chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 16.0
Sex: M
Vaccine: HPV9, TDAP
Symptoms: Extra dose administered
Clinical narrative: pt was given an extra set of vaccines today, HPV & TDaP. Pt EHR had no vaccine input and pt. chart had no HPV or TDaP. After vaccines were given pts mother pulled the shot record and handed it to me. When it was given to stamp today's vaccines I noticed pt had already been given the vaccines. Dr. spoke to patient mother.
Age: 87.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Agitation, Asthenia, COVID-19, Confusional state, Delirium
Clinical narrative: Patient with 2 Pfizer vaccinations, last dose 06/30/21, who admitted with positive COVID test.  Provider d/c note below:  "Brief Summary of Hospital Stay: Per H&P: Patient is a 88 YO female with past medical history of rheumatoid arthritis, osteoarthritis, depression, GERD, HTN, and osteoporosis presenting to Hospital with complaint of worsening generalized weakness for the past 3 days. The patient lives at home alone and is home bound. She has care givers that come to her house.    Work up revealed patient was covid positive and had a UTI. Patient was largely asymptomatic for Covid apart from worsened confusion which was also attributed to UTI. She was treated with Rocephin and Keflex until completion of course. Patient did suffer from hospital acquired delirium and some agitation which improved with Seroquel. Assessment by therapy deemed patient appropriate for SNF, however it was important for family that she return home. Hospitalization was prolonged due to care coordination delays at home in finding caregivers through insurance. Patient was ultimately discharged with wheelchair after caregivers were established.  She was started on Seroquel nightly, which was the only medication change made to her regimen.   Issues Requiring Follow Up: PCP"
Age: 87.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Urinary tract infection, Wheelchair user
Clinical narrative: Patient with 2 Pfizer vaccinations, last dose 06/30/21, who admitted with positive COVID test.  Provider d/c note below:  "Brief Summary of Hospital Stay: Per H&P: Patient is a 88 YO female with past medical history of rheumatoid arthritis, osteoarthritis, depression, GERD, HTN, and osteoporosis presenting to Hospital with complaint of worsening generalized weakness for the past 3 days. The patient lives at home alone and is home bound. She has care givers that come to her house.    Work up revealed patient was covid positive and had a UTI. Patient was largely asymptomatic for Covid apart from worsened confusion which was also attributed to UTI. She was treated with Rocephin and Keflex until completion of course. Patient did suffer from hospital acquired delirium and some agitation which improved with Seroquel. Assessment by therapy deemed patient appropriate for SNF, however it was important for family that she return home. Hospitalization was prolonged due to care coordination delays at home in finding caregivers through insurance. Patient was ultimately discharged with wheelchair after caregivers were established.  She was started on Seroquel nightly, which was the only medication change made to her regimen.   Issues Requiring Follow Up: PCP"
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Inappropriate schedule of product administration, Interchange of vaccine products
Clinical narrative: Patient received a dose of MNRA vaccine (Pfizer) on  05/04/22 and a vector vaccine (Janssen) on 05/05/22.
Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain, Abscess, Anaemia, Blood test, Cachexia
Clinical narrative: I started feeling bad and having a lot of swelling. I continued to feel bad for a few weeks. The condition deteriorated and I began to have nausea, vomiting and abdominal pain. I was at work and it became extremely painful and I was taken to the ER and given a cat scan. They determined I had necrotizing pancreatitis. I had just had a wellness check up a few weeks prior and everything was perfect. They checked my gall bladder and there was nothing wrong with it. I developed a pseudo cyst and at that point I was transferred to the local hospital. They kept me stable while attempting to find a doctor to perform the procedure that I needed done. I was transferred to another hospital for a procedure as this was the only doctor with the ability to perform the procedure needed. The procedure was to go in and cut the cyst to get all of the dead tissue out. He performed the procedure and removed the neurotic tissue. The cyst had adhered to my colon and other parts of my intestines where they had to manipulate that from the other organs. I remained in the hospital for a few weeks. I ended up getting an abscess and having to return. I stayed in the hospital for a week and then was sent home with a drain. I had another relapse. I was emaciated and dehydrated so I had to have a PIC line put in with another drain. I was discharged to home health which I had each time I had been discharged. I was sent with the drain and PIC line. I was not able to eat as my pancreas needed time to heal and my spleen was damaged. I had to have weekly CT scans of my abdomen to monitor all of it. 2 weeks later the drain was removed and the PIC was removed a week later. I was released to return to work on April 4th. I also developed pneumonia and became extremely anemic during this process. I lost about 30 pounds.
Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Central venous catheterisation, Computerised tomogram abdomen, Computerised tomogram abnormal, Cyst removal, Dehydration
Clinical narrative: I started feeling bad and having a lot of swelling. I continued to feel bad for a few weeks. The condition deteriorated and I began to have nausea, vomiting and abdominal pain. I was at work and it became extremely painful and I was taken to the ER and given a cat scan. They determined I had necrotizing pancreatitis. I had just had a wellness check up a few weeks prior and everything was perfect. They checked my gall bladder and there was nothing wrong with it. I developed a pseudo cyst and at that point I was transferred to the local hospital. They kept me stable while attempting to find a doctor to perform the procedure that I needed done. I was transferred to another hospital for a procedure as this was the only doctor with the ability to perform the procedure needed. The procedure was to go in and cut the cyst to get all of the dead tissue out. He performed the procedure and removed the neurotic tissue. The cyst had adhered to my colon and other parts of my intestines where they had to manipulate that from the other organs. I remained in the hospital for a few weeks. I ended up getting an abscess and having to return. I stayed in the hospital for a week and then was sent home with a drain. I had another relapse. I was emaciated and dehydrated so I had to have a PIC line put in with another drain. I was discharged to home health which I had each time I had been discharged. I was sent with the drain and PIC line. I was not able to eat as my pancreas needed time to heal and my spleen was damaged. I had to have weekly CT scans of my abdomen to monitor all of it. 2 weeks later the drain was removed and the PIC was removed a week later. I was released to return to work on April 4th. I also developed pneumonia and became extremely anemic during this process. I lost about 30 pounds.
Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Drain placement, Feeding disorder, Feeling abnormal, General physical health deterioration, Impaired work ability
Clinical narrative: I started feeling bad and having a lot of swelling. I continued to feel bad for a few weeks. The condition deteriorated and I began to have nausea, vomiting and abdominal pain. I was at work and it became extremely painful and I was taken to the ER and given a cat scan. They determined I had necrotizing pancreatitis. I had just had a wellness check up a few weeks prior and everything was perfect. They checked my gall bladder and there was nothing wrong with it. I developed a pseudo cyst and at that point I was transferred to the local hospital. They kept me stable while attempting to find a doctor to perform the procedure that I needed done. I was transferred to another hospital for a procedure as this was the only doctor with the ability to perform the procedure needed. The procedure was to go in and cut the cyst to get all of the dead tissue out. He performed the procedure and removed the neurotic tissue. The cyst had adhered to my colon and other parts of my intestines where they had to manipulate that from the other organs. I remained in the hospital for a few weeks. I ended up getting an abscess and having to return. I stayed in the hospital for a week and then was sent home with a drain. I had another relapse. I was emaciated and dehydrated so I had to have a PIC line put in with another drain. I was discharged to home health which I had each time I had been discharged. I was sent with the drain and PIC line. I was not able to eat as my pancreas needed time to heal and my spleen was damaged. I had to have weekly CT scans of my abdomen to monitor all of it. 2 weeks later the drain was removed and the PIC was removed a week later. I was released to return to work on April 4th. I also developed pneumonia and became extremely anemic during this process. I lost about 30 pounds.
Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Laboratory test, Nausea, Pancreatitis necrotising, Pneumonia, Pseudocyst
Clinical narrative: I started feeling bad and having a lot of swelling. I continued to feel bad for a few weeks. The condition deteriorated and I began to have nausea, vomiting and abdominal pain. I was at work and it became extremely painful and I was taken to the ER and given a cat scan. They determined I had necrotizing pancreatitis. I had just had a wellness check up a few weeks prior and everything was perfect. They checked my gall bladder and there was nothing wrong with it. I developed a pseudo cyst and at that point I was transferred to the local hospital. They kept me stable while attempting to find a doctor to perform the procedure that I needed done. I was transferred to another hospital for a procedure as this was the only doctor with the ability to perform the procedure needed. The procedure was to go in and cut the cyst to get all of the dead tissue out. He performed the procedure and removed the neurotic tissue. The cyst had adhered to my colon and other parts of my intestines where they had to manipulate that from the other organs. I remained in the hospital for a few weeks. I ended up getting an abscess and having to return. I stayed in the hospital for a week and then was sent home with a drain. I had another relapse. I was emaciated and dehydrated so I had to have a PIC line put in with another drain. I was discharged to home health which I had each time I had been discharged. I was sent with the drain and PIC line. I was not able to eat as my pancreas needed time to heal and my spleen was damaged. I had to have weekly CT scans of my abdomen to monitor all of it. 2 weeks later the drain was removed and the PIC was removed a week later. I was released to return to work on April 4th. I also developed pneumonia and became extremely anemic during this process. I lost about 30 pounds.
Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Splenic injury, Swelling, Vomiting, Weight decreased
Clinical narrative: I started feeling bad and having a lot of swelling. I continued to feel bad for a few weeks. The condition deteriorated and I began to have nausea, vomiting and abdominal pain. I was at work and it became extremely painful and I was taken to the ER and given a cat scan. They determined I had necrotizing pancreatitis. I had just had a wellness check up a few weeks prior and everything was perfect. They checked my gall bladder and there was nothing wrong with it. I developed a pseudo cyst and at that point I was transferred to the local hospital. They kept me stable while attempting to find a doctor to perform the procedure that I needed done. I was transferred to another hospital for a procedure as this was the only doctor with the ability to perform the procedure needed. The procedure was to go in and cut the cyst to get all of the dead tissue out. He performed the procedure and removed the neurotic tissue. The cyst had adhered to my colon and other parts of my intestines where they had to manipulate that from the other organs. I remained in the hospital for a few weeks. I ended up getting an abscess and having to return. I stayed in the hospital for a week and then was sent home with a drain. I had another relapse. I was emaciated and dehydrated so I had to have a PIC line put in with another drain. I was discharged to home health which I had each time I had been discharged. I was sent with the drain and PIC line. I was not able to eat as my pancreas needed time to heal and my spleen was damaged. I had to have weekly CT scans of my abdomen to monitor all of it. 2 weeks later the drain was removed and the PIC was removed a week later. I was released to return to work on April 4th. I also developed pneumonia and became extremely anemic during this process. I lost about 30 pounds.
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal discomfort, Chest X-ray, Computerised tomogram, Confusional state, Diarrhoea
Clinical narrative: Shortness of breath Couldn?t breath Stomach upset- diarrhea uncontrolled for 1 week Extreme fatigue Confusion Assisted living facility gave nebulizer and then called ambulance at 6pm- approx 4 hours after vaccination.
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Echocardiogram, Fatigue, Laboratory test abnormal, Myocardial infarction
Clinical narrative: Shortness of breath Couldn?t breath Stomach upset- diarrhea uncontrolled for 1 week Extreme fatigue Confusion Assisted living facility gave nebulizer and then called ambulance at 6pm- approx 4 hours after vaccination.
Age: 39.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Agitation, COVID-19, Computerised tomogram head normal, Computerised tomogram neck, Condition aggravated
Clinical narrative: Patient with 2 Moderna COVID vaccinations who admitted with positive COVID test.  Provider discharge note below:  "Brief Summary of Hospital Stay: The patient is a 39 YO male with h/o rheumatoid arthritis, essential tremor, hearing loss, anxiety/depression admitted on 01/24 for worsening tremor, confusion, difficulty speaking for 5 days prior to admission.  Patient was worked up to evaluate for stroke but CT head and CT of the head and neck unremarkable and MRI negative for evidence of infarct or cause of patient's symptoms.  Patient incidentally tested positive for COVID on admission at 1/24 but was otherwise asymptomatic for COVID other than possibly the encephalopathy.  Urine drug screen on admission positive for marijuana and amphetamines.  Patient did admit to marijuana and methamphetamine use on 01/25 a.m. but then otherwise denied use during the rest of hospitalization.  Patient then became quite encephalopathic and agitated during hospitalization requiring aggressive use of Haldol and Ativan and Geodon with restraints before slowly improving to the point such that by time of discharge patient was fully alert oriented without hallucinations or psychosis.  Discontinued patient's hydroxychloroquine for now as this can also cause confusion hallucination although patient had dose on 01/26 without issue and more suspicious of use of amphetamines as cause of patient's encephalopathy.  Reviewed patient's medications with him and none of them appear to be candidates for causing a false positive test.  Given patient's complaint of tremor, did increase propranolol to 160 from 01/20 daily.  Discussed case briefly with Dr. of Psychiatry on 01/27 who advised close follow-up with the doctor whom patient typically follows with, an appointment has been made for 2/10.  On day of discharge patient was alert oriented and neurologically intact and without evidence of confusion and without SI or HI.   Issues Requiring Follow Up:  -follow-up with Psychiatry to evaluate if etiologies patient's confusion potentially could event Psychiatric although other causes including possible methamphetamine use appear to be more likely (versus less likely options such as the hydroxychloroquine and COVID infection) -follow-up with Rheumatology to evaluate potentially restarting hydroxychloroquine versus using another agent."
Age: 39.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Confusional state, Drug screen positive, Encephalopathy, Magnetic resonance imaging head normal, Patient restraint
Clinical narrative: Patient with 2 Moderna COVID vaccinations who admitted with positive COVID test.  Provider discharge note below:  "Brief Summary of Hospital Stay: The patient is a 39 YO male with h/o rheumatoid arthritis, essential tremor, hearing loss, anxiety/depression admitted on 01/24 for worsening tremor, confusion, difficulty speaking for 5 days prior to admission.  Patient was worked up to evaluate for stroke but CT head and CT of the head and neck unremarkable and MRI negative for evidence of infarct or cause of patient's symptoms.  Patient incidentally tested positive for COVID on admission at 1/24 but was otherwise asymptomatic for COVID other than possibly the encephalopathy.  Urine drug screen on admission positive for marijuana and amphetamines.  Patient did admit to marijuana and methamphetamine use on 01/25 a.m. but then otherwise denied use during the rest of hospitalization.  Patient then became quite encephalopathic and agitated during hospitalization requiring aggressive use of Haldol and Ativan and Geodon with restraints before slowly improving to the point such that by time of discharge patient was fully alert oriented without hallucinations or psychosis.  Discontinued patient's hydroxychloroquine for now as this can also cause confusion hallucination although patient had dose on 01/26 without issue and more suspicious of use of amphetamines as cause of patient's encephalopathy.  Reviewed patient's medications with him and none of them appear to be candidates for causing a false positive test.  Given patient's complaint of tremor, did increase propranolol to 160 from 01/20 daily.  Discussed case briefly with Dr. of Psychiatry on 01/27 who advised close follow-up with the doctor whom patient typically follows with, an appointment has been made for 2/10.  On day of discharge patient was alert oriented and neurologically intact and without evidence of confusion and without SI or HI.   Issues Requiring Follow Up:  -follow-up with Psychiatry to evaluate if etiologies patient's confusion potentially could event Psychiatric although other causes including possible methamphetamine use appear to be more likely (versus less likely options such as the hydroxychloroquine and COVID infection) -follow-up with Rheumatology to evaluate potentially restarting hydroxychloroquine versus using another agent."
Age: 39.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Speech disorder, Substance use, Tremor, Urine amphetamine positive
Clinical narrative: Patient with 2 Moderna COVID vaccinations who admitted with positive COVID test.  Provider discharge note below:  "Brief Summary of Hospital Stay: The patient is a 39 YO male with h/o rheumatoid arthritis, essential tremor, hearing loss, anxiety/depression admitted on 01/24 for worsening tremor, confusion, difficulty speaking for 5 days prior to admission.  Patient was worked up to evaluate for stroke but CT head and CT of the head and neck unremarkable and MRI negative for evidence of infarct or cause of patient's symptoms.  Patient incidentally tested positive for COVID on admission at 1/24 but was otherwise asymptomatic for COVID other than possibly the encephalopathy.  Urine drug screen on admission positive for marijuana and amphetamines.  Patient did admit to marijuana and methamphetamine use on 01/25 a.m. but then otherwise denied use during the rest of hospitalization.  Patient then became quite encephalopathic and agitated during hospitalization requiring aggressive use of Haldol and Ativan and Geodon with restraints before slowly improving to the point such that by time of discharge patient was fully alert oriented without hallucinations or psychosis.  Discontinued patient's hydroxychloroquine for now as this can also cause confusion hallucination although patient had dose on 01/26 without issue and more suspicious of use of amphetamines as cause of patient's encephalopathy.  Reviewed patient's medications with him and none of them appear to be candidates for causing a false positive test.  Given patient's complaint of tremor, did increase propranolol to 160 from 01/20 daily.  Discussed case briefly with Dr. of Psychiatry on 01/27 who advised close follow-up with the doctor whom patient typically follows with, an appointment has been made for 2/10.  On day of discharge patient was alert oriented and neurologically intact and without evidence of confusion and without SI or HI.   Issues Requiring Follow Up:  -follow-up with Psychiatry to evaluate if etiologies patient's confusion potentially could event Psychiatric although other causes including possible methamphetamine use appear to be more likely (versus less likely options such as the hydroxychloroquine and COVID infection) -follow-up with Rheumatology to evaluate potentially restarting hydroxychloroquine versus using another agent."
Age: 72.0
Sex: M
Vaccine: UNK
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Patient positive for Covid and was admitted. Patient stated he was vaccinated for Covid. Unable to obtain any more information than this.
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Pain
Clinical narrative: I was fatigued and real achy so I just rested and I took an epsom salt bath & Tylenol.
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Blood test, Pain, Superficial vein thrombosis, Thrombosis, Ultrasound Doppler
Clinical narrative: Blood clots left leg. Superficial saphenous pain thrombus.
Age: 77.0
Sex: M
Vaccine: VARZOS
Symptoms: Pain, Pyrexia
Clinical narrative: Fever, body aches
Age: 96.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Blood alkaline phosphatase increased, Blood creatinine increased, Blood urea increased, COVID-19
Clinical narrative: COVID Vaccine Breakthrough Report  J&J Dose 6/9/21 (lot NA) COVID Positive 12/1/21  11/30/21:  Patient is 96-year-old female past medical history significant for essential hypertension, CAD, dementia, depression, obesity, osteoporosis, psoriasis   Patient presented to the ED after experiencing shortness of breath of 1 day.  SOB is on exertion.  Patient has contact with recent family members wife and grandson positive COVID-19 infection.  Patient took the test at home and was found to be positive.  Per patient daughter patient sleep better recliner last night which was unusual and upon daughter checking pulse ox at home it was 88%   Patient denied any cough or chest pain.  In the emergency room patient was febrile and was saturating 88% on room air and required oxygen supplementation 3 LPM to maintain saturation to acceptable level  Labs were significant for elevated creatinine of 1.04 with BUN/creatinine ratio of 24, mildly elevated alkaline phosphatase of 130.  Chest x-ray showed cardiomegaly with mild pulmonary vascular congestion; also ground-glass opacification likely representing early edema versus atypical infection  12/3/21: 96-year-old female with CAD, dementia, hypertension presented with shortness of breath, hypoxia and fever.  Family tested positive for COVID-19.  Patient admitted for acute hypoxic respiratory failure secondary to COVID-19 with superimposed bacterial pneumonia, was on 3 L nasal cannula oxygen briefly.  She received antibiotics, dexamethasone and remdesivir.  Subsequently weaned off oxygen to room air, remained a febrile with minimal pulmonary symptoms.  Patient will complete the 7 day steroid taper with  She has baseline dementia and considered to be close to her baseline functional status and the discharged home with VNA and family.  On discharge she was a febrile and hemodynamically stable.
Age: 96.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiomegaly, Chest X-ray abnormal, Dyspnoea, Dyspnoea exertional, Exposure to SARS-CoV-2
Clinical narrative: COVID Vaccine Breakthrough Report  J&J Dose 6/9/21 (lot NA) COVID Positive 12/1/21  11/30/21:  Patient is 96-year-old female past medical history significant for essential hypertension, CAD, dementia, depression, obesity, osteoporosis, psoriasis   Patient presented to the ED after experiencing shortness of breath of 1 day.  SOB is on exertion.  Patient has contact with recent family members wife and grandson positive COVID-19 infection.  Patient took the test at home and was found to be positive.  Per patient daughter patient sleep better recliner last night which was unusual and upon daughter checking pulse ox at home it was 88%   Patient denied any cough or chest pain.  In the emergency room patient was febrile and was saturating 88% on room air and required oxygen supplementation 3 LPM to maintain saturation to acceptable level  Labs were significant for elevated creatinine of 1.04 with BUN/creatinine ratio of 24, mildly elevated alkaline phosphatase of 130.  Chest x-ray showed cardiomegaly with mild pulmonary vascular congestion; also ground-glass opacification likely representing early edema versus atypical infection  12/3/21: 96-year-old female with CAD, dementia, hypertension presented with shortness of breath, hypoxia and fever.  Family tested positive for COVID-19.  Patient admitted for acute hypoxic respiratory failure secondary to COVID-19 with superimposed bacterial pneumonia, was on 3 L nasal cannula oxygen briefly.  She received antibiotics, dexamethasone and remdesivir.  Subsequently weaned off oxygen to room air, remained a febrile with minimal pulmonary symptoms.  Patient will complete the 7 day steroid taper with  She has baseline dementia and considered to be close to her baseline functional status and the discharged home with VNA and family.  On discharge she was a febrile and hemodynamically stable.
Age: 96.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoxia, Infection, Laboratory test abnormal, Lung opacity, Pneumonia bacterial
Clinical narrative: COVID Vaccine Breakthrough Report  J&J Dose 6/9/21 (lot NA) COVID Positive 12/1/21  11/30/21:  Patient is 96-year-old female past medical history significant for essential hypertension, CAD, dementia, depression, obesity, osteoporosis, psoriasis   Patient presented to the ED after experiencing shortness of breath of 1 day.  SOB is on exertion.  Patient has contact with recent family members wife and grandson positive COVID-19 infection.  Patient took the test at home and was found to be positive.  Per patient daughter patient sleep better recliner last night which was unusual and upon daughter checking pulse ox at home it was 88%   Patient denied any cough or chest pain.  In the emergency room patient was febrile and was saturating 88% on room air and required oxygen supplementation 3 LPM to maintain saturation to acceptable level  Labs were significant for elevated creatinine of 1.04 with BUN/creatinine ratio of 24, mildly elevated alkaline phosphatase of 130.  Chest x-ray showed cardiomegaly with mild pulmonary vascular congestion; also ground-glass opacification likely representing early edema versus atypical infection  12/3/21: 96-year-old female with CAD, dementia, hypertension presented with shortness of breath, hypoxia and fever.  Family tested positive for COVID-19.  Patient admitted for acute hypoxic respiratory failure secondary to COVID-19 with superimposed bacterial pneumonia, was on 3 L nasal cannula oxygen briefly.  She received antibiotics, dexamethasone and remdesivir.  Subsequently weaned off oxygen to room air, remained a febrile with minimal pulmonary symptoms.  Patient will complete the 7 day steroid taper with  She has baseline dementia and considered to be close to her baseline functional status and the discharged home with VNA and family.  On discharge she was a febrile and hemodynamically stable.
Age: 96.0
Sex: F
Vaccine: COVID19
Symptoms: Pulmonary congestion, Pulmonary oedema, Pyrexia, SARS-CoV-2 test positive, Vaccine breakthrough infection
Clinical narrative: COVID Vaccine Breakthrough Report  J&J Dose 6/9/21 (lot NA) COVID Positive 12/1/21  11/30/21:  Patient is 96-year-old female past medical history significant for essential hypertension, CAD, dementia, depression, obesity, osteoporosis, psoriasis   Patient presented to the ED after experiencing shortness of breath of 1 day.  SOB is on exertion.  Patient has contact with recent family members wife and grandson positive COVID-19 infection.  Patient took the test at home and was found to be positive.  Per patient daughter patient sleep better recliner last night which was unusual and upon daughter checking pulse ox at home it was 88%   Patient denied any cough or chest pain.  In the emergency room patient was febrile and was saturating 88% on room air and required oxygen supplementation 3 LPM to maintain saturation to acceptable level  Labs were significant for elevated creatinine of 1.04 with BUN/creatinine ratio of 24, mildly elevated alkaline phosphatase of 130.  Chest x-ray showed cardiomegaly with mild pulmonary vascular congestion; also ground-glass opacification likely representing early edema versus atypical infection  12/3/21: 96-year-old female with CAD, dementia, hypertension presented with shortness of breath, hypoxia and fever.  Family tested positive for COVID-19.  Patient admitted for acute hypoxic respiratory failure secondary to COVID-19 with superimposed bacterial pneumonia, was on 3 L nasal cannula oxygen briefly.  She received antibiotics, dexamethasone and remdesivir.  Subsequently weaned off oxygen to room air, remained a febrile with minimal pulmonary symptoms.  Patient will complete the 7 day steroid taper with  She has baseline dementia and considered to be close to her baseline functional status and the discharged home with VNA and family.  On discharge she was a febrile and hemodynamically stable.
Age: 64.0
Sex: F
Vaccine: COVID19, COVID19, UNK
Symptoms: Carpal tunnel syndrome, Condition aggravated, Feeling abnormal, Feeling hot, Headache
Clinical narrative: The store was not crowded with consumers and I left but some hours later I felt terrible with a sourness in my right arm where the needle punctured my arm twice so to speak   I did not have symptoms of carpal tunnel for a long time, but the pain of carpal tunnel returned.  I felt hot like feverish and in the morning of the 27th I felt just as bad not unlike a hangover from an martini.  And on the 28th the right side of my head was tender and sore like a vein collapsed and was not supplying blood to my head and causing trauma. I had to take a muscle relaxers [methocarbamol] for a few days to deaden the pain  And there after right up until the present day my vision in my right eye is vague and hazy.
Age: 64.0
Sex: F
Vaccine: COVID19, COVID19, UNK
Symptoms: Injury, Pain, Pain in extremity, Pyrexia, Tenderness
Clinical narrative: The store was not crowded with consumers and I left but some hours later I felt terrible with a sourness in my right arm where the needle punctured my arm twice so to speak   I did not have symptoms of carpal tunnel for a long time, but the pain of carpal tunnel returned.  I felt hot like feverish and in the morning of the 27th I felt just as bad not unlike a hangover from an martini.  And on the 28th the right side of my head was tender and sore like a vein collapsed and was not supplying blood to my head and causing trauma. I had to take a muscle relaxers [methocarbamol] for a few days to deaden the pain  And there after right up until the present day my vision in my right eye is vague and hazy.
Age: 64.0
Sex: F
Vaccine: COVID19, COVID19, UNK
Symptoms: Vein collapse, Vision blurred, Visual impairment
Clinical narrative: The store was not crowded with consumers and I left but some hours later I felt terrible with a sourness in my right arm where the needle punctured my arm twice so to speak   I did not have symptoms of carpal tunnel for a long time, but the pain of carpal tunnel returned.  I felt hot like feverish and in the morning of the 27th I felt just as bad not unlike a hangover from an martini.  And on the 28th the right side of my head was tender and sore like a vein collapsed and was not supplying blood to my head and causing trauma. I had to take a muscle relaxers [methocarbamol] for a few days to deaden the pain  And there after right up until the present day my vision in my right eye is vague and hazy.
Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Arteriosclerosis, Arthralgia, Back pain, Blood glucose increased
Clinical narrative: COVID Vaccine Breakthrough Case   Moderna Dose 1 3/31/21 (026B21A) Moderna Dose 2 4/28/21 (002C21A) COVID Positive 11/27/21 COVID Positive 11/28/21  11/27/21: Patient is 96-year-old female with no significant past medical history presented to ED after she fell down and was complaining of left hip and back pain.  Patient endorses that was walking out of the office and had misstepped and fell down and landed on the left side of the hip and back.  Started to have some pain mainly on the left hip and back area.  Pain was 10/10 initially but improved with pain medications.   Otherwise patient denies any other site of injury.  Patient denies any chest pain palpitation.  Patient had 1 episode of vomiting of ingested material but otherwise denied any abdominal pain and is passing gas   In the emergency room labs significant for COVID-19 positive PCR, elevated blood sugar of 129, BUN/creatinine 32/1.5.  Troponin was elevated 0.07 urinalysis was positive.  Pelvic x-ray of the left hip showed moderately displaced subcapital left femoral neck fracture with distal fragment displaced proximally, moderate atherosclerotic disease and severe osteopenia  11/30/21: Patient was admitted and orthopedic surgery was consulted for a left femoral neck fracture.  She was found to be COVID-19 positive and also have a possible urinary tract infection for which she was started on ceftriaxone. She remained relatively asymptomatic from a COVID-19 infection standpoint.  She underwent left hip hemiarthroplasty on hospital day 2.  She did have some postoperative hypoxemia which improved with Acapella use. Noted to have a mild elevation troponin and echocardiogram was performed which was overall unremarkable.  Had some acute kidney injury on admission which resolved with IV fluids.  Urine culture was negative and has ceftriaxone was stopped.  She worked with PT and OT and recommended to discharge home with home health and family support.  Will discharge with COVID-19 at home program.
Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Blood urea nitrogen/creatinine ratio, COVID-19, Culture urine negative, Echocardiogram normal, Fall
Clinical narrative: COVID Vaccine Breakthrough Case   Moderna Dose 1 3/31/21 (026B21A) Moderna Dose 2 4/28/21 (002C21A) COVID Positive 11/27/21 COVID Positive 11/28/21  11/27/21: Patient is 96-year-old female with no significant past medical history presented to ED after she fell down and was complaining of left hip and back pain.  Patient endorses that was walking out of the office and had misstepped and fell down and landed on the left side of the hip and back.  Started to have some pain mainly on the left hip and back area.  Pain was 10/10 initially but improved with pain medications.   Otherwise patient denies any other site of injury.  Patient denies any chest pain palpitation.  Patient had 1 episode of vomiting of ingested material but otherwise denied any abdominal pain and is passing gas   In the emergency room labs significant for COVID-19 positive PCR, elevated blood sugar of 129, BUN/creatinine 32/1.5.  Troponin was elevated 0.07 urinalysis was positive.  Pelvic x-ray of the left hip showed moderately displaced subcapital left femoral neck fracture with distal fragment displaced proximally, moderate atherosclerotic disease and severe osteopenia  11/30/21: Patient was admitted and orthopedic surgery was consulted for a left femoral neck fracture.  She was found to be COVID-19 positive and also have a possible urinary tract infection for which she was started on ceftriaxone. She remained relatively asymptomatic from a COVID-19 infection standpoint.  She underwent left hip hemiarthroplasty on hospital day 2.  She did have some postoperative hypoxemia which improved with Acapella use. Noted to have a mild elevation troponin and echocardiogram was performed which was overall unremarkable.  Had some acute kidney injury on admission which resolved with IV fluids.  Urine culture was negative and has ceftriaxone was stopped.  She worked with PT and OT and recommended to discharge home with home health and family support.  Will discharge with COVID-19 at home program.
Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Femoral neck fracture, Fracture displacement, Hip arthroplasty, Hypoxia, Osteopenia
Clinical narrative: COVID Vaccine Breakthrough Case   Moderna Dose 1 3/31/21 (026B21A) Moderna Dose 2 4/28/21 (002C21A) COVID Positive 11/27/21 COVID Positive 11/28/21  11/27/21: Patient is 96-year-old female with no significant past medical history presented to ED after she fell down and was complaining of left hip and back pain.  Patient endorses that was walking out of the office and had misstepped and fell down and landed on the left side of the hip and back.  Started to have some pain mainly on the left hip and back area.  Pain was 10/10 initially but improved with pain medications.   Otherwise patient denies any other site of injury.  Patient denies any chest pain palpitation.  Patient had 1 episode of vomiting of ingested material but otherwise denied any abdominal pain and is passing gas   In the emergency room labs significant for COVID-19 positive PCR, elevated blood sugar of 129, BUN/creatinine 32/1.5.  Troponin was elevated 0.07 urinalysis was positive.  Pelvic x-ray of the left hip showed moderately displaced subcapital left femoral neck fracture with distal fragment displaced proximally, moderate atherosclerotic disease and severe osteopenia  11/30/21: Patient was admitted and orthopedic surgery was consulted for a left femoral neck fracture.  She was found to be COVID-19 positive and also have a possible urinary tract infection for which she was started on ceftriaxone. She remained relatively asymptomatic from a COVID-19 infection standpoint.  She underwent left hip hemiarthroplasty on hospital day 2.  She did have some postoperative hypoxemia which improved with Acapella use. Noted to have a mild elevation troponin and echocardiogram was performed which was overall unremarkable.  Had some acute kidney injury on admission which resolved with IV fluids.  Urine culture was negative and has ceftriaxone was stopped.  She worked with PT and OT and recommended to discharge home with home health and family support.  Will discharge with COVID-19 at home program.
Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Troponin increased, Urine analysis abnormal, Vaccine breakthrough infection, Vomiting
Clinical narrative: COVID Vaccine Breakthrough Case   Moderna Dose 1 3/31/21 (026B21A) Moderna Dose 2 4/28/21 (002C21A) COVID Positive 11/27/21 COVID Positive 11/28/21  11/27/21: Patient is 96-year-old female with no significant past medical history presented to ED after she fell down and was complaining of left hip and back pain.  Patient endorses that was walking out of the office and had misstepped and fell down and landed on the left side of the hip and back.  Started to have some pain mainly on the left hip and back area.  Pain was 10/10 initially but improved with pain medications.   Otherwise patient denies any other site of injury.  Patient denies any chest pain palpitation.  Patient had 1 episode of vomiting of ingested material but otherwise denied any abdominal pain and is passing gas   In the emergency room labs significant for COVID-19 positive PCR, elevated blood sugar of 129, BUN/creatinine 32/1.5.  Troponin was elevated 0.07 urinalysis was positive.  Pelvic x-ray of the left hip showed moderately displaced subcapital left femoral neck fracture with distal fragment displaced proximally, moderate atherosclerotic disease and severe osteopenia  11/30/21: Patient was admitted and orthopedic surgery was consulted for a left femoral neck fracture.  She was found to be COVID-19 positive and also have a possible urinary tract infection for which she was started on ceftriaxone. She remained relatively asymptomatic from a COVID-19 infection standpoint.  She underwent left hip hemiarthroplasty on hospital day 2.  She did have some postoperative hypoxemia which improved with Acapella use. Noted to have a mild elevation troponin and echocardiogram was performed which was overall unremarkable.  Had some acute kidney injury on admission which resolved with IV fluids.  Urine culture was negative and has ceftriaxone was stopped.  She worked with PT and OT and recommended to discharge home with home health and family support.  Will discharge with COVID-19 at home program.
Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: X-ray of pelvis and hip abnormal
Clinical narrative: COVID Vaccine Breakthrough Case   Moderna Dose 1 3/31/21 (026B21A) Moderna Dose 2 4/28/21 (002C21A) COVID Positive 11/27/21 COVID Positive 11/28/21  11/27/21: Patient is 96-year-old female with no significant past medical history presented to ED after she fell down and was complaining of left hip and back pain.  Patient endorses that was walking out of the office and had misstepped and fell down and landed on the left side of the hip and back.  Started to have some pain mainly on the left hip and back area.  Pain was 10/10 initially but improved with pain medications.   Otherwise patient denies any other site of injury.  Patient denies any chest pain palpitation.  Patient had 1 episode of vomiting of ingested material but otherwise denied any abdominal pain and is passing gas   In the emergency room labs significant for COVID-19 positive PCR, elevated blood sugar of 129, BUN/creatinine 32/1.5.  Troponin was elevated 0.07 urinalysis was positive.  Pelvic x-ray of the left hip showed moderately displaced subcapital left femoral neck fracture with distal fragment displaced proximally, moderate atherosclerotic disease and severe osteopenia  11/30/21: Patient was admitted and orthopedic surgery was consulted for a left femoral neck fracture.  She was found to be COVID-19 positive and also have a possible urinary tract infection for which she was started on ceftriaxone. She remained relatively asymptomatic from a COVID-19 infection standpoint.  She underwent left hip hemiarthroplasty on hospital day 2.  She did have some postoperative hypoxemia which improved with Acapella use. Noted to have a mild elevation troponin and echocardiogram was performed which was overall unremarkable.  Had some acute kidney injury on admission which resolved with IV fluids.  Urine culture was negative and has ceftriaxone was stopped.  She worked with PT and OT and recommended to discharge home with home health and family support.  Will discharge with COVID-19 at home program.
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Borrelia test negative, C-reactive protein normal, Fatigue, Full blood count normal, Headache
Clinical narrative: Onset April 24, 2022: Constant, boring, daily frontal HA, 5-6/10 intensity, constant, unrelieved by Tylenol or ASA, seems no worse with activity, minimal relief with rest. Associated fatigue and bilateral leg weakness, increased right > left hand tremor. As of May 5, 2022 all symptoms resolved except headache which continues at 1-3/10 intensity, improves with ASA.
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Laboratory test normal, Muscular weakness, Tremor
Clinical narrative: Onset April 24, 2022: Constant, boring, daily frontal HA, 5-6/10 intensity, constant, unrelieved by Tylenol or ASA, seems no worse with activity, minimal relief with rest. Associated fatigue and bilateral leg weakness, increased right > left hand tremor. As of May 5, 2022 all symptoms resolved except headache which continues at 1-3/10 intensity, improves with ASA.
Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Anaemia, Blood creatinine increased, Blood culture positive, Blood magnesium decreased
Clinical narrative: COVID Vaccine Breakthrough Case  Pfizer Dose 1 8/11/21 (ew0179) Pfizer Dose 2 9/2/21 (EW0170) COVID Positive 11/27/21  11/27/21: Patient is a 73 year old female who presented to ED via EMS for altered mental status come possible fall.  Patient is somewhat of a poor historian. History was obtained per chart review, ER staff and from the patient herself. Patient lives at home at baseline with her son. EMS reported the patient was found hypoxic on room air at 80% on arrival. She has a past medical history of paroxysmal atrial fibrillation not on anticoagulation secondary to GI bleed, type 2 diabetes mellitus, hypertension, hyperlipidemia, mixed Alzheimer's and vascular dementia, history of CVA with mild left-sided deficits, CKD stage G4, anemia CKD and asthma. She has decubitus ulcers noted on her coccyx which she has been following wound care for, the patient had a wound VAC in place stopped working approximately 4 days ago.  She has not been on any recent antibiotic therapy for her wounds.   On arrival to ED the patient was febrile and hypoxic on room air at 80%, 2 L supplemental oxygen was applied with improvement oxygen saturation to 95%. Laboratory findings were significant for hypokalemia 3.2. CKD stage G4 Bun 51 and creatinine 2.90.  Hypomagnesemia 1.4.  Leukocytosis 20.62.  Anemia 9.8.  Rapid COVID positive.  D-dimer 1.08. Chest x-ray unremarkable.  CT head no acute findings.  CT abdomen no acute intra-abdominal findings.  No acute inflammatory changes or bowel obstruction.  Small sacrococcygeal decubitus ulcer, no evidence of abscess formation.  Ceftriaxone, vancomycin and Flagyl initiated in ED.  Potassium chloride 20 mEq IV and magnesium 1 g IV given.  12/4/21: 73-year-old woman who was brought in from home by EMS on account of altered mental status.  She was found to be febrile and hypoxic, labs remarkable for leukocytosis and acute kidney injury.  She has a known history of coccygeal decubitus ulcers undergoing wound VAC therapy and wound care as outpatient.  She was admitted to the hospitalist service and started on empiric broad-spectrum antibiotic therapy, blood per cultures were subsequently positive to Streptococcus pyogenes.  She was started on treatment with IV ceftriaxone in keeping with blood culture susceptibility results with good effect, mental status improved to her previous baseline.  IV fluid hydration was initiated with resolution of initial acute kidney injury, electrolyte repleted as indicated.  She was evaluated by Physical and Occupational therapy and recommended for skilled placement, however patient and family declined and preferred to be discharged home with home health services.  She is in stable medical condition at the time of discharge.