chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 48.0
Sex: F
Vaccine: FLU4
Symptoms: Arthralgia, Pain, Pain in extremity
Clinical narrative: Manufacturer: GlaxoSmithKline: ** Please note that I do know the correct vaccine name other than that it was an influenza vaccine and that it was quadrivalent. The site will not allow me to continue without entering a value  Following the injection, I had the typical shoulder/arm soreness that accompanies the influenza vaccine. Since that time, the pain has not abated.  Reaching for an object or stretching my arm causes intense soreness. I believe, but do not have any information to verify, that the injection may have been incorrectly administered secondary to  inaccurate placement of injection at site.  The pain is not incapacitating  and I am able to perform my activities of daily living without issue. I did not have any other symptoms other than arm soreness after the injection. I do not believe the person who performed the injection was careless or intending to cause harm.
Age: 4.0
Sex: F
Vaccine: DTAPIPV, FLUA4, MMRV
Symptoms: Injection site erythema, Injection site pain, Injection site warmth, Pyrexia
Clinical narrative: Patient developed fever within 24 hours of receiving vaccines, and continued daily until seen 3 days after in the ED. She'd received 2 vaccines in the right upper thigh and 2 in the left upper thigh (parent unsure which were given and where). On her left thigh, large area of redness covering most of the thigh that would increase and decrease in severity throughout the day.  Patient also noted pain, but ambulated normally, eating and drinking normally. Lesion was not raised. It was warm to touch. Mom tried tylenol, ibuprofen, and bathing in cool water at home, which only helped a little.  Discharged patient home with 5 day course of cephalexin 20 mg/kg TID.
Age: 0.67
Sex: F
Vaccine: DTPPVHBHPB, PNC20, RV1
Symptoms: Inappropriate schedule of product administration, No adverse event
Clinical narrative: Pt came in for 6 month check but, is currently 8 months, pt had already received 2 rotas in the past and was behind on well check up. Pt was normal after Vaccine was given, no side effects reported
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: No adverse event, Underdose
Clinical narrative: Pt has not had any adverse events. Pt was given the child dose of the covid vaccine instead of the adult dose.
Age: 5.0
Sex: M
Vaccine: FLU4
Symptoms: Injection site erythema, Injection site pruritus
Clinical narrative: Mother, stated that he developed a red itchy area from the deltoid until the elbow last night, 11/07/23. Suggested following up with his pediatrician and suggested Benadryl 25mg 3-4 times a day for the itching and ibuprofen if there is pain.
Age: 24.0
Sex: M
Vaccine: FLU4
Symptoms: Pruritus, Rash, Rash erythematous
Clinical narrative: red rash noticed on arms, legs, back and chest 6Nov23 at night, worse this morning,  Itching on back.  Vaccine received at Pharmacy.
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Diffuse large B-cell lymphoma, Positron emission tomogram abnormal
Clinical narrative: I now have Diffuse Large B cell Lymphoma
Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Blood test, Computerised tomogram, Cranial nerve paralysis, Diplopia, Magnetic resonance imaging
Clinical narrative: Double Vison - Cranial Nerve VI Palsey - Lateral Rectus Palsey left eye
Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: VIth nerve paralysis
Clinical narrative: Double Vison - Cranial Nerve VI Palsey - Lateral Rectus Palsey left eye
Age: 11.0
Sex: M
Vaccine: FLU4, MNQ
Symptoms: Injection site erythema, Injection site induration
Clinical narrative: c/o localized oval-shaped left upper arm erythema and induration, non-tender, non-pruritic.
Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Wrong product administered
Clinical narrative: Patient was here to receive a flu shot and an error was made.  She received the new Comirnaty from Pfizer instead.  She has not had an actual adverse reaction but we were told by our corporate office to report to the VAERS system.
Age: 72.0
Sex: M
Vaccine: VARZOS
Symptoms: No adverse event, Wrong product administered
Clinical narrative: administered shingrix instead of an arexy vaccine  no adverese reaction from patient and patient did not have a shingrix vaccine in the past.
Age: 72.0
Sex: F
Vaccine: RSV
Symptoms: Injection site erythema, Injection site pruritus, Injection site warmth
Clinical narrative: injection site became red/hot to touch also itch area was 8.5cm by 4cm. patient went to emergency room and the doctor who saw her told her to have us report it as an adverse event
Age: 70.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Chills, Diarrhoea, Impaired work ability, Malaise, Mobility decreased
Clinical narrative: Ten hours after vaccine administration, patient experienced a fever of 103 degrees with accompanying shivering and chills and was unable to get out of bed for 2 hours. She treated the fever with alternating ibuprofen and acetaminophen for one and one-half days at which time it came down to 99 degrees. Ten hours later it was back to normal. She also had body aches, maiaise, and diarrhea during this time. She missed 2 days of work.
Age: 70.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Pain, Pyrexia
Clinical narrative: Ten hours after vaccine administration, patient experienced a fever of 103 degrees with accompanying shivering and chills and was unable to get out of bed for 2 hours. She treated the fever with alternating ibuprofen and acetaminophen for one and one-half days at which time it came down to 99 degrees. Ten hours later it was back to normal. She also had body aches, maiaise, and diarrhea during this time. She missed 2 days of work.
Age: 57.0
Sex: F
Vaccine: FLU4
Symptoms: Product administered to patient of inappropriate age
Clinical narrative: High dose given
Age: 12.0
Sex: F
Vaccine: MENB
Symptoms: Product administered to patient of inappropriate age
Clinical narrative: Vaccine administered at incorrect age.
Age: 1.33
Sex: F
Vaccine: MNQ
Symptoms: No adverse event, Product administered to patient of inappropriate age
Clinical narrative: No adverse events occured
Age: 66.0
Sex: M
Vaccine: COVID19, FLUA4, RSV
Symptoms: Haemorrhoidal haemorrhage, Haemorrhoids
Clinical narrative: About 10 days after vaccination I developed bleeding internal hemorrhoids. They took nearly 3 weeks to heal, including a visit to the doctor.  Coincidently, I had also developed hemorrhoids a few days after receiving a C OVID vaccine a couple years prior.  This was also reported to VAERS at the time. DISCOSURE:  I also received a Pfizer Covid Vaccine and a standard flu shot at the same time I received this vaccine.
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Chest discomfort, Musculoskeletal stiffness, Paraesthesia
Clinical narrative: Tingling in face and hands, extreme tightness in chest and back Felt like I was having a heart attack
Age: 53.0
Sex: M
Vaccine: FLU4, TDAP
Symptoms: Arthralgia, Back pain, Mobility decreased, Neck pain, X-ray
Clinical narrative: severe shoulder, back, and neck pain and difficulty moving arm.  Pending Xray results.  Given lidocaine patch and Tylenol
Age: 45.0
Sex: F
Vaccine: FLUC4
Symptoms: Abdominal pain upper, Asthma, Condition aggravated, Injection site erythema, Injection site pain
Clinical narrative: Hives  and intense  itching at injection site (plus pain, redness, swelling) . Minor stomach pain.  Took Benadryl approx 5 hours after injection which relieved itching - temporarily.  Hives and itching persist today.  Asthma exacerbation noted now as well.
Age: 45.0
Sex: F
Vaccine: FLUC4
Symptoms: Injection site pruritus, Injection site swelling, Injection site urticaria
Clinical narrative: Hives  and intense  itching at injection site (plus pain, redness, swelling) . Minor stomach pain.  Took Benadryl approx 5 hours after injection which relieved itching - temporarily.  Hives and itching persist today.  Asthma exacerbation noted now as well.
Age: 11.0
Sex: M
Vaccine: TDAP
Symptoms: Immune system disorder, Impaired quality of life, Lymphadenopathy, Secretion discharge, Sinus disorder
Clinical narrative: Chronic sinus condition began that could never be remedied. Constant mucus buildup. No prior history of mucus, allergy or sinus issues prior to vaccine. Antibiotics were unsuccessful long term. Sinus surgery performed In 10/22. Mucus still builds up, even after surgery.  Strong immune response to the next vaccine given in 2018 (Gardasil)- significantly swollen  lymphatic glands. No doctor ever connected the dots but I have researched and have learned the truth.  Doctors aren't trained to treat the root cause of anything. This vaccine impacted the quality of life for my son.
Age: 11.0
Sex: M
Vaccine: TDAP
Symptoms: Sinus operation, Therapy non-responder
Clinical narrative: Chronic sinus condition began that could never be remedied. Constant mucus buildup. No prior history of mucus, allergy or sinus issues prior to vaccine. Antibiotics were unsuccessful long term. Sinus surgery performed In 10/22. Mucus still builds up, even after surgery.  Strong immune response to the next vaccine given in 2018 (Gardasil)- significantly swollen  lymphatic glands. No doctor ever connected the dots but I have researched and have learned the truth.  Doctors aren't trained to treat the root cause of anything. This vaccine impacted the quality of life for my son.
Age: 51.0
Sex: F
Vaccine: RSV
Symptoms: No adverse event, Product administered to patient of inappropriate age
Clinical narrative: Patient did not report any adverse issues with vaccine. She is under the recommended age to get the vaccine. she is under 60 years old.
Age: 40.0
Sex: F
Vaccine: COVID19
Symptoms: Chest discomfort, Lip swelling, Pruritus
Clinical narrative: Patient arrived at pharmacy on 11/7 to report adverse event starting on 11/4/23. The itching started on her right arm a few hours after administration. She had swelling in her lips and her chest became tight. She went to urgent care.
Age: 64.0
Sex: M
Vaccine: FLUA4
Symptoms: No adverse event, Product administered to patient of inappropriate age
Clinical narrative: Gave high dose flu shot to someone who was not yet 65 years old. Patient did not report any adverse effects or reactions as of this time.
Age: 9.0
Sex: M
Vaccine: FLU4
Symptoms: Injection site urticaria
Clinical narrative: urticaria at injection site
Age: 9.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect dose administered
Clinical narrative: Adult dose for 12+ given to 9 year old patient.
Age: 57.0
Sex: M
Vaccine: HEP
Symptoms: Unevaluable event
Clinical narrative: no reaction
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Acidosis hyperchloraemic, Acute kidney injury, Anaemia, Antineutrophil cytoplasmic antibody negative, Antinuclear antibody negative
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Atelectasis, Biopsy kidney abnormal, Blood creatinine, COVID-19, Chest X-ray abnormal
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Chills, Chronic kidney disease, Circumcision, Complement factor C3, Complement factor C4
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen normal, Computerised tomogram thorax normal, Condition aggravated, Cough, Dyspnoea
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Flatulence, Glycosylated haemoglobin increased, HIV antibody negative, Haemoglobin decreased, Hyperkalaemia
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Immunology test normal, Leukocytosis, Malaise, Occult blood negative, Pneumonia
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Pyrexia, Renal injury, Renal tubular necrosis, SARS-CoV-2 test positive, Sepsis
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Tachycardia, Transfusion, Ultrasound kidney abnormal, Urine analysis normal, White blood cell count increased
Clinical narrative: Patient is a 27-year-old male with PMH of HTN, HLD, DM type II, CKD, dwarfism, severe phimosis s/p circumcision on July 2023 presented to Facility with cough fever, malaise chills.  He was found to be COVID-positive with signs of sepsis, CXR showed possible pneumonia versus atelectasis.  Patient had high fever secondary.  Currently on room air.   Pt doing well. Wants to go. Willing to leave AMA. PE unremarkable. D/w Dr., leukocytosis likely reactive. F/u with PCP and Nephrology as OP.     Acute Renal Failure with Hyperkalemia CKD stage IIIb Non Anion Gap Metabolic Acidosis History of severe phimosis s/p circumcision on July 2023 Creatinine on admission 7.28, was 2.4 on 8/2 UA is negative for infection Ultrasound and renal showed left kidney is obscured by bowel gas, no hydronephrosis or nephrolithiasis Serum immunofixation is negative, C3, C4, ANA and ANCA are negative. HIV antibody nonreactive September 5. 9/27 status post kidney biopsy?per nephrology show complement of ATN however there is also chronic damage from DM nephropathy.   Covid-19 Virus Infection Possible sepsis Pneumonia ruled out Covid-19 Virus Infection Date of onset of symptoms: 9/23 Symptoms present on admission: Yes Date of covid positive test: 9/23 Vaccination status: vaccinated Imaging: Chest x-ray Oxygen requirements on admission: Yes Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: ID Anticipated special isolation end date: 10/3 Admitted with subjective fever chills shortness of breath  COVID-positive CXR atelectasis versus developing pneumonia and left lung Currently on room air  Leukocytosis Elevated WBCs, tachycardic on 10/3 D/w ID - CT CAP ordered and negative for acute inflammation OK for discharge per ID   Anemia Check stool for heme occult Transfuse for hb <7 No obvious bleeding Hemoglobin 6.8 on 9/28 Transfuse 1 unit Hemoglobin stable D/w Nephrology who thinks this is all CKD and hydration dilution of Hb.   Occult blood negative Hematology consulted for Retacrit   Learning disability MRDD Depends on aunt for decision making Lives alone since mom died recently CM working on safe discharge plan and helping him with services Discussed with his aunt today they are working on getting some help at home.  We will try to optimize services at home   Insulin Dependent DM Type II HgA1c 4/28/23: 9.4 Hold metformin Continue home lispro and lantus. Accuchecks AC/HS with ISS coverage Endocrinology consulted   Essential Hypertension Hold lisinopril Start patient on hydralazine 50 mg tid   Dyslipidemia Continue atorvastatin
Age: 64.0
Sex: F
Vaccine: COVID19-2
Symptoms: Arthralgia, Injection site pain, Lethargy
Clinical narrative: Severe joint pain throughout entire body and lethargy that lasted 24 hours. Minimal injection site soreness
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Aortic valve incompetence, COVID-19, Colonoscopy abnormal, Computerised tomogram abdomen abnormal, Computerised tomogram thorax abnormal
Clinical narrative: Patient is a 76 y.o. female patient of DO with history of CAD, SSS, pAfib, CHF presented to Medical Center with worsening cough, sob recent covid since at least 9/19, CT imaging with concern for RLL PNA.   Right Lower Lobe Pneumonia Recent COVID (resolved) Leukocytosis (resolved) Diagnosed with covid 9/19 or earlier; given Decadron 6mg x6 days per PCP and recommended for mucinex, zinc and vit D CT abd/pelvis noted sign of RLL infiltrate, suspect 2/2 bacterial pna  Urine Ag negative, Resp PCR negative Cefuroxime antibiotic course was completed   Abnormal CT abd Hematochezia-resolved CT abd/pelvis-consistent with proctitis GI consulted- colonoscopy on Monday 10/2 Colonoscopy 10/2 - 7 mm polyp in sigmoid resected and retrieved. Diverticulosis of sigmoid and descending colon and ascending colon.  Internal hemorrhoids.   Recommended for high fiber diet   Hemoglobin remained stable    Resistant hypertension-resolved Renal artery stenosis-severely diseased Vascular surgery was consulted-Follow up with Dr. (vasc sx) and continuing ASA, plavix, statin Nephrology was consulted-recommended below BP meds Discharge meds: BP meds-Hydralazine 25mg tid, spironolactone, losartan, metoprolol Renal artery stenosis- ASA, plavix and statin    COPD Seasonal allergies Meds: antihistamine, prn inhaler   Hyperglycemia-resolved Likely from steroids A1c 5.8 SSI was later dc'd   Coronary artery disease CHFpEF LHC 4/2023 - PCI to RCA and hx of CABG Echo 5/23 -EF 60-65%, mild-mod AR, no pulm HTN Meds- DAPT, Lipitor, metoprolol, losartan, aldactone   Paroxysmal Afib Follows with: heart and vascular, s/p MAZE and LAA clip Monitored on telemetry Meds-lopressor, Cardizem   PAD CTA C/A/P 9/9 - significant atherosclerotic disease in multiple areas Meds: DAPT   SSS S/p PPM   Left Carotid Artery stenosis S/p L CEA Meds: dapt and statin   Hypothyroidism Meds: Cont home synthroid   GERD On omeprazole, would dc on pantoprazole with plavix use   Tobacco use disorder Counseled cessation   Addendum was made to below discharge med list- prednisone 5mg x 3 more doses to complete taper (not 10mg as reflected below).
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Diverticulum intestinal, Dyspnoea, Echocardiogram abnormal, Ejection fraction
Clinical narrative: Patient is a 76 y.o. female patient of DO with history of CAD, SSS, pAfib, CHF presented to Medical Center with worsening cough, sob recent covid since at least 9/19, CT imaging with concern for RLL PNA.   Right Lower Lobe Pneumonia Recent COVID (resolved) Leukocytosis (resolved) Diagnosed with covid 9/19 or earlier; given Decadron 6mg x6 days per PCP and recommended for mucinex, zinc and vit D CT abd/pelvis noted sign of RLL infiltrate, suspect 2/2 bacterial pna  Urine Ag negative, Resp PCR negative Cefuroxime antibiotic course was completed   Abnormal CT abd Hematochezia-resolved CT abd/pelvis-consistent with proctitis GI consulted- colonoscopy on Monday 10/2 Colonoscopy 10/2 - 7 mm polyp in sigmoid resected and retrieved. Diverticulosis of sigmoid and descending colon and ascending colon.  Internal hemorrhoids.   Recommended for high fiber diet   Hemoglobin remained stable    Resistant hypertension-resolved Renal artery stenosis-severely diseased Vascular surgery was consulted-Follow up with Dr. (vasc sx) and continuing ASA, plavix, statin Nephrology was consulted-recommended below BP meds Discharge meds: BP meds-Hydralazine 25mg tid, spironolactone, losartan, metoprolol Renal artery stenosis- ASA, plavix and statin    COPD Seasonal allergies Meds: antihistamine, prn inhaler   Hyperglycemia-resolved Likely from steroids A1c 5.8 SSI was later dc'd   Coronary artery disease CHFpEF LHC 4/2023 - PCI to RCA and hx of CABG Echo 5/23 -EF 60-65%, mild-mod AR, no pulm HTN Meds- DAPT, Lipitor, metoprolol, losartan, aldactone   Paroxysmal Afib Follows with: heart and vascular, s/p MAZE and LAA clip Monitored on telemetry Meds-lopressor, Cardizem   PAD CTA C/A/P 9/9 - significant atherosclerotic disease in multiple areas Meds: DAPT   SSS S/p PPM   Left Carotid Artery stenosis S/p L CEA Meds: dapt and statin   Hypothyroidism Meds: Cont home synthroid   GERD On omeprazole, would dc on pantoprazole with plavix use   Tobacco use disorder Counseled cessation   Addendum was made to below discharge med list- prednisone 5mg x 3 more doses to complete taper (not 10mg as reflected below).
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Glycosylated haemoglobin normal, Haematochezia, Haemoglobin normal, Haemorrhoids, Hyperglycaemia
Clinical narrative: Patient is a 76 y.o. female patient of DO with history of CAD, SSS, pAfib, CHF presented to Medical Center with worsening cough, sob recent covid since at least 9/19, CT imaging with concern for RLL PNA.   Right Lower Lobe Pneumonia Recent COVID (resolved) Leukocytosis (resolved) Diagnosed with covid 9/19 or earlier; given Decadron 6mg x6 days per PCP and recommended for mucinex, zinc and vit D CT abd/pelvis noted sign of RLL infiltrate, suspect 2/2 bacterial pna  Urine Ag negative, Resp PCR negative Cefuroxime antibiotic course was completed   Abnormal CT abd Hematochezia-resolved CT abd/pelvis-consistent with proctitis GI consulted- colonoscopy on Monday 10/2 Colonoscopy 10/2 - 7 mm polyp in sigmoid resected and retrieved. Diverticulosis of sigmoid and descending colon and ascending colon.  Internal hemorrhoids.   Recommended for high fiber diet   Hemoglobin remained stable    Resistant hypertension-resolved Renal artery stenosis-severely diseased Vascular surgery was consulted-Follow up with Dr. (vasc sx) and continuing ASA, plavix, statin Nephrology was consulted-recommended below BP meds Discharge meds: BP meds-Hydralazine 25mg tid, spironolactone, losartan, metoprolol Renal artery stenosis- ASA, plavix and statin    COPD Seasonal allergies Meds: antihistamine, prn inhaler   Hyperglycemia-resolved Likely from steroids A1c 5.8 SSI was later dc'd   Coronary artery disease CHFpEF LHC 4/2023 - PCI to RCA and hx of CABG Echo 5/23 -EF 60-65%, mild-mod AR, no pulm HTN Meds- DAPT, Lipitor, metoprolol, losartan, aldactone   Paroxysmal Afib Follows with: heart and vascular, s/p MAZE and LAA clip Monitored on telemetry Meds-lopressor, Cardizem   PAD CTA C/A/P 9/9 - significant atherosclerotic disease in multiple areas Meds: DAPT   SSS S/p PPM   Left Carotid Artery stenosis S/p L CEA Meds: dapt and statin   Hypothyroidism Meds: Cont home synthroid   GERD On omeprazole, would dc on pantoprazole with plavix use   Tobacco use disorder Counseled cessation   Addendum was made to below discharge med list- prednisone 5mg x 3 more doses to complete taper (not 10mg as reflected below).
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertension, Large intestine polyp, Leukocytosis, Lung infiltration, Pneumonia
Clinical narrative: Patient is a 76 y.o. female patient of DO with history of CAD, SSS, pAfib, CHF presented to Medical Center with worsening cough, sob recent covid since at least 9/19, CT imaging with concern for RLL PNA.   Right Lower Lobe Pneumonia Recent COVID (resolved) Leukocytosis (resolved) Diagnosed with covid 9/19 or earlier; given Decadron 6mg x6 days per PCP and recommended for mucinex, zinc and vit D CT abd/pelvis noted sign of RLL infiltrate, suspect 2/2 bacterial pna  Urine Ag negative, Resp PCR negative Cefuroxime antibiotic course was completed   Abnormal CT abd Hematochezia-resolved CT abd/pelvis-consistent with proctitis GI consulted- colonoscopy on Monday 10/2 Colonoscopy 10/2 - 7 mm polyp in sigmoid resected and retrieved. Diverticulosis of sigmoid and descending colon and ascending colon.  Internal hemorrhoids.   Recommended for high fiber diet   Hemoglobin remained stable    Resistant hypertension-resolved Renal artery stenosis-severely diseased Vascular surgery was consulted-Follow up with Dr. (vasc sx) and continuing ASA, plavix, statin Nephrology was consulted-recommended below BP meds Discharge meds: BP meds-Hydralazine 25mg tid, spironolactone, losartan, metoprolol Renal artery stenosis- ASA, plavix and statin    COPD Seasonal allergies Meds: antihistamine, prn inhaler   Hyperglycemia-resolved Likely from steroids A1c 5.8 SSI was later dc'd   Coronary artery disease CHFpEF LHC 4/2023 - PCI to RCA and hx of CABG Echo 5/23 -EF 60-65%, mild-mod AR, no pulm HTN Meds- DAPT, Lipitor, metoprolol, losartan, aldactone   Paroxysmal Afib Follows with: heart and vascular, s/p MAZE and LAA clip Monitored on telemetry Meds-lopressor, Cardizem   PAD CTA C/A/P 9/9 - significant atherosclerotic disease in multiple areas Meds: DAPT   SSS S/p PPM   Left Carotid Artery stenosis S/p L CEA Meds: dapt and statin   Hypothyroidism Meds: Cont home synthroid   GERD On omeprazole, would dc on pantoprazole with plavix use   Tobacco use disorder Counseled cessation   Addendum was made to below discharge med list- prednisone 5mg x 3 more doses to complete taper (not 10mg as reflected below).
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Pneumonia bacterial, Polymerase chain reaction negative, Polypectomy, Proctitis, Renal artery stenosis
Clinical narrative: Patient is a 76 y.o. female patient of DO with history of CAD, SSS, pAfib, CHF presented to Medical Center with worsening cough, sob recent covid since at least 9/19, CT imaging with concern for RLL PNA.   Right Lower Lobe Pneumonia Recent COVID (resolved) Leukocytosis (resolved) Diagnosed with covid 9/19 or earlier; given Decadron 6mg x6 days per PCP and recommended for mucinex, zinc and vit D CT abd/pelvis noted sign of RLL infiltrate, suspect 2/2 bacterial pna  Urine Ag negative, Resp PCR negative Cefuroxime antibiotic course was completed   Abnormal CT abd Hematochezia-resolved CT abd/pelvis-consistent with proctitis GI consulted- colonoscopy on Monday 10/2 Colonoscopy 10/2 - 7 mm polyp in sigmoid resected and retrieved. Diverticulosis of sigmoid and descending colon and ascending colon.  Internal hemorrhoids.   Recommended for high fiber diet   Hemoglobin remained stable    Resistant hypertension-resolved Renal artery stenosis-severely diseased Vascular surgery was consulted-Follow up with Dr. (vasc sx) and continuing ASA, plavix, statin Nephrology was consulted-recommended below BP meds Discharge meds: BP meds-Hydralazine 25mg tid, spironolactone, losartan, metoprolol Renal artery stenosis- ASA, plavix and statin    COPD Seasonal allergies Meds: antihistamine, prn inhaler   Hyperglycemia-resolved Likely from steroids A1c 5.8 SSI was later dc'd   Coronary artery disease CHFpEF LHC 4/2023 - PCI to RCA and hx of CABG Echo 5/23 -EF 60-65%, mild-mod AR, no pulm HTN Meds- DAPT, Lipitor, metoprolol, losartan, aldactone   Paroxysmal Afib Follows with: heart and vascular, s/p MAZE and LAA clip Monitored on telemetry Meds-lopressor, Cardizem   PAD CTA C/A/P 9/9 - significant atherosclerotic disease in multiple areas Meds: DAPT   SSS S/p PPM   Left Carotid Artery stenosis S/p L CEA Meds: dapt and statin   Hypothyroidism Meds: Cont home synthroid   GERD On omeprazole, would dc on pantoprazole with plavix use   Tobacco use disorder Counseled cessation   Addendum was made to below discharge med list- prednisone 5mg x 3 more doses to complete taper (not 10mg as reflected below).
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Urine antigen test
Clinical narrative: Patient is a 76 y.o. female patient of DO with history of CAD, SSS, pAfib, CHF presented to Medical Center with worsening cough, sob recent covid since at least 9/19, CT imaging with concern for RLL PNA.   Right Lower Lobe Pneumonia Recent COVID (resolved) Leukocytosis (resolved) Diagnosed with covid 9/19 or earlier; given Decadron 6mg x6 days per PCP and recommended for mucinex, zinc and vit D CT abd/pelvis noted sign of RLL infiltrate, suspect 2/2 bacterial pna  Urine Ag negative, Resp PCR negative Cefuroxime antibiotic course was completed   Abnormal CT abd Hematochezia-resolved CT abd/pelvis-consistent with proctitis GI consulted- colonoscopy on Monday 10/2 Colonoscopy 10/2 - 7 mm polyp in sigmoid resected and retrieved. Diverticulosis of sigmoid and descending colon and ascending colon.  Internal hemorrhoids.   Recommended for high fiber diet   Hemoglobin remained stable    Resistant hypertension-resolved Renal artery stenosis-severely diseased Vascular surgery was consulted-Follow up with Dr. (vasc sx) and continuing ASA, plavix, statin Nephrology was consulted-recommended below BP meds Discharge meds: BP meds-Hydralazine 25mg tid, spironolactone, losartan, metoprolol Renal artery stenosis- ASA, plavix and statin    COPD Seasonal allergies Meds: antihistamine, prn inhaler   Hyperglycemia-resolved Likely from steroids A1c 5.8 SSI was later dc'd   Coronary artery disease CHFpEF LHC 4/2023 - PCI to RCA and hx of CABG Echo 5/23 -EF 60-65%, mild-mod AR, no pulm HTN Meds- DAPT, Lipitor, metoprolol, losartan, aldactone   Paroxysmal Afib Follows with: heart and vascular, s/p MAZE and LAA clip Monitored on telemetry Meds-lopressor, Cardizem   PAD CTA C/A/P 9/9 - significant atherosclerotic disease in multiple areas Meds: DAPT   SSS S/p PPM   Left Carotid Artery stenosis S/p L CEA Meds: dapt and statin   Hypothyroidism Meds: Cont home synthroid   GERD On omeprazole, would dc on pantoprazole with plavix use   Tobacco use disorder Counseled cessation   Addendum was made to below discharge med list- prednisone 5mg x 3 more doses to complete taper (not 10mg as reflected below).
Age: 11.0
Sex: F
Vaccine: COVID19, FLUC4
Symptoms: Loss of consciousness
Clinical narrative: passed out shortly after being administered the second vaccine (flu vaccine).
Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Angiogram pulmonary abnormal, Anxiety, Arteriosclerosis coronary artery, Arthralgia
Clinical narrative: Patient is a 64 y.o. female patient of, CNP with history of DM type 2 without insulin use, HTN, HLD and depression who presented to Doctors Hospital with shortness of breath and hypoxia. Problem based management in the hospital is as follows:   Acute respiratory failure with hypoxia, resolved Covid-19 Virus Infection Date of onset of symptoms: 10/10 Symptoms present on admission: Fatigue and shortness of breath.  Date of covid positive test: 10/13 Vaccination status: vaccinated Imaging: CTPA showed severe multivessel coronary calcifications.  0.7 cm noncalcified nodule and anterior lateral right mid chest, 0.4 cm stable noncalcified nodule in posterior medial left lower chest.  A 1.4 cm hypodense nodule within the left lobe of the thyroid gland. Oxygen requirements on admission: 2 L Current oxygen requirements: Room air Medical therapy: remdesivir and steroids while inpatient, discharged on steroid taper Consultants following: ID were consulted Anticipated special isolation end date: 10/20   Elevated troponin Likely related to COVID-19 infection Troponin 30 then 24, delta -6 EKG with mild ST depressions in lateral leads otherwise unremarkable. Patient denies any chest pain No further inpatient work-up indicated   Chronic back pain and left hip pain Reports acute aggravation over the last week or so Has history of previous back surgery with a scar but she is unable to explain what kind of surgery was She takes gabapentin 600 mg nightly, changed to 200 3 times daily for now. Recommend continued outpatient follow-up with surgery  Hypokalemia, resolved K3.4 on arrival Replaced Recheck tomorrow   Lung nodules Noted on CTPA as above Recommend repeat CT chest in 6 months   Thyroid nodule Noted on CTPA as above TSH WNL Recommend outpatient thyroid ultrasound   DM Type II without insulin use or complications Uncontrolled.  Takes metformin at home Held oral meds and SSI for now   Benign Essential HTN Takes amlodipine, Hyzaar at home Continue home meds Continue monitoring   Mixed Hyperlipidemia Continued home dose statin    GERD Continued home PPI   Anxiety and depression Continued home BuSpar, Depakote and Zoloft   Insomnia Continued home Ambien as needed   After 2 days of hospital stay, patient was doing well so he was discharged in stable condition. Advised to f/u with PCP and spine surgery. All questions and concerns were addressed before discharge.