tightness. May cause rapid heart rate or tremors. Tylenol low dose: 325-500 mg every 4 hours if needed for body aches or fever.    Continue masking and minimizing covid exposure especially next 2-4 weeks.   "     FOLLOW-UP:   COURSE & MEDICAL DECISION MAKING Patient was triaged to ED room and evaluated by me. Given her concerns, cardiac panel ordered, resp panel, treated with Zofran, low dose Tylenol and trial of albuterol. Nothing to suggest PE clinically or by history.  Troponin I negative.  CXR clear. Other labs reassuring.  She is feeling improved upon arrival here, expresses that she did feel anxious.
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Endotracheal intubation, Exposure to SARS-CoV-2, Foreign travel, Intensive care
Clinical narrative: Hospitalization for COVID with required intubation. Family out of the country with COVID, patient was with family and had family ill with COVID and some expired there. Patient wanted to return there but required intubation in ICU.
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: Hospitalization for COVID with required intubation. Family out of the country with COVID, patient was with family and had family ill with COVID and some expired there. Patient wanted to return there but required intubation in ICU.
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Condition aggravated, Cough, Dyspnoea, Endotracheal intubation, Intensive care
Clinical narrative: Hospitalization for COVID with required intubation. Family out of the country with COVID, patient was with family and had family ill with COVID and some expired there. Patient wanted to return there but required intubation in ICU.
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Endotracheal intubation, Exposure to SARS-CoV-2, Foreign travel, Intensive care
Clinical narrative: Came to ER with SOB and cough, admitted to ICU, condition worsened, intubated 9/7/2021, pt is still intubated
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: Came to ER with SOB and cough, admitted to ICU, condition worsened, intubated 9/7/2021, pt is still intubated
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Condition aggravated, Cough, Dyspnoea, Endotracheal intubation, Intensive care
Clinical narrative: Came to ER with SOB and cough, admitted to ICU, condition worsened, intubated 9/7/2021, pt is still intubated
Age: 52.0
Sex: F
Vaccine: COVID19
Symptoms: Deep vein thrombosis, Ultrasound Doppler abnormal
Clinical narrative: DVT, left leg
Age: 53.0
Sex: F
Vaccine: FLUR4
Symptoms: Injection site pain, Injection site pruritus, Injection site reaction, Injection site swelling, Injection site urticaria
Clinical narrative: Injection site reaction/pain:  Swelling, muscle stiffness, soreness, and itching at the injection site (left deltoid) within 15 - 20 minutes following injection on 9/7/2021.   No treatment administered; as of 1:45 pm on 9/8/2021, symptoms have not resolved.  Painful itching and hives left shoulder blade, upper back, neck, and right arm occurred approximately 1.5 to 2 hours following injection on 9/7/2021.  No treatment administered; as of 1:45 pm on 9/8/2021, symptoms have not resolved.  Muscle spasm in right foot and leg - duration: approximately 20 - 30 minutes; occurred at approximately 1:30 am on 9/8/2021.  No treatment administered; symptoms resolved.
Age: 53.0
Sex: F
Vaccine: FLUR4
Symptoms: Muscle spasms, Rash, Urticaria
Clinical narrative: Injection site reaction/pain:  Swelling, muscle stiffness, soreness, and itching at the injection site (left deltoid) within 15 - 20 minutes following injection on 9/7/2021.   No treatment administered; as of 1:45 pm on 9/8/2021, symptoms have not resolved.  Painful itching and hives left shoulder blade, upper back, neck, and right arm occurred approximately 1.5 to 2 hours following injection on 9/7/2021.  No treatment administered; as of 1:45 pm on 9/8/2021, symptoms have not resolved.  Muscle spasm in right foot and leg - duration: approximately 20 - 30 minutes; occurred at approximately 1:30 am on 9/8/2021.  No treatment administered; symptoms resolved.
Age: 22.0
Sex: M
Vaccine: COVID19
Symptoms: Alcohol use, Angiogram abnormal, Anion gap, Blood calcium decreased, Blood creatine phosphokinase increased
Clinical narrative: Patient was vaccinated on 09/01 with first dose of Pfizer vaccine. Patient was transferred to hospital on the evening of 09/06.  Patient was found with altered mental status in a camper by friend. Friend said they had been drinking and snorting cocaine. Upon arrival of first hospital, patient was tachycardic, confused, had LLE pain, and left buttock pain (concerning for compartment syndrome). CT angio runoff of bilateral LE showed nonspecific muscular edema involving left gluteus, adductor musculature, and left hamstring musculature. CXR results consistent with pneumonia. Initial procal was 12 at another hospital, was 47 when arrived here. Initial CK was 40,000, but had increased to more than 80,000 one day later. K+ was 8.9 and serum creatinine was 3. BNP was 314 and lactate was 3.3. Patient required pressors at first hospital (dobutamine and levophed) but was off by the time he arrived here. UDS was presumed positive for cocaine. Initial EF was 20-30%, which was concerning for cardiogenic shock. Once transferred to MICU, patient was treated for rhabdomyolysis and hyperkalemia. Treated hyperkalemia with bicarb, dextrose, insulin, and calcium. Rhabdo was treated with IV fluid resuscitation (lactated ringers). It is unclear if events was substance use rhabdomyolysis or vaccine induced. Unable to verify causation.
Age: 22.0
Sex: M
Vaccine: COVID19
Symptoms: Blood creatinine increased, Blood lactic acid, Blood pH decreased, Blood phosphorus increased, Blood potassium increased
Clinical narrative: Patient was vaccinated on 09/01 with first dose of Pfizer vaccine. Patient was transferred to hospital on the evening of 09/06.  Patient was found with altered mental status in a camper by friend. Friend said they had been drinking and snorting cocaine. Upon arrival of first hospital, patient was tachycardic, confused, had LLE pain, and left buttock pain (concerning for compartment syndrome). CT angio runoff of bilateral LE showed nonspecific muscular edema involving left gluteus, adductor musculature, and left hamstring musculature. CXR results consistent with pneumonia. Initial procal was 12 at another hospital, was 47 when arrived here. Initial CK was 40,000, but had increased to more than 80,000 one day later. K+ was 8.9 and serum creatinine was 3. BNP was 314 and lactate was 3.3. Patient required pressors at first hospital (dobutamine and levophed) but was off by the time he arrived here. UDS was presumed positive for cocaine. Initial EF was 20-30%, which was concerning for cardiogenic shock. Once transferred to MICU, patient was treated for rhabdomyolysis and hyperkalemia. Treated hyperkalemia with bicarb, dextrose, insulin, and calcium. Rhabdo was treated with IV fluid resuscitation (lactated ringers). It is unclear if events was substance use rhabdomyolysis or vaccine induced. Unable to verify causation.