chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 89.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Seizure like phenomena, Vertebral artery stenosis, Vertebral foraminal stenosis
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/2/2023 Discharge Date: 8/4/2023 Discharge Disposition:  home health care svc      Active Issues Requiring Follow-up: Hyponatremia ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Generalized weakness [R53.1] COVID-19 [U07.1]   HOSPITAL COURSE: Patient presented to the ED on 8/2/2023 with concerns for brief loss of consciousness, bilateral lower limb weakness, seizure like activity and possible facial droop on the left side. Blood pressure at presentation was 194/76. NIH 4.    We admitted for Loss of consciousness with possible left sided facial drop and seizure like activity: CT of the head showed no acute process. CTA showed high grade stenosis of the proximal right ICA and left common carotid and vertebral artery.  We consulted neurology they recommended aspirin 81mg, permissive hypertension,  MRI of the brain with and without contrast and continuous EEG. Both showed no acute process. We started patient on continuous telemetry and echo which shows LVEF of 62%. We also started patient on ASA + Plavix x 90 days, then ASA thereafter.   Patient also complained of Generalized weakness and multiple falls at home. We ordered MRI lumber spine to rule out stenosis. No high-grade spinal canal stenosis was seen but there was multiple Mild to moderate stenosis of the neural foramina. PT/OT /SLP were consulted. They saw patient and recommended patient be discharged into skilled nursing facility. Patient preferred to be home with family.   Patient has Hyponatremia on admission we discontinue the HCTZ medication he uses at home and we gave saline bolus and it improved. Blood sodium dropped the next day so we discharged patient home with sodium chloride salt and ordered a repeat lab in 2 days. We cc the PCP so that result could be followed-up. Patient examined today and discharged in stable condition. Follow-up instruction given to patient
Age: 5.0
Sex: F
Vaccine: DTAPIPV, FLU4, MMRV
Symptoms: Injection site induration, Injection site nodule, Injection site pain, Injection site pruritus, Injection site swelling
Clinical narrative: On November 8, 2023 when child woke up left thigh had a large softball sized hard knot that was raised, hot to touch and painful to touch.  The site was also itchy.  Mother presented child to ER.  Treatment prescribed was hydrocortizone cream and cold compress.
Age: 5.0
Sex: F
Vaccine: DTAPIPV, FLU4, MMRV
Symptoms: Injection site warmth
Clinical narrative: On November 8, 2023 when child woke up left thigh had a large softball sized hard knot that was raised, hot to touch and painful to touch.  The site was also itchy.  Mother presented child to ER.  Treatment prescribed was hydrocortizone cream and cold compress.
Age: 64.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Muscle spasms
Clinical narrative: body cramps/spasms for 3 days . Cramping muscles were, arms, fingers, back, abdomen, thighs, calves, etc.
Age: 37.0
Sex: F
Vaccine: RSV
Symptoms: Exposure during pregnancy, Premature delivery, Premature labour
Clinical narrative: I was 35 w 6 d pregnant. The following day I started with contractions and I delivered on early  (days after receiving vaccine). Delivered at 36 w 1 d.  Birth weight 6 lbs 2 oz.  Estimated date of delivery was 11/10.   Prior history of prematurity.  Last delivery was 33w. Also had received the Covid vaccine at 32 w 5 d and my water broke the day after receiving the Covid vaccine.
Age: 71.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Acute kidney injury, Ankle fracture, Blood creatinine, COVID-19, Diuretic therapy
Clinical narrative: Discharge Physician: DO Primary Care Physician: MD  Date of Admission: 8/1/2023 Discharge Date: 8/6/2023 Room Number: 2025/2025-1 DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: ARF (acute renal failure) (HCC) [N17.9] AKI (acute kidney injury) (HCC) [N17.9] Trimalleolar fracture, left, closed, initial encounter [S82.852A] Open trimalleolar fracture, left, sequela [S82.852S] COVID-19 virus infection [U07.1]   72-year-old woman with a past medical history of type 2 diabetes, CKD 3, hypertension who presented after being sent home from a recent trimalleolar fracture.  Patient had been instructed to follow up outpatient with Orthopedic surgery as an outpatient after she had a splint placed in the emergency department.  However, when she returned home the skin broke and she experienced bleeding that soaked through her splint and dressing.  When she presented back to the emergency department labs were drawn which revealed a creatinine of 3.11.  She was also she COVID positive after describing a few days of body aches, sore throat, upper respiratory symptoms. She had poor PO intake but had continued to take her home lasix.  Pt was hypoxic on arrival, so placed on decadron and remdesivir. Patient was able to be weaned quickly off oxygen and remained on room air for the remainder of her admission.   Patient was aggressively fluid resuscitated due to acute kidney injury.  She went to the OR on 08/02/2023 for open reduction external fixation of her ankle fracture.  Renal function initially improved but not significantly over the course of 2-3 days.  Nephrology was contacted on 08/04 who recommended initiation of Lasix diuresis 40 mg IV twice daily as well as an echocardiogram. Patient renal function declined after initiation of diuretics. Patient was transferred to Butterworth for a formal nephrology evaluation. Case was discussed with ortho trauma prior to transfer so they could arrange to follow/evaluation her at the receiving facility. Patient was in agreement with the plan and she was transferred in stable condition.
Age: 71.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Haemorrhage, Hypophagia, Hypoxia, Open reduction of fracture, Oropharyngeal pain
Clinical narrative: Discharge Physician: DO Primary Care Physician: MD  Date of Admission: 8/1/2023 Discharge Date: 8/6/2023 Room Number: 2025/2025-1 DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: ARF (acute renal failure) (HCC) [N17.9] AKI (acute kidney injury) (HCC) [N17.9] Trimalleolar fracture, left, closed, initial encounter [S82.852A] Open trimalleolar fracture, left, sequela [S82.852S] COVID-19 virus infection [U07.1]   72-year-old woman with a past medical history of type 2 diabetes, CKD 3, hypertension who presented after being sent home from a recent trimalleolar fracture.  Patient had been instructed to follow up outpatient with Orthopedic surgery as an outpatient after she had a splint placed in the emergency department.  However, when she returned home the skin broke and she experienced bleeding that soaked through her splint and dressing.  When she presented back to the emergency department labs were drawn which revealed a creatinine of 3.11.  She was also she COVID positive after describing a few days of body aches, sore throat, upper respiratory symptoms. She had poor PO intake but had continued to take her home lasix.  Pt was hypoxic on arrival, so placed on decadron and remdesivir. Patient was able to be weaned quickly off oxygen and remained on room air for the remainder of her admission.   Patient was aggressively fluid resuscitated due to acute kidney injury.  She went to the OR on 08/02/2023 for open reduction external fixation of her ankle fracture.  Renal function initially improved but not significantly over the course of 2-3 days.  Nephrology was contacted on 08/04 who recommended initiation of Lasix diuresis 40 mg IV twice daily as well as an echocardiogram. Patient renal function declined after initiation of diuretics. Patient was transferred to Butterworth for a formal nephrology evaluation. Case was discussed with ortho trauma prior to transfer so they could arrange to follow/evaluation her at the receiving facility. Patient was in agreement with the plan and she was transferred in stable condition.
Age: 71.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Pain, Renal impairment, Respiratory symptom, SARS-CoV-2 test positive, Skin wound
Clinical narrative: Discharge Physician: DO Primary Care Physician: MD  Date of Admission: 8/1/2023 Discharge Date: 8/6/2023 Room Number: 2025/2025-1 DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: ARF (acute renal failure) (HCC) [N17.9] AKI (acute kidney injury) (HCC) [N17.9] Trimalleolar fracture, left, closed, initial encounter [S82.852A] Open trimalleolar fracture, left, sequela [S82.852S] COVID-19 virus infection [U07.1]   72-year-old woman with a past medical history of type 2 diabetes, CKD 3, hypertension who presented after being sent home from a recent trimalleolar fracture.  Patient had been instructed to follow up outpatient with Orthopedic surgery as an outpatient after she had a splint placed in the emergency department.  However, when she returned home the skin broke and she experienced bleeding that soaked through her splint and dressing.  When she presented back to the emergency department labs were drawn which revealed a creatinine of 3.11.  She was also she COVID positive after describing a few days of body aches, sore throat, upper respiratory symptoms. She had poor PO intake but had continued to take her home lasix.  Pt was hypoxic on arrival, so placed on decadron and remdesivir. Patient was able to be weaned quickly off oxygen and remained on room air for the remainder of her admission.   Patient was aggressively fluid resuscitated due to acute kidney injury.  She went to the OR on 08/02/2023 for open reduction external fixation of her ankle fracture.  Renal function initially improved but not significantly over the course of 2-3 days.  Nephrology was contacted on 08/04 who recommended initiation of Lasix diuresis 40 mg IV twice daily as well as an echocardiogram. Patient renal function declined after initiation of diuretics. Patient was transferred to Butterworth for a formal nephrology evaluation. Case was discussed with ortho trauma prior to transfer so they could arrange to follow/evaluation her at the receiving facility. Patient was in agreement with the plan and she was transferred in stable condition.
Age: 71.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Splint application, Wound treatment
Clinical narrative: Discharge Physician: DO Primary Care Physician: MD  Date of Admission: 8/1/2023 Discharge Date: 8/6/2023 Room Number: 2025/2025-1 DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: ARF (acute renal failure) (HCC) [N17.9] AKI (acute kidney injury) (HCC) [N17.9] Trimalleolar fracture, left, closed, initial encounter [S82.852A] Open trimalleolar fracture, left, sequela [S82.852S] COVID-19 virus infection [U07.1]   72-year-old woman with a past medical history of type 2 diabetes, CKD 3, hypertension who presented after being sent home from a recent trimalleolar fracture.  Patient had been instructed to follow up outpatient with Orthopedic surgery as an outpatient after she had a splint placed in the emergency department.  However, when she returned home the skin broke and she experienced bleeding that soaked through her splint and dressing.  When she presented back to the emergency department labs were drawn which revealed a creatinine of 3.11.  She was also she COVID positive after describing a few days of body aches, sore throat, upper respiratory symptoms. She had poor PO intake but had continued to take her home lasix.  Pt was hypoxic on arrival, so placed on decadron and remdesivir. Patient was able to be weaned quickly off oxygen and remained on room air for the remainder of her admission.   Patient was aggressively fluid resuscitated due to acute kidney injury.  She went to the OR on 08/02/2023 for open reduction external fixation of her ankle fracture.  Renal function initially improved but not significantly over the course of 2-3 days.  Nephrology was contacted on 08/04 who recommended initiation of Lasix diuresis 40 mg IV twice daily as well as an echocardiogram. Patient renal function declined after initiation of diuretics. Patient was transferred to Butterworth for a formal nephrology evaluation. Case was discussed with ortho trauma prior to transfer so they could arrange to follow/evaluation her at the receiving facility. Patient was in agreement with the plan and she was transferred in stable condition.
Age: 70.0
Sex: F
Vaccine: RSV
Symptoms: Electrocardiogram, Sleep disorder, Tachycardia
Clinical narrative: tachycardia that began within twelve hours and woke her up from sleep at around 30 hours post vaccination
Age: 69.0
Sex: F
Vaccine: FLUA4, HEP
Symptoms: Oropharyngeal pain, Pruritus, Respiratory tract congestion, Urticaria
Clinical narrative: Heavy itching  on arms, hives congestion sore throat
Age: 45.0
Sex: M
Vaccine: UNK
Symptoms: Product storage error, Vaccination error
Clinical narrative: Vaccine error: Vaccine was administered after the use by date ( though not after the expiration date) Since it was being stored in the refrigerator.
Age: 94.0
Sex: F
Vaccine: COVID19-2
Symptoms: Aspartate aminotransferase increased, Asthenia, Bile duct stent insertion, Bile duct stent removal, Blood bilirubin increased
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: DO Admission Date: 8/2/2023 Discharge Date: 8/5/2023 Discharge Disposition:  Home with services - Occupational therapy and Physical therapy  DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 94 y.o. female who presented to Hospital with generalized weakness fever, chills.  In the emergency department she had a temperature 39.4°, with leukocytosis and tachycardia.  She is found to be COVID-19 positive.  X-rays showed left opacity, suspicious for infection.  Prolactin levels were increased, blood cultures are negative since discharge.    Throughout the hospital course patient was on room air and did not complain of any SOB. She did note to have generalized weakness.  PT and OT recommended home with healthcare, patient is agreeable and understands the plan.   Patient also had elevated liver enzymes with AST in the 70-60 range.  Was noted in the past patient had a biliary stent placed and removed sometime this year.  Since then is noted that her bilirubin and liver enzymes have been elevated. Her bilirubin levels were increasing, however patient was asymptomatic and will be seeing PCP on 8/8. Will need further workup outpatient.    She was discharged on stable condition and was to complete her antibiotic course.
Age: 94.0
Sex: F
Vaccine: COVID19-2
Symptoms: Blood culture negative, Blood prolactin increased, COVID-19, Chest X-ray abnormal, Chills
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: DO Admission Date: 8/2/2023 Discharge Date: 8/5/2023 Discharge Disposition:  Home with services - Occupational therapy and Physical therapy  DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 94 y.o. female who presented to Hospital with generalized weakness fever, chills.  In the emergency department she had a temperature 39.4°, with leukocytosis and tachycardia.  She is found to be COVID-19 positive.  X-rays showed left opacity, suspicious for infection.  Prolactin levels were increased, blood cultures are negative since discharge.    Throughout the hospital course patient was on room air and did not complain of any SOB. She did note to have generalized weakness.  PT and OT recommended home with healthcare, patient is agreeable and understands the plan.   Patient also had elevated liver enzymes with AST in the 70-60 range.  Was noted in the past patient had a biliary stent placed and removed sometime this year.  Since then is noted that her bilirubin and liver enzymes have been elevated. Her bilirubin levels were increasing, however patient was asymptomatic and will be seeing PCP on 8/8. Will need further workup outpatient.    She was discharged on stable condition and was to complete her antibiotic course.
Age: 94.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hepatic enzyme increased, Leukocytosis, Lung opacity, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: DO Admission Date: 8/2/2023 Discharge Date: 8/5/2023 Discharge Disposition:  Home with services - Occupational therapy and Physical therapy  DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 94 y.o. female who presented to Hospital with generalized weakness fever, chills.  In the emergency department she had a temperature 39.4°, with leukocytosis and tachycardia.  She is found to be COVID-19 positive.  X-rays showed left opacity, suspicious for infection.  Prolactin levels were increased, blood cultures are negative since discharge.    Throughout the hospital course patient was on room air and did not complain of any SOB. She did note to have generalized weakness.  PT and OT recommended home with healthcare, patient is agreeable and understands the plan.   Patient also had elevated liver enzymes with AST in the 70-60 range.  Was noted in the past patient had a biliary stent placed and removed sometime this year.  Since then is noted that her bilirubin and liver enzymes have been elevated. Her bilirubin levels were increasing, however patient was asymptomatic and will be seeing PCP on 8/8. Will need further workup outpatient.    She was discharged on stable condition and was to complete her antibiotic course.
Age: 94.0
Sex: F
Vaccine: COVID19-2
Symptoms: Tachycardia
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: DO Admission Date: 8/2/2023 Discharge Date: 8/5/2023 Discharge Disposition:  Home with services - Occupational therapy and Physical therapy  DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 94 y.o. female who presented to Hospital with generalized weakness fever, chills.  In the emergency department she had a temperature 39.4°, with leukocytosis and tachycardia.  She is found to be COVID-19 positive.  X-rays showed left opacity, suspicious for infection.  Prolactin levels were increased, blood cultures are negative since discharge.    Throughout the hospital course patient was on room air and did not complain of any SOB. She did note to have generalized weakness.  PT and OT recommended home with healthcare, patient is agreeable and understands the plan.   Patient also had elevated liver enzymes with AST in the 70-60 range.  Was noted in the past patient had a biliary stent placed and removed sometime this year.  Since then is noted that her bilirubin and liver enzymes have been elevated. Her bilirubin levels were increasing, however patient was asymptomatic and will be seeing PCP on 8/8. Will need further workup outpatient.    She was discharged on stable condition and was to complete her antibiotic course.
Age: 69.0
Sex: F
Vaccine: RSV
Symptoms: Pharyngeal swelling, Swollen tongue
Clinical narrative: Patient c/o swelling of the tongue and throat. EMS was called and resumed care of patient
Age: 0.17
Sex: M
Vaccine: DTPPVHBHPB, PNC20, RV5, UNK
Symptoms: Asthenia, Decreased appetite, Rash
Clinical narrative: Shortly after Vaxelis, PCV20, Rota AND Beyfortus given for pt.'s 2 month well check (all on the same day) -- he developed poor appetite, decreased energy and a rash on his face (later that day).  Symptoms lasted for about 4-5 days.  Benadryl used once and seemed to have helped with the rash.     No worsening symptoms and managed with supportive care at home.
Age: 26.0
Sex: M
Vaccine: UNK
Symptoms: Product storage error
Clinical narrative: Vaccine error: Vaccine was administered after the use by date ( though not after the expiration date) Since it was being stored in the refrigerator.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Agitation, Anaemia, Blood culture positive, Blunted affect, Brain natriuretic peptide normal
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/13/2023 Discharge Date: Aug 15, 2023 Discharge Disposition:  skilled nursing facility  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute cystitis without hematuria [N30.00] Acute COVID-19 [U07.1] COVID-19 [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is an 84-year-old female with a past medical history of recurrent urinary tract infection, dementia, rheumatoid arthritis on methotrexate, anemia, GERD and anxiety who presented with a chief complaint of low oxygen levels from her facility.  She was recently diagnosed with a urinary tract infection on 07/26/2023 and treated with a course of antibiotics.  She was then diagnosed with COVID-19 on 08/07/2023 and completed a course hepatic flow void of the day prior to admission.  She was sent from her facility to the emergency department due to low oxygen levels at 80% on pulse ox.  In the emergency department she was tachypneic and hypoxic.  She required 3 L nasal cannula.  Labs were unremarkable, including CMP and complete blood count which showed chronic anemia.  BNP was normal, but toward the upper limits of norma.  UA with positive for possible infection, but showed 7 squamous cells.  EKG showed artifact, but did show a prolonged QTC.  Chest x-ray showed volume loss of the left hemithorax consistent with partial left pneumonectomy and blunting of the left costophrenic sulcus.  She was given Rocephin for possible urinary tract infection and dexamethasone for COVID-19 infection.  She was admitted to the hospitalist service for COVID-19 pneumonia.   At admission, she was started on Decadron and remdesivir IV.  She was having difficulty with maintaining her oxygen on due to agitation in the setting of her dementia, but she tolerated leading to room air on 08/14/2023.     Rocephin was discontinued as she did not have symptoms of a urinary tract infection and was not septic appearing.  She was very recently treated for urinary tract infection.    8/15:  one blood culture bottle from admission was positive for CNS and this was felt to be a contaminant given her overall clinical improvement. patient was able to be weaned to room air almost immediately and remained stable after improvement, subsequently she was cleared for discharge; because she was able to be weaned to room air so quickly and maintained her saturations it was decided that she would not need to be discharged on steroids. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. per CM family updated prior to discharge.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Condition aggravated, Cystitis
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/13/2023 Discharge Date: Aug 15, 2023 Discharge Disposition:  skilled nursing facility  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute cystitis without hematuria [N30.00] Acute COVID-19 [U07.1] COVID-19 [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is an 84-year-old female with a past medical history of recurrent urinary tract infection, dementia, rheumatoid arthritis on methotrexate, anemia, GERD and anxiety who presented with a chief complaint of low oxygen levels from her facility.  She was recently diagnosed with a urinary tract infection on 07/26/2023 and treated with a course of antibiotics.  She was then diagnosed with COVID-19 on 08/07/2023 and completed a course hepatic flow void of the day prior to admission.  She was sent from her facility to the emergency department due to low oxygen levels at 80% on pulse ox.  In the emergency department she was tachypneic and hypoxic.  She required 3 L nasal cannula.  Labs were unremarkable, including CMP and complete blood count which showed chronic anemia.  BNP was normal, but toward the upper limits of norma.  UA with positive for possible infection, but showed 7 squamous cells.  EKG showed artifact, but did show a prolonged QTC.  Chest x-ray showed volume loss of the left hemithorax consistent with partial left pneumonectomy and blunting of the left costophrenic sulcus.  She was given Rocephin for possible urinary tract infection and dexamethasone for COVID-19 infection.  She was admitted to the hospitalist service for COVID-19 pneumonia.   At admission, she was started on Decadron and remdesivir IV.  She was having difficulty with maintaining her oxygen on due to agitation in the setting of her dementia, but she tolerated leading to room air on 08/14/2023.     Rocephin was discontinued as she did not have symptoms of a urinary tract infection and was not septic appearing.  She was very recently treated for urinary tract infection.    8/15:  one blood culture bottle from admission was positive for CNS and this was felt to be a contaminant given her overall clinical improvement. patient was able to be weaned to room air almost immediately and remained stable after improvement, subsequently she was cleared for discharge; because she was able to be weaned to room air so quickly and maintained her saturations it was decided that she would not need to be discharged on steroids. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. per CM family updated prior to discharge.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Dementia, Electrocardiogram QT prolonged, Full blood count abnormal, Hypoxia, Metabolic function test abnormal
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/13/2023 Discharge Date: Aug 15, 2023 Discharge Disposition:  skilled nursing facility  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute cystitis without hematuria [N30.00] Acute COVID-19 [U07.1] COVID-19 [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is an 84-year-old female with a past medical history of recurrent urinary tract infection, dementia, rheumatoid arthritis on methotrexate, anemia, GERD and anxiety who presented with a chief complaint of low oxygen levels from her facility.  She was recently diagnosed with a urinary tract infection on 07/26/2023 and treated with a course of antibiotics.  She was then diagnosed with COVID-19 on 08/07/2023 and completed a course hepatic flow void of the day prior to admission.  She was sent from her facility to the emergency department due to low oxygen levels at 80% on pulse ox.  In the emergency department she was tachypneic and hypoxic.  She required 3 L nasal cannula.  Labs were unremarkable, including CMP and complete blood count which showed chronic anemia.  BNP was normal, but toward the upper limits of norma.  UA with positive for possible infection, but showed 7 squamous cells.  EKG showed artifact, but did show a prolonged QTC.  Chest x-ray showed volume loss of the left hemithorax consistent with partial left pneumonectomy and blunting of the left costophrenic sulcus.  She was given Rocephin for possible urinary tract infection and dexamethasone for COVID-19 infection.  She was admitted to the hospitalist service for COVID-19 pneumonia.   At admission, she was started on Decadron and remdesivir IV.  She was having difficulty with maintaining her oxygen on due to agitation in the setting of her dementia, but she tolerated leading to room air on 08/14/2023.     Rocephin was discontinued as she did not have symptoms of a urinary tract infection and was not septic appearing.  She was very recently treated for urinary tract infection.    8/15:  one blood culture bottle from admission was positive for CNS and this was felt to be a contaminant given her overall clinical improvement. patient was able to be weaned to room air almost immediately and remained stable after improvement, subsequently she was cleared for discharge; because she was able to be weaned to room air so quickly and maintained her saturations it was decided that she would not need to be discharged on steroids. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. per CM family updated prior to discharge.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Oxygen saturation decreased, Pneumonectomy, Tachypnoea, Urinary sediment present, Urinary tract infection
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/13/2023 Discharge Date: Aug 15, 2023 Discharge Disposition:  skilled nursing facility  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute cystitis without hematuria [N30.00] Acute COVID-19 [U07.1] COVID-19 [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is an 84-year-old female with a past medical history of recurrent urinary tract infection, dementia, rheumatoid arthritis on methotrexate, anemia, GERD and anxiety who presented with a chief complaint of low oxygen levels from her facility.  She was recently diagnosed with a urinary tract infection on 07/26/2023 and treated with a course of antibiotics.  She was then diagnosed with COVID-19 on 08/07/2023 and completed a course hepatic flow void of the day prior to admission.  She was sent from her facility to the emergency department due to low oxygen levels at 80% on pulse ox.  In the emergency department she was tachypneic and hypoxic.  She required 3 L nasal cannula.  Labs were unremarkable, including CMP and complete blood count which showed chronic anemia.  BNP was normal, but toward the upper limits of norma.  UA with positive for possible infection, but showed 7 squamous cells.  EKG showed artifact, but did show a prolonged QTC.  Chest x-ray showed volume loss of the left hemithorax consistent with partial left pneumonectomy and blunting of the left costophrenic sulcus.  She was given Rocephin for possible urinary tract infection and dexamethasone for COVID-19 infection.  She was admitted to the hospitalist service for COVID-19 pneumonia.   At admission, she was started on Decadron and remdesivir IV.  She was having difficulty with maintaining her oxygen on due to agitation in the setting of her dementia, but she tolerated leading to room air on 08/14/2023.     Rocephin was discontinued as she did not have symptoms of a urinary tract infection and was not septic appearing.  She was very recently treated for urinary tract infection.    8/15:  one blood culture bottle from admission was positive for CNS and this was felt to be a contaminant given her overall clinical improvement. patient was able to be weaned to room air almost immediately and remained stable after improvement, subsequently she was cleared for discharge; because she was able to be weaned to room air so quickly and maintained her saturations it was decided that she would not need to be discharged on steroids. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. per CM family updated prior to discharge.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Urine analysis abnormal
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/13/2023 Discharge Date: Aug 15, 2023 Discharge Disposition:  skilled nursing facility  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute cystitis without hematuria [N30.00] Acute COVID-19 [U07.1] COVID-19 [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is an 84-year-old female with a past medical history of recurrent urinary tract infection, dementia, rheumatoid arthritis on methotrexate, anemia, GERD and anxiety who presented with a chief complaint of low oxygen levels from her facility.  She was recently diagnosed with a urinary tract infection on 07/26/2023 and treated with a course of antibiotics.  She was then diagnosed with COVID-19 on 08/07/2023 and completed a course hepatic flow void of the day prior to admission.  She was sent from her facility to the emergency department due to low oxygen levels at 80% on pulse ox.  In the emergency department she was tachypneic and hypoxic.  She required 3 L nasal cannula.  Labs were unremarkable, including CMP and complete blood count which showed chronic anemia.  BNP was normal, but toward the upper limits of norma.  UA with positive for possible infection, but showed 7 squamous cells.  EKG showed artifact, but did show a prolonged QTC.  Chest x-ray showed volume loss of the left hemithorax consistent with partial left pneumonectomy and blunting of the left costophrenic sulcus.  She was given Rocephin for possible urinary tract infection and dexamethasone for COVID-19 infection.  She was admitted to the hospitalist service for COVID-19 pneumonia.   At admission, she was started on Decadron and remdesivir IV.  She was having difficulty with maintaining her oxygen on due to agitation in the setting of her dementia, but she tolerated leading to room air on 08/14/2023.     Rocephin was discontinued as she did not have symptoms of a urinary tract infection and was not septic appearing.  She was very recently treated for urinary tract infection.    8/15:  one blood culture bottle from admission was positive for CNS and this was felt to be a contaminant given her overall clinical improvement. patient was able to be weaned to room air almost immediately and remained stable after improvement, subsequently she was cleared for discharge; because she was able to be weaned to room air so quickly and maintained her saturations it was decided that she would not need to be discharged on steroids. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. per CM family updated prior to discharge.
Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Breakthrough COVID-19
Clinical narrative: Covid-19 Breakthrough Infection
Age: 3.0
Sex: F
Vaccine: DTAPHEPBIP, FLU4
Symptoms: Extra dose administered
Clinical narrative: NONE
Age: 75.0
Sex: M
Vaccine: COVID19, FLUA4
Symptoms: COVID-19, Condition aggravated, Dementia, Dysphagia, Lethargy
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 8/13/2023 Discharge Date: 08/17/2023  Discharge Disposition: Home  PRESENTING PROBLEM: AMS & Lethargy   HOSPITAL COURSE: Patient is a 77 year-old male who was admitted on 8/13/23 for sepsis 2/2 COVID-19 infection with metabolic encephalopathy. Patient was given fluid hydration, he was not hypoxic so no steroids or Remdesivir was given. Due to AMS he was having difficulties following commands to eat and was made NPO for 2 days. Yesterday 8/16 he has fully returned to baseline dementia mentation, he passed RN swallow screen and has tolerated dental soft diet. SLP evaluated 8/17 and notes mild dysphagia, but can continue with thin liquid and dental soft (bite-sized foods) diet.   Vitals are stable, medically cleared for discharge. No changes to medications.
Age: 75.0
Sex: M
Vaccine: COVID19, FLUA4
Symptoms: Mental status changes, Metabolic encephalopathy, Sepsis
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 8/13/2023 Discharge Date: 08/17/2023  Discharge Disposition: Home  PRESENTING PROBLEM: AMS & Lethargy   HOSPITAL COURSE: Patient is a 77 year-old male who was admitted on 8/13/23 for sepsis 2/2 COVID-19 infection with metabolic encephalopathy. Patient was given fluid hydration, he was not hypoxic so no steroids or Remdesivir was given. Due to AMS he was having difficulties following commands to eat and was made NPO for 2 days. Yesterday 8/16 he has fully returned to baseline dementia mentation, he passed RN swallow screen and has tolerated dental soft diet. SLP evaluated 8/17 and notes mild dysphagia, but can continue with thin liquid and dental soft (bite-sized foods) diet.   Vitals are stable, medically cleared for discharge. No changes to medications.
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Headache, Injection site erythema, Injection site warmth, Muscle tightness
Clinical narrative: Increase in shoulder and upper arm aching, 3x3 inch area of heat, erythema 2 inches below the injection site. Left side of neck and ear feel tight. Frontal headache.  Slight nausea. 800 mg of ibuprofen on board after food.
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Nausea, Pain in extremity
Clinical narrative: Increase in shoulder and upper arm aching, 3x3 inch area of heat, erythema 2 inches below the injection site. Left side of neck and ear feel tight. Frontal headache.  Slight nausea. 800 mg of ibuprofen on board after food.
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, COVID-19, COVID-19 pneumonia, Chest X-ray normal, Confusional state
Clinical narrative: Discharging Provider:  MD PCP:  DO   Admission Duration: 8/10/2023 to 08/12/2023  Discharging to:  LTC HOSPITAL COURSE: Presenting Problem List:  Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1]   Discharge Problem List: Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 08/10/2023 Yes   Resolved Hospital Problems No resolved problems to display.   Hospital Course:   Acute COVID-19: Two days of symptoms at facility, this includes persistent new cough, fatigue, confusion, possibly diarrhea.  Patient was on room air throughout his admission.  CXR without evidence of pneumonia.  No respiratory distress. No leukocytosis noted and lower concern for bacterial superimposed infection.  Patient received 3 days of remdesivir and discharged with Tessalon PRN and guaifenesin for some mild cough   Acute Weakness:  Normally can ambulate with walker, with COVID much weaker and needed hoyer lift last the night prior to admission. PT/OT evaluated and recommended SNF, CM arrange for patient to return to long-term Care with continued isolation precautions, this facility does not offer subacute rehab level of care but they plan to add home health care
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Cough, Fatigue, Gait disturbance, Walking aid user
Clinical narrative: Discharging Provider:  MD PCP:  DO   Admission Duration: 8/10/2023 to 08/12/2023  Discharging to:  LTC HOSPITAL COURSE: Presenting Problem List:  Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1]   Discharge Problem List: Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 08/10/2023 Yes   Resolved Hospital Problems No resolved problems to display.   Hospital Course:   Acute COVID-19: Two days of symptoms at facility, this includes persistent new cough, fatigue, confusion, possibly diarrhea.  Patient was on room air throughout his admission.  CXR without evidence of pneumonia.  No respiratory distress. No leukocytosis noted and lower concern for bacterial superimposed infection.  Patient received 3 days of remdesivir and discharged with Tessalon PRN and guaifenesin for some mild cough   Acute Weakness:  Normally can ambulate with walker, with COVID much weaker and needed hoyer lift last the night prior to admission. PT/OT evaluated and recommended SNF, CM arrange for patient to return to long-term Care with continued isolation precautions, this facility does not offer subacute rehab level of care but they plan to add home health care
Age: 59.0
Sex: M
Vaccine: COVID19
Symptoms: Product preparation issue
Clinical narrative: Patient received Moderna Spikevax 2023-2024 Formula on 10/30/23.  Our team was given some training before administering the vaccine, but we did not know that the vaccine needed a thaw time and Medical Assistant was applying heat to the frozen vaccine with her hands for up to 15-20 min until it turned into liquid. Patient has been called and stated no symptoms signs or any effects after receiving the vaccine.
Age: 55.0
Sex: M
Vaccine: UNK
Symptoms: Product storage error, Vaccination error
Clinical narrative: Vaccine error: Vaccine was administered after the use by date ( though not after the expiration date) Since it was being stored in the refrigerator.
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Cerebral haemorrhage, Computerised tomogram, Magnetic resonance imaging
Clinical narrative: Hemorrhage of right cerebral hemisphere of brain
Age: 69.0
Sex: F
Vaccine: RSV
Symptoms: Arthralgia, Fatigue, Myalgia, Pain in extremity
Clinical narrative: First tired. Then sore arm. Then extreme muscle and joint pain
Age: 77.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Atrial fibrillation, Blood culture negative, Brain natriuretic peptide increased, COVID-19, COVID-19 pneumonia
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: FNP  Admission Date: 8/9/2023 Discharge Date: 8/11/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] UTI (urinary tract infection) [N39.0]   HOSPITAL COURSE:     Patient is a 78 y.o. female who presented to the emergency department with complaints of chills with nausea, and shortness of breath.  Patient has a past medical history including Wegener's granulomatosis, vitamin B12 deficiency, CKD, hypertension, anemia, persistent atrial fibrillation, combined systolic and diastolic heart failure, and obesity. Patient states that she developed feelings of chills, nausea, shortness of breath and generalized body aches .  She states that approximately 10 days ago, she was exposed to COVID-19 while at a concert.  She developed cold-like symptoms approximately 2 days later.   She presented to the emergency department for evaluation.  In the emergency department, patient was tachycardic, tachypneic, and was hypoxic with activity.  She was afebrile, however.  Complete blood count revealed leukocytosis without lactic acidosis.  CMP showed CKD, which is chronic for this patient.  Additionally, BNP was 31000, which is near baseline for this patient.  COVID-19 was positive.  Urinalysis showed moderate leukocytes without nitrites.  Patient has no urinary symptoms.  Procalcitonin was 7.76 chest x-ray showed no acute cardiopulmonary disease.  EKG showed atrial fibrillation, which is chronic for this patient.  Patient was admitted for further evaluation and management of sepsis due to pneumonia 2/2 COVID 19 and UTI.    Patient was managed symptomatically for COVID-19 pneumonia.  No antiviral drugs or steroids were administered.  Patient was on room air and asymptomatic.  She was treated with IV Rocephin for urinary tract infection.  Blood cultures remained negative.  Urine culture was contaminated.  Given improvement with IV Rocephin patient was transitioned to oral Ceftin on discharge to complete a 5 day course.  Patient was evaluated by PT OT and was recommended home with home health PT.  Patient was discharged home in    PS:  Patient's Eliquis was changed to 5 mg 2 times a day as per renal dosing.
Age: 77.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Chest X-ray normal, Chills, Chronic kidney disease, Condition aggravated, Culture urine
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: FNP  Admission Date: 8/9/2023 Discharge Date: 8/11/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] UTI (urinary tract infection) [N39.0]   HOSPITAL COURSE:     Patient is a 78 y.o. female who presented to the emergency department with complaints of chills with nausea, and shortness of breath.  Patient has a past medical history including Wegener's granulomatosis, vitamin B12 deficiency, CKD, hypertension, anemia, persistent atrial fibrillation, combined systolic and diastolic heart failure, and obesity. Patient states that she developed feelings of chills, nausea, shortness of breath and generalized body aches .  She states that approximately 10 days ago, she was exposed to COVID-19 while at a concert.  She developed cold-like symptoms approximately 2 days later.   She presented to the emergency department for evaluation.  In the emergency department, patient was tachycardic, tachypneic, and was hypoxic with activity.  She was afebrile, however.  Complete blood count revealed leukocytosis without lactic acidosis.  CMP showed CKD, which is chronic for this patient.  Additionally, BNP was 31000, which is near baseline for this patient.  COVID-19 was positive.  Urinalysis showed moderate leukocytes without nitrites.  Patient has no urinary symptoms.  Procalcitonin was 7.76 chest x-ray showed no acute cardiopulmonary disease.  EKG showed atrial fibrillation, which is chronic for this patient.  Patient was admitted for further evaluation and management of sepsis due to pneumonia 2/2 COVID 19 and UTI.    Patient was managed symptomatically for COVID-19 pneumonia.  No antiviral drugs or steroids were administered.  Patient was on room air and asymptomatic.  She was treated with IV Rocephin for urinary tract infection.  Blood cultures remained negative.  Urine culture was contaminated.  Given improvement with IV Rocephin patient was transitioned to oral Ceftin on discharge to complete a 5 day course.  Patient was evaluated by PT OT and was recommended home with home health PT.  Patient was discharged home in    PS:  Patient's Eliquis was changed to 5 mg 2 times a day as per renal dosing.
Age: 77.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Dyspnoea, Electrocardiogram abnormal, Exposure to SARS-CoV-2, Full blood count abnormal, Hypoxia
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: FNP  Admission Date: 8/9/2023 Discharge Date: 8/11/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] UTI (urinary tract infection) [N39.0]   HOSPITAL COURSE:     Patient is a 78 y.o. female who presented to the emergency department with complaints of chills with nausea, and shortness of breath.  Patient has a past medical history including Wegener's granulomatosis, vitamin B12 deficiency, CKD, hypertension, anemia, persistent atrial fibrillation, combined systolic and diastolic heart failure, and obesity. Patient states that she developed feelings of chills, nausea, shortness of breath and generalized body aches .  She states that approximately 10 days ago, she was exposed to COVID-19 while at a concert.  She developed cold-like symptoms approximately 2 days later.   She presented to the emergency department for evaluation.  In the emergency department, patient was tachycardic, tachypneic, and was hypoxic with activity.  She was afebrile, however.  Complete blood count revealed leukocytosis without lactic acidosis.  CMP showed CKD, which is chronic for this patient.  Additionally, BNP was 31000, which is near baseline for this patient.  COVID-19 was positive.  Urinalysis showed moderate leukocytes without nitrites.  Patient has no urinary symptoms.  Procalcitonin was 7.76 chest x-ray showed no acute cardiopulmonary disease.  EKG showed atrial fibrillation, which is chronic for this patient.  Patient was admitted for further evaluation and management of sepsis due to pneumonia 2/2 COVID 19 and UTI.    Patient was managed symptomatically for COVID-19 pneumonia.  No antiviral drugs or steroids were administered.  Patient was on room air and asymptomatic.  She was treated with IV Rocephin for urinary tract infection.  Blood cultures remained negative.  Urine culture was contaminated.  Given improvement with IV Rocephin patient was transitioned to oral Ceftin on discharge to complete a 5 day course.  Patient was evaluated by PT OT and was recommended home with home health PT.  Patient was discharged home in    PS:  Patient's Eliquis was changed to 5 mg 2 times a day as per renal dosing.