chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Influenza A virus test negative, Influenza B virus test, International normalised ratio normal, Laboratory test, Lymphocyte count
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Lymphocyte count decreased, Lymphocyte percentage decreased, Macrocytosis, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Mean cell volume increased, Mean platelet volume, Metamyelocyte percentage, Monocyte count normal, Monocyte percentage
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Neutrophil percentage, Nitrite urine absent, Platelet count, Pneumonia, Procalcitonin
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Protein total normal, Protein urine, Prothrombin time prolonged, Red blood cell abnormality, Red blood cell count decreased
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Red cell distribution width normal, Respiratory syncytial virus test negative, Rheumatoid arthritis, Rhonchi, SARS-CoV-2 test positive
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Specific gravity urine increased, Troponin I increased, Urinary casts, Urinary sediment, Urine abnormality
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Urine ketone body present, Urine leukocyte esterase positive, Urobilinogen urine, Use of accessory respiratory muscles, Wheezing
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: White blood cell count normal, White blood cells urine positive, pH urine normal
Clinical narrative: Narrative:  1/4/23 - Pt presented to ED with SOB x 2 weeks, but recently worsening with cough and weakness. Pt had breath sounds with wheezing and rhonchi, Hx of COPD. Respirations mildly labored, and Pt states he can hear himself wheezing esp. in afternoons and when laying flat. Pt denies chest pain or any loss of taste/smell. Pt diagnosis = COVID, CAP Pt received the following meds in ED: solumedrol 125mg, albuterol 8 puffs, rocephin, oxygen @ 2L NC, tylenol for HA. Pt admitted to medical floor 1/4/23 (later to be discharged on 1/10/23). Medical floor diagnosis: PRINCIPAL DIAGNOSIS (Reason for admission after study): acute hypoxic respiratory failure due to covid 19 and exacerbation of chronic obstructive pulmonary disease ADDITIONAL DIAGNOSIS: acute hypoxic respiratory failure covid 19 infection chronic obstructive pulmonary disease exacerbation chronic hypertension benign prostatic hypertrophy elevated glucose ( without dx of diabetes) chronic hypothyroidism rheumatoid arthritis hyperlipidemia HOSPITAL COURSE: Pt admitted to the hospital. initial dx cap ,copde and covid. pt started on remdesivir and decadron ( chronic RA meds held). oxygen as needed to maintain sats. cont chronic htn meds. ssi insulin. antibiotics stopped on day 2. by day 3 pt starting to feel better. still requiring oxygen. pt cont to require oxygen. completed 5 days of remdesivir and decadron. unable to wean off oxygen. did qualify for home oxygen. due to chronic steroids, pt placed on prednisone taper till on chronic RA dose. pt stable for d/c to home on 1/10/23.
Age: 46.0
Sex: F
Vaccine: FLUX
Symptoms: Epistaxis, Pyrexia, Swelling, Urticaria
Clinical narrative: Narrative: A 45 yo female with PMH of Asthma, Allergic Rhinitis, Psoriasis, Psoriatic Arthritis and Food Allergy. Per October 5, 2022, Allergy and Immunology consult note: The patient had a historical ADR of Flu vaccine induced fever hives and local swelling including nasal Flu vaccine induced nasal bleeding and swelling. Also on October 5, 2022 the attending reported the patient had a historical ADR of Influenza vaccine induced urticaria and Fever classified as moderate. No other detailed information regarding the vaccines were provided including where it was administered or by who.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase normal, Anaemia, Angiogram pulmonary abnormal, Anion gap, Aspartate aminotransferase increased
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, Basophil count normal, Basophil percentage increased, Benign prostatic hyperplasia, Blood alkaline phosphatase normal
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Blood bilirubin normal, Blood calcium normal, Blood creatinine increased, Blood glucose normal, Blood potassium normal
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Blood sodium normal, Blood thyroid stimulating hormone decreased, Blood urea increased, COVID-19, COVID-19 pneumonia
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Carbon dioxide normal, Coronary artery disease, Cough, Decreased appetite, Dementia
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Encephalopathy, Eosinophil count normal, Eosinophil percentage, Fatigue, Flat affect
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Glomerular filtration rate decreased, Granulocyte count, Granulocyte percentage, Hyperlipidaemia, Hypertension
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Laboratory test, Loss of personal independence in daily activities, Lung opacity, Lymphocyte count normal, Lymphocyte percentage decreased
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Mean cell volume normal, Mean platelet volume decreased, Mental status changes
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Mobility decreased, Monocyte count normal, Monocyte percentage increased, Mucosal dryness, Nasal congestion
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Platelet count normal, Post-acute COVID-19 syndrome, Protein total normal, Protrusion tongue, Rales
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Red blood cell count decreased, Red cell distribution width normal, SARS-CoV-2 test positive, Thyroid mass, Ultrasound thyroid abnormal
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Urinary tract infection, Weight decreased, White blood cell count normal
Clinical narrative: Narrative:  1/9/23 - Pt's wife and daughter called agency call center for advise on patient who tested positive for COVID on 12/28. Patient has decreased appetite (lost 8-10 lbs.), cough, fatigue/weakness. Family feels as though he is improving. He was seen in community hospital ED. Requested a team member return call - family advised by RN to bring patient to ED. 1/9/23 at 13:23 - Patient reported to ED. Daughter concerned father is not ambulatory as usual and not taking meds. Resp. = 28, but not labored and denies SOB. HPI: Pt tested positive for COVID at a community hospital several weeks ago her wife, but did not take paxlovid d/t his other medications/interactions. Overall his nasal congestion is improving. He has had ongoing mild cough during the night and in the mornings. His wife brings him in today due to general body weakness, poor appetite, fatigue, and not taking his medications for the last several days. Pt received Rocephin 1gm IV for possible UTI. Pt has no hypoxia on pulse oximeter. Pt is outside of paxlovid window. ASSESSMENTS: gbw and fatigue COVID19+ anemia UTI Plan to admit pending CT of head and chest. Pt was admitted to medicine floor 1/9 with principal diagnosis of acute encephalopathy on chronic dementia, rt/ long COVID. ADDITIONAL DIAGNOSES: covid 19 pneumonia abnormal thyroid US BPH hyperlipidemia hypertension coronary artery disease CTA showed mild peripheral nodular groundglass opacity with a basilar predominance concerning for infectious or inflammatory process including COVID 19, no pulmonary embolism, heterogeneous thyroid with multiple nodules with the largest in the right thyroid lobe measuring approximately 2 cm. HOSPITAL COURSE: Pt was admmitted for +COVID-19 test possible Pneumonia. Pt had cta which showed gg opacities, NO PE, and abn thyroid read. Pt was started on cefepime and given one dose of dexamethasone, was on O2 overnight, then AMS improved somewhat. Difficult to tell baseline with one encounter. He was not started on remdesivir given patient tested positive for COVID more than 1 week prior to arrival in our facility. Pt was cautioned to keep up with fluid and PO intake at dc. Endocrine was consulted for Abnormal thyroid imaging Noted on CTA, and nodules found on thyroid US as well as low tsh level. Patient discharged 1/11/23.