chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Red cell distribution width increased, SARS-CoV-2 test positive, Spinal X-ray abnormal, Troponin increased, Type 2 diabetes mellitus
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: White blood cell count decreased
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 56.0
Sex: M
Vaccine: COVID19
Symptoms: Angina unstable, COVID-19, Chest pain, SARS-CoV-2 test positive
Clinical narrative: Physician Discharge Summary   Patient ID:   56 y.o.    Admit Date:  7/31/2022   Discharge Date: 8/1/22   Principal Dx/ Final Dx: Angina at rest   Relevant Inpt Dx: Principal Problem:   Angina at rest Active Problems:   Stage 1 mild COPD by GOLD classification   Chronic pulmonary embolism   CAD (coronary artery disease)   Type 2 diabetes mellitus without complication, without long-term current use of insulin   Essential hypertension       HPI:   Hospital Course:   This 56 year old man was admitted with chest pain.  He did not have MI.  He did test positive for covid.  He was seen by cardiology.  Decision made for medical treatment with further evaluation planned when seen in office in 2 weeks
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Back pain, Blood culture negative, Computerised tomogram, Computerised tomogram abdomen, Injection site erythema
Clinical narrative: Received Covid booster Friday morning (8/19),  Was advised to not take tylenol or Ibuprofen and was my temp as my MD was watching for possible osteomyelitis due to my back pain.  By the evening of 8/19, my temp was 99 (my normal is 97). On 8/20, my arm was quite sore (normal for me after covid vaccine) and had body aches (also this was expected.  My temp slowly climbed. By mid afternoon on 8/20, my temp was 100.8. I went to Urgent Care as directed by my PCP but by the time I got there (15 minutes) my temp was 102.2 and they sent me to the ER. My temp was registered at 102.7. Since I am immunocompromised and only partial response to tylenol, I was admitted and placed on IV antibiotics while tests were run.  My temp slowly came down by 8/22 when the blood cultures and MRIs were negative. They stopped the IV antibiotics and watched for 24 hours. Remained afebrile but my upper right arm became very reddened, firm and hot.  (just below injection site).   Fever resolved, the arm got no worse after being off antibiotics. I was discharged home on 8/23.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site induration, Injection site warmth, Magnetic resonance imaging neck, Magnetic resonance imaging normal, Magnetic resonance imaging spinal normal
Clinical narrative: Received Covid booster Friday morning (8/19),  Was advised to not take tylenol or Ibuprofen and was my temp as my MD was watching for possible osteomyelitis due to my back pain.  By the evening of 8/19, my temp was 99 (my normal is 97). On 8/20, my arm was quite sore (normal for me after covid vaccine) and had body aches (also this was expected.  My temp slowly climbed. By mid afternoon on 8/20, my temp was 100.8. I went to Urgent Care as directed by my PCP but by the time I got there (15 minutes) my temp was 102.2 and they sent me to the ER. My temp was registered at 102.7. Since I am immunocompromised and only partial response to tylenol, I was admitted and placed on IV antibiotics while tests were run.  My temp slowly came down by 8/22 when the blood cultures and MRIs were negative. They stopped the IV antibiotics and watched for 24 hours. Remained afebrile but my upper right arm became very reddened, firm and hot.  (just below injection site).   Fever resolved, the arm got no worse after being off antibiotics. I was discharged home on 8/23.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Pain, Pain in extremity, Pyrexia
Clinical narrative: Received Covid booster Friday morning (8/19),  Was advised to not take tylenol or Ibuprofen and was my temp as my MD was watching for possible osteomyelitis due to my back pain.  By the evening of 8/19, my temp was 99 (my normal is 97). On 8/20, my arm was quite sore (normal for me after covid vaccine) and had body aches (also this was expected.  My temp slowly climbed. By mid afternoon on 8/20, my temp was 100.8. I went to Urgent Care as directed by my PCP but by the time I got there (15 minutes) my temp was 102.2 and they sent me to the ER. My temp was registered at 102.7. Since I am immunocompromised and only partial response to tylenol, I was admitted and placed on IV antibiotics while tests were run.  My temp slowly came down by 8/22 when the blood cultures and MRIs were negative. They stopped the IV antibiotics and watched for 24 hours. Remained afebrile but my upper right arm became very reddened, firm and hot.  (just below injection site).   Fever resolved, the arm got no worse after being off antibiotics. I was discharged home on 8/23.
Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Atrial fibrillation, COVID-19, Chronic obstructive pulmonary disease, Colitis
Clinical narrative: Patient ID:   81 y.o.    Admit Date:  7/31/2022   Discharge Date: 8/6/22   Principal Dx/ Final Dx: Colitis   Relevant Inpt Dx: Principal Problem:   Colitis Active Problems:   AKI (acute kidney injury)   COPD (chronic obstructive pulmonary disease)   COVID-19 virus detected       HPI:   Hospital Course:    This 81 year old woman was admitted with diarrhea.  She had recent covid.  She had ct abdomen that showed colitis of descending colon.  She was treated with iv antibiotics and is improved.  She was seen by GI and they recommended colonoscopy in future..  Today her abdomen is soft.  Outpatient follow up with pcp and GI.   She did have acute kidney injury on admission.  /theis was felt to be due to dehydration and did resolve with iv hydration.     She has copd and did cough up purulent phlegm.  Home on antibiotics as above.   She did test positive for covid but did not require treatment for this.    She did have paroxysmal atrial fibrillation.  He was seen by EP cardiology.  Sotalol was stopped and amiodarone was started.  She remains in sinus rhythm today.  She will go home on aspirin.  She is not on further anticoagulation due to recent colitis.          Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY IP CONSULT TO AIMS PROGRAM     Disposition:  home   Discharge Condition:  fair
Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen abnormal, Dehydration, Diarrhoea, Productive cough, SARS-CoV-2 test positive
Clinical narrative: Patient ID:   81 y.o.    Admit Date:  7/31/2022   Discharge Date: 8/6/22   Principal Dx/ Final Dx: Colitis   Relevant Inpt Dx: Principal Problem:   Colitis Active Problems:   AKI (acute kidney injury)   COPD (chronic obstructive pulmonary disease)   COVID-19 virus detected       HPI:   Hospital Course:    This 81 year old woman was admitted with diarrhea.  She had recent covid.  She had ct abdomen that showed colitis of descending colon.  She was treated with iv antibiotics and is improved.  She was seen by GI and they recommended colonoscopy in future..  Today her abdomen is soft.  Outpatient follow up with pcp and GI.   She did have acute kidney injury on admission.  /theis was felt to be due to dehydration and did resolve with iv hydration.     She has copd and did cough up purulent phlegm.  Home on antibiotics as above.   She did test positive for covid but did not require treatment for this.    She did have paroxysmal atrial fibrillation.  He was seen by EP cardiology.  Sotalol was stopped and amiodarone was started.  She remains in sinus rhythm today.  She will go home on aspirin.  She is not on further anticoagulation due to recent colitis.          Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY IP CONSULT TO AIMS PROGRAM     Disposition:  home   Discharge Condition:  fair
Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Sinus rhythm, Sputum purulent
Clinical narrative: Patient ID:   81 y.o.    Admit Date:  7/31/2022   Discharge Date: 8/6/22   Principal Dx/ Final Dx: Colitis   Relevant Inpt Dx: Principal Problem:   Colitis Active Problems:   AKI (acute kidney injury)   COPD (chronic obstructive pulmonary disease)   COVID-19 virus detected       HPI:   Hospital Course:    This 81 year old woman was admitted with diarrhea.  She had recent covid.  She had ct abdomen that showed colitis of descending colon.  She was treated with iv antibiotics and is improved.  She was seen by GI and they recommended colonoscopy in future..  Today her abdomen is soft.  Outpatient follow up with pcp and GI.   She did have acute kidney injury on admission.  /theis was felt to be due to dehydration and did resolve with iv hydration.     She has copd and did cough up purulent phlegm.  Home on antibiotics as above.   She did test positive for covid but did not require treatment for this.    She did have paroxysmal atrial fibrillation.  He was seen by EP cardiology.  Sotalol was stopped and amiodarone was started.  She remains in sinus rhythm today.  She will go home on aspirin.  She is not on further anticoagulation due to recent colitis.          Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY IP CONSULT TO AIMS PROGRAM     Disposition:  home   Discharge Condition:  fair
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Atrial fibrillation, COVID-19, Chronic obstructive pulmonary disease, Colitis
Clinical narrative: Patient ID:   81 y.o.    Admit Date:  7/31/2022   Discharge Date: 8/6/22   Principal Dx/ Final Dx: Colitis   Relevant Inpt Dx: Principal Problem:   Colitis Active Problems:   AKI (acute kidney injury)   COPD (chronic obstructive pulmonary disease)   COVID-19 virus detected       HPI:   Hospital Course:    This 81 year old woman was admitted with diarrhea.  She had recent covid.  She had ct abdomen that showed colitis of descending colon.  She was treated with iv antibiotics and is improved.  She was seen by GI and they recommended colonoscopy in future..  Today her abdomen is soft.  Outpatient follow up with pcp and GI.   She did have acute kidney injury on admission.  /theis was felt to be due to dehydration and did resolve with iv hydration.     She has copd and did cough up purulent phlegm.  Home on antibiotics as above.   She did test positive for covid but did not require treatment for this.    She did have paroxysmal atrial fibrillation.  He was seen by EP cardiology.  Sotalol was stopped and amiodarone was started.  She remains in sinus rhythm today.  She will go home on aspirin.  She is not on further anticoagulation due to recent colitis.          Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY IP CONSULT TO AIMS PROGRAM     Disposition:  home   Discharge Condition:  fair
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen abnormal, Cough, Dehydration, Diarrhoea, Productive cough
Clinical narrative: Patient ID:   81 y.o.    Admit Date:  7/31/2022   Discharge Date: 8/6/22   Principal Dx/ Final Dx: Colitis   Relevant Inpt Dx: Principal Problem:   Colitis Active Problems:   AKI (acute kidney injury)   COPD (chronic obstructive pulmonary disease)   COVID-19 virus detected       HPI:   Hospital Course:    This 81 year old woman was admitted with diarrhea.  She had recent covid.  She had ct abdomen that showed colitis of descending colon.  She was treated with iv antibiotics and is improved.  She was seen by GI and they recommended colonoscopy in future..  Today her abdomen is soft.  Outpatient follow up with pcp and GI.   She did have acute kidney injury on admission.  /theis was felt to be due to dehydration and did resolve with iv hydration.     She has copd and did cough up purulent phlegm.  Home on antibiotics as above.   She did test positive for covid but did not require treatment for this.    She did have paroxysmal atrial fibrillation.  He was seen by EP cardiology.  Sotalol was stopped and amiodarone was started.  She remains in sinus rhythm today.  She will go home on aspirin.  She is not on further anticoagulation due to recent colitis.          Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY IP CONSULT TO AIMS PROGRAM     Disposition:  home   Discharge Condition:  fair
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: Patient ID:   81 y.o.    Admit Date:  7/31/2022   Discharge Date: 8/6/22   Principal Dx/ Final Dx: Colitis   Relevant Inpt Dx: Principal Problem:   Colitis Active Problems:   AKI (acute kidney injury)   COPD (chronic obstructive pulmonary disease)   COVID-19 virus detected       HPI:   Hospital Course:    This 81 year old woman was admitted with diarrhea.  She had recent covid.  She had ct abdomen that showed colitis of descending colon.  She was treated with iv antibiotics and is improved.  She was seen by GI and they recommended colonoscopy in future..  Today her abdomen is soft.  Outpatient follow up with pcp and GI.   She did have acute kidney injury on admission.  /theis was felt to be due to dehydration and did resolve with iv hydration.     She has copd and did cough up purulent phlegm.  Home on antibiotics as above.   She did test positive for covid but did not require treatment for this.    She did have paroxysmal atrial fibrillation.  He was seen by EP cardiology.  Sotalol was stopped and amiodarone was started.  She remains in sinus rhythm today.  She will go home on aspirin.  She is not on further anticoagulation due to recent colitis.          Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY IP CONSULT TO AIMS PROGRAM     Disposition:  home   Discharge Condition:  fair
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Cerebellar infarction, Cerebellar stroke, Condition aggravated, Hypertension
Clinical narrative: Age: 88 y.o. Admit Date: 7/31/2022  9:54 AM Discharge Date:  8/6/2022 Admitting Physician:  Discharge Physician:   Discharge Diagnosis: Principal Problem:   Cerebellar stroke Active Problems:   Internal carotid artery stenosis, left   Primary hypertension   Vertigo   DM type 2 (diabetes mellitus, type 2)       HPI:    Patient is a 88 y.o. male with a history below admitted for Vertigo. Pt came in with complaints of nausea, vomiting, starting 5am. Noticed room appeared to be spinning. Worse with movement. Vomitus was bilious. No abdominal pain / tenderness. Recent covid infection, but no longer symptomatic and only had mild course. No suspicious foods or recent sick contacts. No fever / chills, no diarrhea / constipation. Discussed with er. Will admit      Hospital Course: No notes on file He was initially admitted to the coverage unit after he tested positive for COV ID?19 infection. He was initially diagnosed with this medical condition last July 8. Osseous already completed his quadrant. He was transferred to neurology floor. He had  MRI of the head that shows an acute infarct in the right cerebellum measuring 1.5 cm. Carotid ultrasound was done and it showed a possible greater than 70% stenosis of the left ICA. Permissive hypertension was observed. He was seen by PT, OT, ST. He was started on aspirin. He was seen by neurology. His condition improved he was also seen by possible surgery and further review of the don't think patient has significant stenosis. He is currently doing better. He'll be discharged to rehabilitation center today. He will follow up with vascular surgery in 6 months. Discharge was held for a day as he was complaining with leg pain. Venous doppler did not show DVT and there was popliteal cyst. He is doing better and will be discharged to rehab today.                 Physical Exam on the Date of Discharge: Physical exam:  General Appearance: alert, NAD  Neck: no JVD, no LN enlargement  Lungs: clear, no wheezing   Heart: RRR, S1 S2 heard  Abdomen / GI: soft, non-tender, no ascites  Extremities / musculoskeletal:  edema, no synovitis   Skin: no rash, dry skin  Neuro: follows commands, moves extremities with right leg weakness           Consults:   IP CONSULT TO SOCIAL WORK IP CONSULT TO VASCULAR SURGERY IP CONSULT TO NEUROLOGY   Significant Diagnostic Studies:    Mri head as above     Disposition:  SNF   Discharge Condition:  good
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Magnetic resonance imaging head abnormal, Malaise, Muscular weakness, Nausea, Oedema
Clinical narrative: Age: 88 y.o. Admit Date: 7/31/2022  9:54 AM Discharge Date:  8/6/2022 Admitting Physician:  Discharge Physician:   Discharge Diagnosis: Principal Problem:   Cerebellar stroke Active Problems:   Internal carotid artery stenosis, left   Primary hypertension   Vertigo   DM type 2 (diabetes mellitus, type 2)       HPI:    Patient is a 88 y.o. male with a history below admitted for Vertigo. Pt came in with complaints of nausea, vomiting, starting 5am. Noticed room appeared to be spinning. Worse with movement. Vomitus was bilious. No abdominal pain / tenderness. Recent covid infection, but no longer symptomatic and only had mild course. No suspicious foods or recent sick contacts. No fever / chills, no diarrhea / constipation. Discussed with er. Will admit      Hospital Course: No notes on file He was initially admitted to the coverage unit after he tested positive for COV ID?19 infection. He was initially diagnosed with this medical condition last July 8. Osseous already completed his quadrant. He was transferred to neurology floor. He had  MRI of the head that shows an acute infarct in the right cerebellum measuring 1.5 cm. Carotid ultrasound was done and it showed a possible greater than 70% stenosis of the left ICA. Permissive hypertension was observed. He was seen by PT, OT, ST. He was started on aspirin. He was seen by neurology. His condition improved he was also seen by possible surgery and further review of the don't think patient has significant stenosis. He is currently doing better. He'll be discharged to rehabilitation center today. He will follow up with vascular surgery in 6 months. Discharge was held for a day as he was complaining with leg pain. Venous doppler did not show DVT and there was popliteal cyst. He is doing better and will be discharged to rehab today.                 Physical Exam on the Date of Discharge: Physical exam:  General Appearance: alert, NAD  Neck: no JVD, no LN enlargement  Lungs: clear, no wheezing   Heart: RRR, S1 S2 heard  Abdomen / GI: soft, non-tender, no ascites  Extremities / musculoskeletal:  edema, no synovitis   Skin: no rash, dry skin  Neuro: follows commands, moves extremities with right leg weakness           Consults:   IP CONSULT TO SOCIAL WORK IP CONSULT TO VASCULAR SURGERY IP CONSULT TO NEUROLOGY   Significant Diagnostic Studies:    Mri head as above     Disposition:  SNF   Discharge Condition:  good
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Pain in extremity, SARS-CoV-2 test positive, Synovial cyst, Ultrasound Doppler, Ultrasound Doppler abnormal
Clinical narrative: Age: 88 y.o. Admit Date: 7/31/2022  9:54 AM Discharge Date:  8/6/2022 Admitting Physician:  Discharge Physician:   Discharge Diagnosis: Principal Problem:   Cerebellar stroke Active Problems:   Internal carotid artery stenosis, left   Primary hypertension   Vertigo   DM type 2 (diabetes mellitus, type 2)       HPI:    Patient is a 88 y.o. male with a history below admitted for Vertigo. Pt came in with complaints of nausea, vomiting, starting 5am. Noticed room appeared to be spinning. Worse with movement. Vomitus was bilious. No abdominal pain / tenderness. Recent covid infection, but no longer symptomatic and only had mild course. No suspicious foods or recent sick contacts. No fever / chills, no diarrhea / constipation. Discussed with er. Will admit      Hospital Course: No notes on file He was initially admitted to the coverage unit after he tested positive for COV ID?19 infection. He was initially diagnosed with this medical condition last July 8. Osseous already completed his quadrant. He was transferred to neurology floor. He had  MRI of the head that shows an acute infarct in the right cerebellum measuring 1.5 cm. Carotid ultrasound was done and it showed a possible greater than 70% stenosis of the left ICA. Permissive hypertension was observed. He was seen by PT, OT, ST. He was started on aspirin. He was seen by neurology. His condition improved he was also seen by possible surgery and further review of the don't think patient has significant stenosis. He is currently doing better. He'll be discharged to rehabilitation center today. He will follow up with vascular surgery in 6 months. Discharge was held for a day as he was complaining with leg pain. Venous doppler did not show DVT and there was popliteal cyst. He is doing better and will be discharged to rehab today.                 Physical Exam on the Date of Discharge: Physical exam:  General Appearance: alert, NAD  Neck: no JVD, no LN enlargement  Lungs: clear, no wheezing   Heart: RRR, S1 S2 heard  Abdomen / GI: soft, non-tender, no ascites  Extremities / musculoskeletal:  edema, no synovitis   Skin: no rash, dry skin  Neuro: follows commands, moves extremities with right leg weakness           Consults:   IP CONSULT TO SOCIAL WORK IP CONSULT TO VASCULAR SURGERY IP CONSULT TO NEUROLOGY   Significant Diagnostic Studies:    Mri head as above     Disposition:  SNF   Discharge Condition:  good
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Vertigo, Vomiting
Clinical narrative: Age: 88 y.o. Admit Date: 7/31/2022  9:54 AM Discharge Date:  8/6/2022 Admitting Physician:  Discharge Physician:   Discharge Diagnosis: Principal Problem:   Cerebellar stroke Active Problems:   Internal carotid artery stenosis, left   Primary hypertension   Vertigo   DM type 2 (diabetes mellitus, type 2)       HPI:    Patient is a 88 y.o. male with a history below admitted for Vertigo. Pt came in with complaints of nausea, vomiting, starting 5am. Noticed room appeared to be spinning. Worse with movement. Vomitus was bilious. No abdominal pain / tenderness. Recent covid infection, but no longer symptomatic and only had mild course. No suspicious foods or recent sick contacts. No fever / chills, no diarrhea / constipation. Discussed with er. Will admit      Hospital Course: No notes on file He was initially admitted to the coverage unit after he tested positive for COV ID?19 infection. He was initially diagnosed with this medical condition last July 8. Osseous already completed his quadrant. He was transferred to neurology floor. He had  MRI of the head that shows an acute infarct in the right cerebellum measuring 1.5 cm. Carotid ultrasound was done and it showed a possible greater than 70% stenosis of the left ICA. Permissive hypertension was observed. He was seen by PT, OT, ST. He was started on aspirin. He was seen by neurology. His condition improved he was also seen by possible surgery and further review of the don't think patient has significant stenosis. He is currently doing better. He'll be discharged to rehabilitation center today. He will follow up with vascular surgery in 6 months. Discharge was held for a day as he was complaining with leg pain. Venous doppler did not show DVT and there was popliteal cyst. He is doing better and will be discharged to rehab today.                 Physical Exam on the Date of Discharge: Physical exam:  General Appearance: alert, NAD  Neck: no JVD, no LN enlargement  Lungs: clear, no wheezing   Heart: RRR, S1 S2 heard  Abdomen / GI: soft, non-tender, no ascites  Extremities / musculoskeletal:  edema, no synovitis   Skin: no rash, dry skin  Neuro: follows commands, moves extremities with right leg weakness           Consults:   IP CONSULT TO SOCIAL WORK IP CONSULT TO VASCULAR SURGERY IP CONSULT TO NEUROLOGY   Significant Diagnostic Studies:    Mri head as above     Disposition:  SNF   Discharge Condition:  good
Age: 55.0
Sex: F
Vaccine: FLU4
Symptoms: Headache, Hypoaesthesia, Injection site pain, Injection site swelling, Neck pain
Clinical narrative: Site: Pain at Injection Site-Mild, Site: Swelling at Injection Site-Mild, Systemic: Headache-Medium, Systemic: Numbness (specify: facial area, extremities)-Mild, Additional Details: Patient called to report that she had pain on her arm and back of her neck.She says that she experienced the same symptoms last years when she got the flu vaccine at pharmacy.3 years ago, she experience severe flu like symptoms. Patient is reporting her symptoms so she can get a document from us that proves that she is allergic to the flu shot so she can submit it to the school. I refered the patient to her PCP.
Age: 55.0
Sex: F
Vaccine: FLU4
Symptoms: Pain in extremity
Clinical narrative: Site: Pain at Injection Site-Mild, Site: Swelling at Injection Site-Mild, Systemic: Headache-Medium, Systemic: Numbness (specify: facial area, extremities)-Mild, Additional Details: Patient called to report that she had pain on her arm and back of her neck.She says that she experienced the same symptoms last years when she got the flu vaccine at pharmacy.3 years ago, she experience severe flu like symptoms. Patient is reporting her symptoms so she can get a document from us that proves that she is allergic to the flu shot so she can submit it to the school. I refered the patient to her PCP.
Age: 63.0
Sex: F
Vaccine: PPV
Symptoms: Injection site pain
Clinical narrative: Site: Pain at Injection Site-Severe
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. The HCF consulted with the local Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. The HCF is working with the health dept. on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine stored beyond 30 days recommended in the refrigerated state. Event reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. It was recommended repeating this dose. Patient sent a letter to inform them of the need to repeat the dose. We are working on a compliance improvement plan. Reinstated vaccination privileges.
Age: 49.0
Sex: M
Vaccine: SMALLMNK
Symptoms: Extra dose administered, Wrong technique in product usage process
Clinical narrative: Client's intradermal Jynneos-BN 0.1mL injected into Left Forearm at 5 degrees did not produce a wheal or bleb, client informed that this was not expected result and would need another injection, he verbalized understanding and 0.5mL Jynneos-BN given subcutaneously in the back of the left arm.
Age: 55.0
Sex: M
Vaccine: SMALLMNK
Symptoms: Immediate post-injection reaction, Incorrect dose administered, Injection site extravasation, Wrong technique in product usage process
Clinical narrative: Injected the 0.1 dose of vaccine to the site but upon removal of needle, a  large amount of the vaccine leaked out of the wheal and the wheal flattened immediately, leaving a flattened blanched area in the skin. Due to not knowing how much of the dose actually remained inside the wheal area, the vaccine was re-administered using the Subcutaneous method in the posterior Left upper arm. Patient reported no pain at the initial intradermal injection site.
Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Healthcare facility consulted with the regulatory authority and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare facility is working with the regulatory authority on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 46.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Consulted with the Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare is working on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. The HCF consulted with the local Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. The HCF is working with the health dept. on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine stored beyond 30 days recommended in the refrigerated state. Event reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. It was recommended repeating this dose. Patient sent a letter to inform them of the need to repeat the dose. We are working on a compliance improvement plan. Reinstated vaccination privileges.
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. The HCF consulted with the local Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. The HCF is working with the health dept. on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Anticoagulant therapy, Asymptomatic COVID-19, Culture urine positive, Dehydration, Dysstasia
Clinical narrative: Age: 86 y.o. Admit Date: 8/1/2022 10:50 PM Discharge Date:  8/5/22 Admitting Physician:  Discharge Physician:     Discharge Diagnosis: Principal Problem:   Fall Active Problems:   Dehydration   Hyponatremia   Hypokalemia   Hypocalcemia       HPI: Patient is a 86 y.o. female who was brought here by EMS after she called her family stating she could not get up. She lives alone. When they arrived, the door was locked and they had to call the fire department to break down the door. The patient was found sitting at the kitchen table but could not get up without assistance. She is not cleared about whether she fell prior. She is a poor historian. She has electrolyte disturbnaces on labs. Family is requesting for possible placement since they do not think she can live alone anymore.   Hospital Course: Patient was given IVF. COVID +, asymptomatic and was not treated. Urine culture positive for Ecoli however patient denied symptoms. She will DC to rehab      Dehydration -s/p IVF   Falls-PT/OT. Nursing facility placement   COVID-asymptomatic. On room air, not on treatment   Urine culture + ecoli. She denies urinary symptoms.   Heparin SC Nursing facility on DC.        Physical Exam on the Date of Discharge: Physical Exam Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert.       Consults:   IP CONSULT TO SOCIAL WORK     Disposition:  Nursing facility   Discharge Condition:  good
Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Electrolyte imbalance, Escherichia test positive, Fall, Hypocalcaemia, Hypokalaemia
Clinical narrative: Age: 86 y.o. Admit Date: 8/1/2022 10:50 PM Discharge Date:  8/5/22 Admitting Physician:  Discharge Physician:     Discharge Diagnosis: Principal Problem:   Fall Active Problems:   Dehydration   Hyponatremia   Hypokalemia   Hypocalcemia       HPI: Patient is a 86 y.o. female who was brought here by EMS after she called her family stating she could not get up. She lives alone. When they arrived, the door was locked and they had to call the fire department to break down the door. The patient was found sitting at the kitchen table but could not get up without assistance. She is not cleared about whether she fell prior. She is a poor historian. She has electrolyte disturbnaces on labs. Family is requesting for possible placement since they do not think she can live alone anymore.   Hospital Course: Patient was given IVF. COVID +, asymptomatic and was not treated. Urine culture positive for Ecoli however patient denied symptoms. She will DC to rehab      Dehydration -s/p IVF   Falls-PT/OT. Nursing facility placement   COVID-asymptomatic. On room air, not on treatment   Urine culture + ecoli. She denies urinary symptoms.   Heparin SC Nursing facility on DC.        Physical Exam on the Date of Discharge: Physical Exam Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert.       Consults:   IP CONSULT TO SOCIAL WORK     Disposition:  Nursing facility   Discharge Condition:  good
Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Hyponatraemia, Laboratory test abnormal, SARS-CoV-2 test positive
Clinical narrative: Age: 86 y.o. Admit Date: 8/1/2022 10:50 PM Discharge Date:  8/5/22 Admitting Physician:  Discharge Physician:     Discharge Diagnosis: Principal Problem:   Fall Active Problems:   Dehydration   Hyponatremia   Hypokalemia   Hypocalcemia       HPI: Patient is a 86 y.o. female who was brought here by EMS after she called her family stating she could not get up. She lives alone. When they arrived, the door was locked and they had to call the fire department to break down the door. The patient was found sitting at the kitchen table but could not get up without assistance. She is not cleared about whether she fell prior. She is a poor historian. She has electrolyte disturbnaces on labs. Family is requesting for possible placement since they do not think she can live alone anymore.   Hospital Course: Patient was given IVF. COVID +, asymptomatic and was not treated. Urine culture positive for Ecoli however patient denied symptoms. She will DC to rehab      Dehydration -s/p IVF   Falls-PT/OT. Nursing facility placement   COVID-asymptomatic. On room air, not on treatment   Urine culture + ecoli. She denies urinary symptoms.   Heparin SC Nursing facility on DC.        Physical Exam on the Date of Discharge: Physical Exam Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert.       Consults:   IP CONSULT TO SOCIAL WORK     Disposition:  Nursing facility   Discharge Condition:  good
Age: 54.0
Sex: M
Vaccine: VARZOS
Symptoms: Fatigue, Headache, Pain, Pyrexia
Clinical narrative: Fever, body aches, fatigue, headache
Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. The HCF consulted with the local Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. The HCF is working with the health dept. on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 36.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Agency consulted with the Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare is working with the DPHE on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Consulted with the Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare is working on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 41.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Facility consulted with the Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare facility is working with the DPHE on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: No adverse event, Wrong product administered
Clinical narrative: Patient was given monovalent instead of bivalent as the booster dose. this was the 1st day after the new recommendations came out to no longer give monovalent as a booster and before the pharmacy protocol was updated. also, before bivalent was in stores yet. No actual adverse reaction from pt.
Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Consulted with the Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare is working on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 1.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect dose administered, Needle issue
Clinical narrative: 12 month old patient arrived accompanied by his mother who gave permission for her son to received 2nd dose of (PEDS) Moderna. Although child was properly position, and securely held by his mother, he was able to jerk his left, his flexed muscle ejected the needle before complete dose could be administered. Nurse confirmed that approximately .10 ml, still remained in the needle, discarded needle into safety hazard bin, and reported the event to the Lead Nurse.   Lead Nurse and Management discussed the matter with mother, who chose to go home.
Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine stored beyond 30 days recommended in the refrigerated state. Event reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. It was recommended repeating this dose. Patient sent a letter to inform them of the need to repeat the dose. We are working on a compliance improvement plan. Reinstated vaccination privileges.
Age: 55.0
Sex: M
Vaccine: COVID19
Symptoms: No adverse event, Wrong product administered
Clinical narrative: Patient was given monovalent instead of bivalent as the booster dose. this was the 1st day after the new recommendations came out to no longer give monovalent as a booster and before the pharmacy protocol was updated. also, before bivalent was in stores yet. No actual adverse reaction from pt.
Age: 29.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Consulted with the Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare is working on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. The HCF consulted with the local Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. The HCF is working with the health dept. on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 43.0
Sex: M
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: Patient received a vaccine that was stored beyond the 30 days recommended in the refrigerated state. This event was reported to the manufacturer. The manufacturer tested the lot number in question. Data revealed that the vaccine administered did not maintain activity necessary to protect against the SARS-CoV-2 (COVID-19) virus at time of administration. Consulted with the Dept of Public Health and Environment and recommended repeating this dose in question. Patient was sent a letter to inform them of the need to repeat the dose in question. Healthcare is working on a compliance improvement plan and has been reinstated vaccination privileges.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Injection site pain
Clinical narrative: Patient is still having arm pain in the left arm 9 months after vaccine.  Has followed up with their physician assistant.