chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 77.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Leukocytosis, Metabolic function test abnormal, Nasopharyngitis, Nausea, Nitrite urine absent
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: FNP  Admission Date: 8/9/2023 Discharge Date: 8/11/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] UTI (urinary tract infection) [N39.0]   HOSPITAL COURSE:     Patient is a 78 y.o. female who presented to the emergency department with complaints of chills with nausea, and shortness of breath.  Patient has a past medical history including Wegener's granulomatosis, vitamin B12 deficiency, CKD, hypertension, anemia, persistent atrial fibrillation, combined systolic and diastolic heart failure, and obesity. Patient states that she developed feelings of chills, nausea, shortness of breath and generalized body aches .  She states that approximately 10 days ago, she was exposed to COVID-19 while at a concert.  She developed cold-like symptoms approximately 2 days later.   She presented to the emergency department for evaluation.  In the emergency department, patient was tachycardic, tachypneic, and was hypoxic with activity.  She was afebrile, however.  Complete blood count revealed leukocytosis without lactic acidosis.  CMP showed CKD, which is chronic for this patient.  Additionally, BNP was 31000, which is near baseline for this patient.  COVID-19 was positive.  Urinalysis showed moderate leukocytes without nitrites.  Patient has no urinary symptoms.  Procalcitonin was 7.76 chest x-ray showed no acute cardiopulmonary disease.  EKG showed atrial fibrillation, which is chronic for this patient.  Patient was admitted for further evaluation and management of sepsis due to pneumonia 2/2 COVID 19 and UTI.    Patient was managed symptomatically for COVID-19 pneumonia.  No antiviral drugs or steroids were administered.  Patient was on room air and asymptomatic.  She was treated with IV Rocephin for urinary tract infection.  Blood cultures remained negative.  Urine culture was contaminated.  Given improvement with IV Rocephin patient was transitioned to oral Ceftin on discharge to complete a 5 day course.  Patient was evaluated by PT OT and was recommended home with home health PT.  Patient was discharged home in    PS:  Patient's Eliquis was changed to 5 mg 2 times a day as per renal dosing.
Age: 77.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Pain, Pneumonia, Procalcitonin, SARS-CoV-2 test positive, Sepsis
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: FNP  Admission Date: 8/9/2023 Discharge Date: 8/11/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] UTI (urinary tract infection) [N39.0]   HOSPITAL COURSE:     Patient is a 78 y.o. female who presented to the emergency department with complaints of chills with nausea, and shortness of breath.  Patient has a past medical history including Wegener's granulomatosis, vitamin B12 deficiency, CKD, hypertension, anemia, persistent atrial fibrillation, combined systolic and diastolic heart failure, and obesity. Patient states that she developed feelings of chills, nausea, shortness of breath and generalized body aches .  She states that approximately 10 days ago, she was exposed to COVID-19 while at a concert.  She developed cold-like symptoms approximately 2 days later.   She presented to the emergency department for evaluation.  In the emergency department, patient was tachycardic, tachypneic, and was hypoxic with activity.  She was afebrile, however.  Complete blood count revealed leukocytosis without lactic acidosis.  CMP showed CKD, which is chronic for this patient.  Additionally, BNP was 31000, which is near baseline for this patient.  COVID-19 was positive.  Urinalysis showed moderate leukocytes without nitrites.  Patient has no urinary symptoms.  Procalcitonin was 7.76 chest x-ray showed no acute cardiopulmonary disease.  EKG showed atrial fibrillation, which is chronic for this patient.  Patient was admitted for further evaluation and management of sepsis due to pneumonia 2/2 COVID 19 and UTI.    Patient was managed symptomatically for COVID-19 pneumonia.  No antiviral drugs or steroids were administered.  Patient was on room air and asymptomatic.  She was treated with IV Rocephin for urinary tract infection.  Blood cultures remained negative.  Urine culture was contaminated.  Given improvement with IV Rocephin patient was transitioned to oral Ceftin on discharge to complete a 5 day course.  Patient was evaluated by PT OT and was recommended home with home health PT.  Patient was discharged home in    PS:  Patient's Eliquis was changed to 5 mg 2 times a day as per renal dosing.
Age: 77.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Tachycardia, Tachypnoea, Urinary tract infection, White blood cells urine positive
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: FNP  Admission Date: 8/9/2023 Discharge Date: 8/11/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] UTI (urinary tract infection) [N39.0]   HOSPITAL COURSE:     Patient is a 78 y.o. female who presented to the emergency department with complaints of chills with nausea, and shortness of breath.  Patient has a past medical history including Wegener's granulomatosis, vitamin B12 deficiency, CKD, hypertension, anemia, persistent atrial fibrillation, combined systolic and diastolic heart failure, and obesity. Patient states that she developed feelings of chills, nausea, shortness of breath and generalized body aches .  She states that approximately 10 days ago, she was exposed to COVID-19 while at a concert.  She developed cold-like symptoms approximately 2 days later.   She presented to the emergency department for evaluation.  In the emergency department, patient was tachycardic, tachypneic, and was hypoxic with activity.  She was afebrile, however.  Complete blood count revealed leukocytosis without lactic acidosis.  CMP showed CKD, which is chronic for this patient.  Additionally, BNP was 31000, which is near baseline for this patient.  COVID-19 was positive.  Urinalysis showed moderate leukocytes without nitrites.  Patient has no urinary symptoms.  Procalcitonin was 7.76 chest x-ray showed no acute cardiopulmonary disease.  EKG showed atrial fibrillation, which is chronic for this patient.  Patient was admitted for further evaluation and management of sepsis due to pneumonia 2/2 COVID 19 and UTI.    Patient was managed symptomatically for COVID-19 pneumonia.  No antiviral drugs or steroids were administered.  Patient was on room air and asymptomatic.  She was treated with IV Rocephin for urinary tract infection.  Blood cultures remained negative.  Urine culture was contaminated.  Given improvement with IV Rocephin patient was transitioned to oral Ceftin on discharge to complete a 5 day course.  Patient was evaluated by PT OT and was recommended home with home health PT.  Patient was discharged home in    PS:  Patient's Eliquis was changed to 5 mg 2 times a day as per renal dosing.
Age: 92.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Computerised tomogram head normal
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/9/2023 Discharge Date: Aug 19, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: PCP ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Weakness [R53.1] Fall, initial encounter [W19.XXXA] COVID [U07.1] COVID-19 virus infection [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is a 93-year-old female with a past medical history of chronic thrombocytopenia, diabetes mellitus type 2, hypertension, hyperlipidemia and dementia who presents with a chief complaint of fall.  Patient's daughter tested positive for COVID-19 a week prior to admission.  She tested positive at home on 08/08/2023 for COVID.  Family noted she had progressive weakness over the last week.  She had an unwitnessed fall.  Her daughter did not believe she hit her head.  She also was noted to be increasingly confused for the last few days prior to admission.  In the emergency department, she was hemodynamically stable.  She was afebrile.  She was not hypoxic.  Her she was noted to have pancytopenia which was acute on chronic in terms of her platelet level.  CT head and CT C-spine were unremarkable for acute injury, though there was questionable findings that could be consistent with compression fractures in her cervical spine.  Chest x-ray showed bilateral opacities.   She was admitted under observation to the hospitalist service for COVID-19 pneumonia.  She was treated with IV remdesivir.   PT/OT recommended SAR.  The patient was discharged to subacute rehab 8/19. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. advised to follow-up with PCP after rehab.
Age: 92.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram spine, Confusional state, Fall, Lung opacity, Pancytopenia
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/9/2023 Discharge Date: Aug 19, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: PCP ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Weakness [R53.1] Fall, initial encounter [W19.XXXA] COVID [U07.1] COVID-19 virus infection [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is a 93-year-old female with a past medical history of chronic thrombocytopenia, diabetes mellitus type 2, hypertension, hyperlipidemia and dementia who presents with a chief complaint of fall.  Patient's daughter tested positive for COVID-19 a week prior to admission.  She tested positive at home on 08/08/2023 for COVID.  Family noted she had progressive weakness over the last week.  She had an unwitnessed fall.  Her daughter did not believe she hit her head.  She also was noted to be increasingly confused for the last few days prior to admission.  In the emergency department, she was hemodynamically stable.  She was afebrile.  She was not hypoxic.  Her she was noted to have pancytopenia which was acute on chronic in terms of her platelet level.  CT head and CT C-spine were unremarkable for acute injury, though there was questionable findings that could be consistent with compression fractures in her cervical spine.  Chest x-ray showed bilateral opacities.   She was admitted under observation to the hospitalist service for COVID-19 pneumonia.  She was treated with IV remdesivir.   PT/OT recommended SAR.  The patient was discharged to subacute rehab 8/19. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. advised to follow-up with PCP after rehab.
Age: 92.0
Sex: F
Vaccine: COVID19
Symptoms: Platelet count decreased, SARS-CoV-2 test positive
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/9/2023 Discharge Date: Aug 19, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: PCP ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Weakness [R53.1] Fall, initial encounter [W19.XXXA] COVID [U07.1] COVID-19 virus infection [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is a 93-year-old female with a past medical history of chronic thrombocytopenia, diabetes mellitus type 2, hypertension, hyperlipidemia and dementia who presents with a chief complaint of fall.  Patient's daughter tested positive for COVID-19 a week prior to admission.  She tested positive at home on 08/08/2023 for COVID.  Family noted she had progressive weakness over the last week.  She had an unwitnessed fall.  Her daughter did not believe she hit her head.  She also was noted to be increasingly confused for the last few days prior to admission.  In the emergency department, she was hemodynamically stable.  She was afebrile.  She was not hypoxic.  Her she was noted to have pancytopenia which was acute on chronic in terms of her platelet level.  CT head and CT C-spine were unremarkable for acute injury, though there was questionable findings that could be consistent with compression fractures in her cervical spine.  Chest x-ray showed bilateral opacities.   She was admitted under observation to the hospitalist service for COVID-19 pneumonia.  She was treated with IV remdesivir.   PT/OT recommended SAR.  The patient was discharged to subacute rehab 8/19. at the time of discharge patient was in good spirits and eager to leave. all questions and concerns addressed, all meds and follow-ups reviewed. advised to follow-up with PCP after rehab.
Age: 91.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Acute kidney injury, Asthenia, Blood pressure abnormal, COVID-19, Cough
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/8/2023 Discharge Date: Aug 10, 2023 Discharge Disposition:  home or self care   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19 [U07.1] Weakness [R53.1]   HOSPITAL COURSE: 92-year-old male with a past medical history significant for hypertension diabetes as well as CKD stage IIIA who presents due to complaints of generalized weakness with cough and fatigue.  Patient was found to have COVID-19 but was otherwise hemodynamically stable with an acute on chronic kidney injury noted on admission.  Patient was given dexamethasone despite being on room air and was thought to warrant admission to the hospital.   By 8/9, renal function had improved and patient remained on room air and was feeling somewhat better.  Dexamethasone was discontinued and remdesivir was started.   After observing the patient on 08/09 overnight, by 8/10, he is feeling well enough to go home.  His blood pressure had improved his baseline and he was thought to be stable for discharge home with resumption of his home oral antihypertensive agents.  Patient discharged home in stable condition.
Age: 91.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Fatigue, Renal impairment
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/8/2023 Discharge Date: Aug 10, 2023 Discharge Disposition:  home or self care   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19 [U07.1] Weakness [R53.1]   HOSPITAL COURSE: 92-year-old male with a past medical history significant for hypertension diabetes as well as CKD stage IIIA who presents due to complaints of generalized weakness with cough and fatigue.  Patient was found to have COVID-19 but was otherwise hemodynamically stable with an acute on chronic kidney injury noted on admission.  Patient was given dexamethasone despite being on room air and was thought to warrant admission to the hospital.   By 8/9, renal function had improved and patient remained on room air and was feeling somewhat better.  Dexamethasone was discontinued and remdesivir was started.   After observing the patient on 08/09 overnight, by 8/10, he is feeling well enough to go home.  His blood pressure had improved his baseline and he was thought to be stable for discharge home with resumption of his home oral antihypertensive agents.  Patient discharged home in stable condition.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Contusion
Clinical narrative: extreme bruising in a checkerboard like pattern
Age: 76.0
Sex: F
Vaccine: RSV
Symptoms: Asthenia, Chills, Liquid product physical issue, Mobility decreased, Pain in extremity
Clinical narrative: She got her vaccine, initially she had a sore arm.  The vaccine itself was much thicker than others so could feel it going in.  At 5:00 AM she woke up with shaking chills, and had to get extra blankets to put on her.  She tried to get up out of bed, and could not and actually urinated in her bed due to the weakness.  Then she spiked a fever of 103.2 and lives with a pharmacist who told her to take Tylenol, which she did and able to keep it down.  Her fever came down fairly quickly but stayed in bed the rest of the day due to being worn out.  The chills passed, and this reaction lasted for 24 hours.  She then did not have any other symptoms.  She has had 2 COVID shots for which she had the same reactions.
Age: 76.0
Sex: F
Vaccine: RSV
Symptoms: Pyrexia, Sensory disturbance, Sleep disorder, Tremor, Urinary incontinence
Clinical narrative: She got her vaccine, initially she had a sore arm.  The vaccine itself was much thicker than others so could feel it going in.  At 5:00 AM she woke up with shaking chills, and had to get extra blankets to put on her.  She tried to get up out of bed, and could not and actually urinated in her bed due to the weakness.  Then she spiked a fever of 103.2 and lives with a pharmacist who told her to take Tylenol, which she did and able to keep it down.  Her fever came down fairly quickly but stayed in bed the rest of the day due to being worn out.  The chills passed, and this reaction lasted for 24 hours.  She then did not have any other symptoms.  She has had 2 COVID shots for which she had the same reactions.
Age: 51.0
Sex: F
Vaccine: COVID19-2, FLU4, HEP
Symptoms: Asthma, COVID-19, Chills, Condition aggravated, Dyspnoea
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/21/2023 Discharge Date: Aug 22, 2023 Discharge Disposition:  home or self care  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Moderate persistent asthma with exacerbation [J45.41] Acute COVID-19 [U07.1] COVID-19 [U07.1]   HOSPITAL COURSE: 52-year-old female with past medical history of moderate persistent asthma, hypertension, pituitary micro adenoma status post resection, presented to the emergency department with a chief complaint of shortness of breath with productive cough.  Patient reported symptoms of fevers and chills for approximately 4 days prior to coming in.  On arrival to the emergency department, she was assessed to be likely an asthma exacerbation.  patient tested positive for COVID-19 and was noted with significant hypokalemia.  Patient was admitted for further workup of likely asthma exacerbation. Overnight patient had good response to steroids and did not require any supplemental oxygen.  Patient reports significant improvement in symptoms.  Electrolytes were replaced with suspected likely secondary to hydrochlorothiazide and reported nausea vomiting.   On discharge, hydrochlorothiazide was discontinued and hydralazine 10 mg 3 times a day was initiated.  Patient was advised to have close follow-up with PCP for further ambulatory blood pressure monitoring   In regards to her respiratory status, patient will be discharged on steroid taper with follow-up with PCP for further asthma management.  All questions and concerns addressed.  Patient discharged in stable condition.
Age: 51.0
Sex: F
Vaccine: COVID19-2, FLU4, HEP
Symptoms: Electrolyte substitution therapy, Hypokalaemia, Nausea, Productive cough, Pyrexia
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/21/2023 Discharge Date: Aug 22, 2023 Discharge Disposition:  home or self care  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Moderate persistent asthma with exacerbation [J45.41] Acute COVID-19 [U07.1] COVID-19 [U07.1]   HOSPITAL COURSE: 52-year-old female with past medical history of moderate persistent asthma, hypertension, pituitary micro adenoma status post resection, presented to the emergency department with a chief complaint of shortness of breath with productive cough.  Patient reported symptoms of fevers and chills for approximately 4 days prior to coming in.  On arrival to the emergency department, she was assessed to be likely an asthma exacerbation.  patient tested positive for COVID-19 and was noted with significant hypokalemia.  Patient was admitted for further workup of likely asthma exacerbation. Overnight patient had good response to steroids and did not require any supplemental oxygen.  Patient reports significant improvement in symptoms.  Electrolytes were replaced with suspected likely secondary to hydrochlorothiazide and reported nausea vomiting.   On discharge, hydrochlorothiazide was discontinued and hydralazine 10 mg 3 times a day was initiated.  Patient was advised to have close follow-up with PCP for further ambulatory blood pressure monitoring   In regards to her respiratory status, patient will be discharged on steroid taper with follow-up with PCP for further asthma management.  All questions and concerns addressed.  Patient discharged in stable condition.
Age: 51.0
Sex: F
Vaccine: COVID19-2, FLU4, HEP
Symptoms: SARS-CoV-2 test positive, Vomiting
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/21/2023 Discharge Date: Aug 22, 2023 Discharge Disposition:  home or self care  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Moderate persistent asthma with exacerbation [J45.41] Acute COVID-19 [U07.1] COVID-19 [U07.1]   HOSPITAL COURSE: 52-year-old female with past medical history of moderate persistent asthma, hypertension, pituitary micro adenoma status post resection, presented to the emergency department with a chief complaint of shortness of breath with productive cough.  Patient reported symptoms of fevers and chills for approximately 4 days prior to coming in.  On arrival to the emergency department, she was assessed to be likely an asthma exacerbation.  patient tested positive for COVID-19 and was noted with significant hypokalemia.  Patient was admitted for further workup of likely asthma exacerbation. Overnight patient had good response to steroids and did not require any supplemental oxygen.  Patient reports significant improvement in symptoms.  Electrolytes were replaced with suspected likely secondary to hydrochlorothiazide and reported nausea vomiting.   On discharge, hydrochlorothiazide was discontinued and hydralazine 10 mg 3 times a day was initiated.  Patient was advised to have close follow-up with PCP for further ambulatory blood pressure monitoring   In regards to her respiratory status, patient will be discharged on steroid taper with follow-up with PCP for further asthma management.  All questions and concerns addressed.  Patient discharged in stable condition.
Age: 68.0
Sex: F
Vaccine: COVID19-2
Symptoms: Angiogram cerebral normal, Aphasia, Arthralgia, Asthenia, COVID-19
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/20/2023 Discharge Date: Aug 28, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: Pt. will follow up with her PCP and ortho outpatient  ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Fluid overload [E87.70]   HOSPITAL COURSE: This is a pleasant 69-year-old woman with past medical history of ESRD on hemodialysis MWF, OSA on CPAP, hypothyroidism, GERD, recurrent diverticulitis, and orthostatic hypotension  who presented for SOB and requesting HD.  Patient missed HD on 8/14 but did have HD on the following Wednesday and Friday.  She has had one-week history of cough with shortness of breath, congestion, and generalized weakness.  She was found to be COVID positive. Patient was mildly hypoxic requiring 1 L nasal cannula.  Chest x-ray with no acute cardiopulmonary process.  NT proBNP was significantly elevated. She was given dose of IV Solu-Medrol and transferred to hospital for HD.  Patient was quickly able to be weaned off of oxygen so further steroids were held. Patient also complained of right shoulder pain with known chronic right anterior shoulder dislocation for which orthopedic surgery was consulted and rec sling with outpatient follow up with her establish orthopedic surgeon Dr. Pt. did have complications of episode of aphasia during her stay that quickly resolved. Neuro was consulted. CT head with chronic bilateral basal ganglia lacunar infarctions. MRI/MRA brain was obtained with no acute abnormalities. Carotid U/S without significant stenosis. Neuro felt her symptoms were due to metabolic encephalopathy with hospital acquired delirium and recommended no further inpatient workup. PT/OT recommended SAR. Pt. will follow up with her PCP and ortho outpatient. Pt. is discharging to SAR in improved and stable condition.
Age: 68.0
Sex: F
Vaccine: COVID19-2
Symptoms: Chest X-ray normal, Computerised tomogram head abnormal, Cough, Delirium, Dyspnoea
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/20/2023 Discharge Date: Aug 28, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: Pt. will follow up with her PCP and ortho outpatient  ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Fluid overload [E87.70]   HOSPITAL COURSE: This is a pleasant 69-year-old woman with past medical history of ESRD on hemodialysis MWF, OSA on CPAP, hypothyroidism, GERD, recurrent diverticulitis, and orthostatic hypotension  who presented for SOB and requesting HD.  Patient missed HD on 8/14 but did have HD on the following Wednesday and Friday.  She has had one-week history of cough with shortness of breath, congestion, and generalized weakness.  She was found to be COVID positive. Patient was mildly hypoxic requiring 1 L nasal cannula.  Chest x-ray with no acute cardiopulmonary process.  NT proBNP was significantly elevated. She was given dose of IV Solu-Medrol and transferred to hospital for HD.  Patient was quickly able to be weaned off of oxygen so further steroids were held. Patient also complained of right shoulder pain with known chronic right anterior shoulder dislocation for which orthopedic surgery was consulted and rec sling with outpatient follow up with her establish orthopedic surgeon Dr. Pt. did have complications of episode of aphasia during her stay that quickly resolved. Neuro was consulted. CT head with chronic bilateral basal ganglia lacunar infarctions. MRI/MRA brain was obtained with no acute abnormalities. Carotid U/S without significant stenosis. Neuro felt her symptoms were due to metabolic encephalopathy with hospital acquired delirium and recommended no further inpatient workup. PT/OT recommended SAR. Pt. will follow up with her PCP and ortho outpatient. Pt. is discharging to SAR in improved and stable condition.
Age: 68.0
Sex: F
Vaccine: COVID19-2
Symptoms: Haemodialysis, Hypervolaemia, Hypoxia, Joint dislocation, Lacunar infarction
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/20/2023 Discharge Date: Aug 28, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: Pt. will follow up with her PCP and ortho outpatient  ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Fluid overload [E87.70]   HOSPITAL COURSE: This is a pleasant 69-year-old woman with past medical history of ESRD on hemodialysis MWF, OSA on CPAP, hypothyroidism, GERD, recurrent diverticulitis, and orthostatic hypotension  who presented for SOB and requesting HD.  Patient missed HD on 8/14 but did have HD on the following Wednesday and Friday.  She has had one-week history of cough with shortness of breath, congestion, and generalized weakness.  She was found to be COVID positive. Patient was mildly hypoxic requiring 1 L nasal cannula.  Chest x-ray with no acute cardiopulmonary process.  NT proBNP was significantly elevated. She was given dose of IV Solu-Medrol and transferred to hospital for HD.  Patient was quickly able to be weaned off of oxygen so further steroids were held. Patient also complained of right shoulder pain with known chronic right anterior shoulder dislocation for which orthopedic surgery was consulted and rec sling with outpatient follow up with her establish orthopedic surgeon Dr. Pt. did have complications of episode of aphasia during her stay that quickly resolved. Neuro was consulted. CT head with chronic bilateral basal ganglia lacunar infarctions. MRI/MRA brain was obtained with no acute abnormalities. Carotid U/S without significant stenosis. Neuro felt her symptoms were due to metabolic encephalopathy with hospital acquired delirium and recommended no further inpatient workup. PT/OT recommended SAR. Pt. will follow up with her PCP and ortho outpatient. Pt. is discharging to SAR in improved and stable condition.
Age: 68.0
Sex: F
Vaccine: COVID19-2
Symptoms: Magnetic resonance imaging head normal, Metabolic encephalopathy, N-terminal prohormone brain natriuretic peptide increased, Respiratory tract congestion, SARS-CoV-2 test positive
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/20/2023 Discharge Date: Aug 28, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: Pt. will follow up with her PCP and ortho outpatient  ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Fluid overload [E87.70]   HOSPITAL COURSE: This is a pleasant 69-year-old woman with past medical history of ESRD on hemodialysis MWF, OSA on CPAP, hypothyroidism, GERD, recurrent diverticulitis, and orthostatic hypotension  who presented for SOB and requesting HD.  Patient missed HD on 8/14 but did have HD on the following Wednesday and Friday.  She has had one-week history of cough with shortness of breath, congestion, and generalized weakness.  She was found to be COVID positive. Patient was mildly hypoxic requiring 1 L nasal cannula.  Chest x-ray with no acute cardiopulmonary process.  NT proBNP was significantly elevated. She was given dose of IV Solu-Medrol and transferred to hospital for HD.  Patient was quickly able to be weaned off of oxygen so further steroids were held. Patient also complained of right shoulder pain with known chronic right anterior shoulder dislocation for which orthopedic surgery was consulted and rec sling with outpatient follow up with her establish orthopedic surgeon Dr. Pt. did have complications of episode of aphasia during her stay that quickly resolved. Neuro was consulted. CT head with chronic bilateral basal ganglia lacunar infarctions. MRI/MRA brain was obtained with no acute abnormalities. Carotid U/S without significant stenosis. Neuro felt her symptoms were due to metabolic encephalopathy with hospital acquired delirium and recommended no further inpatient workup. PT/OT recommended SAR. Pt. will follow up with her PCP and ortho outpatient. Pt. is discharging to SAR in improved and stable condition.
Age: 68.0
Sex: F
Vaccine: COVID19-2
Symptoms: Ultrasound Doppler, Ultrasound Doppler normal
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/20/2023 Discharge Date: Aug 28, 2023 Discharge Disposition:  skilled nursing facility      Active Issues Requiring Follow-up: Pt. will follow up with her PCP and ortho outpatient  ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Fluid overload [E87.70]   HOSPITAL COURSE: This is a pleasant 69-year-old woman with past medical history of ESRD on hemodialysis MWF, OSA on CPAP, hypothyroidism, GERD, recurrent diverticulitis, and orthostatic hypotension  who presented for SOB and requesting HD.  Patient missed HD on 8/14 but did have HD on the following Wednesday and Friday.  She has had one-week history of cough with shortness of breath, congestion, and generalized weakness.  She was found to be COVID positive. Patient was mildly hypoxic requiring 1 L nasal cannula.  Chest x-ray with no acute cardiopulmonary process.  NT proBNP was significantly elevated. She was given dose of IV Solu-Medrol and transferred to hospital for HD.  Patient was quickly able to be weaned off of oxygen so further steroids were held. Patient also complained of right shoulder pain with known chronic right anterior shoulder dislocation for which orthopedic surgery was consulted and rec sling with outpatient follow up with her establish orthopedic surgeon Dr. Pt. did have complications of episode of aphasia during her stay that quickly resolved. Neuro was consulted. CT head with chronic bilateral basal ganglia lacunar infarctions. MRI/MRA brain was obtained with no acute abnormalities. Carotid U/S without significant stenosis. Neuro felt her symptoms were due to metabolic encephalopathy with hospital acquired delirium and recommended no further inpatient workup. PT/OT recommended SAR. Pt. will follow up with her PCP and ortho outpatient. Pt. is discharging to SAR in improved and stable condition.
Age: 11.0
Sex: F
Vaccine: MNQ
Symptoms: Injection site erythema, Injection site swelling, Injection site warmth
Clinical narrative: Redness, warmth, swelling at injection site on left arm.  Treatment at home: ice/heat, ibuprofen and outlined redness to watch for spreading.
Age: 91.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Agitation, Asthenia, Bundle branch block right, COVID-19, Chest X-ray abnormal
Clinical narrative: Discharge Date: Aug 22, 2023 Discharge Provider: MD Primary Care Provider : MD    Admission Date: 8/17/2023 Details of Hospital Stay PRESENTING PROBLEM: COVID-19   HOSPITAL COURSE: 91 y.o. male who presents today with a past medical history of diabetes mellitus type 2, DVT on Coumadin, prostate cancer status post surgery, restless leg syndrome who presented from his independent living facility after a fall.  He slid out of his chair and then was too weak to walk.  He crawled to his alert button and then was brought to the ER.  He has not been feeling well for 2 days. He had fever, mild shortness of breath and a dry cough.  In the facility he was diagnosed with COVID-19 which was also confirmed with the ER.  He has been vaccinated.   In the ED, he had mild tachycardia, no hypoxia but was placed on 2L oxygen.  EKG with right bundle branch block, chest x-ray with left lower lobe opacity suspicious for pneumonia, knee x-ray with degenerative joint disease, CT head is negative.  Patient was admitted for further management and observation.  He was taken off of oxygen and did not have any episodes of hypoxia.  He was started on remdesivir and empiric antibiotics for possible superimposed bacterial pneumonia.  Patient had sundowning and episodes of confusion, impulsiveness, agitation at night times requiring into placed in a Posey bed.  During the severe was discontinued in case it is contributing to his confusion.  He worked with therapy who recommended discharge back to his living facility if 247 assist can be provided, and home health care.  Due to contact precaution policies in his current independent living facility, daughter opted to bring the patient home to live with her temporarily.  This was arranged and the patient discharged to daughter's home today.  He had finished 5 days of antibiotics.
Age: 91.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Computerised tomogram head normal, Condition aggravated, Confusional state, Cough, Delirium
Clinical narrative: Discharge Date: Aug 22, 2023 Discharge Provider: MD Primary Care Provider : MD    Admission Date: 8/17/2023 Details of Hospital Stay PRESENTING PROBLEM: COVID-19   HOSPITAL COURSE: 91 y.o. male who presents today with a past medical history of diabetes mellitus type 2, DVT on Coumadin, prostate cancer status post surgery, restless leg syndrome who presented from his independent living facility after a fall.  He slid out of his chair and then was too weak to walk.  He crawled to his alert button and then was brought to the ER.  He has not been feeling well for 2 days. He had fever, mild shortness of breath and a dry cough.  In the facility he was diagnosed with COVID-19 which was also confirmed with the ER.  He has been vaccinated.   In the ED, he had mild tachycardia, no hypoxia but was placed on 2L oxygen.  EKG with right bundle branch block, chest x-ray with left lower lobe opacity suspicious for pneumonia, knee x-ray with degenerative joint disease, CT head is negative.  Patient was admitted for further management and observation.  He was taken off of oxygen and did not have any episodes of hypoxia.  He was started on remdesivir and empiric antibiotics for possible superimposed bacterial pneumonia.  Patient had sundowning and episodes of confusion, impulsiveness, agitation at night times requiring into placed in a Posey bed.  During the severe was discontinued in case it is contributing to his confusion.  He worked with therapy who recommended discharge back to his living facility if 247 assist can be provided, and home health care.  Due to contact precaution policies in his current independent living facility, daughter opted to bring the patient home to live with her temporarily.  This was arranged and the patient discharged to daughter's home today.  He had finished 5 days of antibiotics.
Age: 91.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Dyspnoea, Electrocardiogram abnormal, Fall, Gait inability, Impulsive behaviour
Clinical narrative: Discharge Date: Aug 22, 2023 Discharge Provider: MD Primary Care Provider : MD    Admission Date: 8/17/2023 Details of Hospital Stay PRESENTING PROBLEM: COVID-19   HOSPITAL COURSE: 91 y.o. male who presents today with a past medical history of diabetes mellitus type 2, DVT on Coumadin, prostate cancer status post surgery, restless leg syndrome who presented from his independent living facility after a fall.  He slid out of his chair and then was too weak to walk.  He crawled to his alert button and then was brought to the ER.  He has not been feeling well for 2 days. He had fever, mild shortness of breath and a dry cough.  In the facility he was diagnosed with COVID-19 which was also confirmed with the ER.  He has been vaccinated.   In the ED, he had mild tachycardia, no hypoxia but was placed on 2L oxygen.  EKG with right bundle branch block, chest x-ray with left lower lobe opacity suspicious for pneumonia, knee x-ray with degenerative joint disease, CT head is negative.  Patient was admitted for further management and observation.  He was taken off of oxygen and did not have any episodes of hypoxia.  He was started on remdesivir and empiric antibiotics for possible superimposed bacterial pneumonia.  Patient had sundowning and episodes of confusion, impulsiveness, agitation at night times requiring into placed in a Posey bed.  During the severe was discontinued in case it is contributing to his confusion.  He worked with therapy who recommended discharge back to his living facility if 247 assist can be provided, and home health care.  Due to contact precaution policies in his current independent living facility, daughter opted to bring the patient home to live with her temporarily.  This was arranged and the patient discharged to daughter's home today.  He had finished 5 days of antibiotics.
Age: 91.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Lung opacity, Malaise, Osteoarthritis, Pyrexia, Tachycardia
Clinical narrative: Discharge Date: Aug 22, 2023 Discharge Provider: MD Primary Care Provider : MD    Admission Date: 8/17/2023 Details of Hospital Stay PRESENTING PROBLEM: COVID-19   HOSPITAL COURSE: 91 y.o. male who presents today with a past medical history of diabetes mellitus type 2, DVT on Coumadin, prostate cancer status post surgery, restless leg syndrome who presented from his independent living facility after a fall.  He slid out of his chair and then was too weak to walk.  He crawled to his alert button and then was brought to the ER.  He has not been feeling well for 2 days. He had fever, mild shortness of breath and a dry cough.  In the facility he was diagnosed with COVID-19 which was also confirmed with the ER.  He has been vaccinated.   In the ED, he had mild tachycardia, no hypoxia but was placed on 2L oxygen.  EKG with right bundle branch block, chest x-ray with left lower lobe opacity suspicious for pneumonia, knee x-ray with degenerative joint disease, CT head is negative.  Patient was admitted for further management and observation.  He was taken off of oxygen and did not have any episodes of hypoxia.  He was started on remdesivir and empiric antibiotics for possible superimposed bacterial pneumonia.  Patient had sundowning and episodes of confusion, impulsiveness, agitation at night times requiring into placed in a Posey bed.  During the severe was discontinued in case it is contributing to his confusion.  He worked with therapy who recommended discharge back to his living facility if 247 assist can be provided, and home health care.  Due to contact precaution policies in his current independent living facility, daughter opted to bring the patient home to live with her temporarily.  This was arranged and the patient discharged to daughter's home today.  He had finished 5 days of antibiotics.
Age: 91.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: X-ray limb abnormal
Clinical narrative: Discharge Date: Aug 22, 2023 Discharge Provider: MD Primary Care Provider : MD    Admission Date: 8/17/2023 Details of Hospital Stay PRESENTING PROBLEM: COVID-19   HOSPITAL COURSE: 91 y.o. male who presents today with a past medical history of diabetes mellitus type 2, DVT on Coumadin, prostate cancer status post surgery, restless leg syndrome who presented from his independent living facility after a fall.  He slid out of his chair and then was too weak to walk.  He crawled to his alert button and then was brought to the ER.  He has not been feeling well for 2 days. He had fever, mild shortness of breath and a dry cough.  In the facility he was diagnosed with COVID-19 which was also confirmed with the ER.  He has been vaccinated.   In the ED, he had mild tachycardia, no hypoxia but was placed on 2L oxygen.  EKG with right bundle branch block, chest x-ray with left lower lobe opacity suspicious for pneumonia, knee x-ray with degenerative joint disease, CT head is negative.  Patient was admitted for further management and observation.  He was taken off of oxygen and did not have any episodes of hypoxia.  He was started on remdesivir and empiric antibiotics for possible superimposed bacterial pneumonia.  Patient had sundowning and episodes of confusion, impulsiveness, agitation at night times requiring into placed in a Posey bed.  During the severe was discontinued in case it is contributing to his confusion.  He worked with therapy who recommended discharge back to his living facility if 247 assist can be provided, and home health care.  Due to contact precaution policies in his current independent living facility, daughter opted to bring the patient home to live with her temporarily.  This was arranged and the patient discharged to daughter's home today.  He had finished 5 days of antibiotics.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Chest X-ray normal, Electrocardiogram T wave inversion, Hypertension, Hypertensive urgency
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD   Admission Date: 8/17/2023 Discharge Date: 8/19/2023 Condition on discharge: Improved   DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: Patient is a 84 y.o. female with past medical history of severe profound hearing loss, poor controlled hypertension, CKD stage 4, AFib/prior DVT no longer on anticoagulation, prior GI bleed who had recent admission in August for anemia and left AMA during that admission. She presented to the ER on 8/17/23 as directed by PCP for concern of PE as patient was complaining about pleuritic chest pain in the office.  Upon arrival, found to be severely hypertensive, and COVID-19 positive.  VQ scan with low probability for pulmonary embolism. She is very difficult to provide history as she cannot hear given her severe hearing loss.  Was doing text to talk to communicate with her best I could.   Given patient was not responding to p.r.n. IV meds in ER she was started on nicardipine drip and admitted to ICU as a CC2 hypertensive urgency.  EKG with T wave inversion lead III but otherwise does not show any evidence of new ischemic changes.  Tropes flat x2. Chest x-ray no acute process.  Satting 100% on room air.  Bilateral extremity ultrasound negative for DVT.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Intensive care, Pleuritic pain, SARS-CoV-2 test positive, Troponin normal, Ultrasound Doppler normal
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD   Admission Date: 8/17/2023 Discharge Date: 8/19/2023 Condition on discharge: Improved   DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: Patient is a 84 y.o. female with past medical history of severe profound hearing loss, poor controlled hypertension, CKD stage 4, AFib/prior DVT no longer on anticoagulation, prior GI bleed who had recent admission in August for anemia and left AMA during that admission. She presented to the ER on 8/17/23 as directed by PCP for concern of PE as patient was complaining about pleuritic chest pain in the office.  Upon arrival, found to be severely hypertensive, and COVID-19 positive.  VQ scan with low probability for pulmonary embolism. She is very difficult to provide history as she cannot hear given her severe hearing loss.  Was doing text to talk to communicate with her best I could.   Given patient was not responding to p.r.n. IV meds in ER she was started on nicardipine drip and admitted to ICU as a CC2 hypertensive urgency.  EKG with T wave inversion lead III but otherwise does not show any evidence of new ischemic changes.  Tropes flat x2. Chest x-ray no acute process.  Satting 100% on room air.  Bilateral extremity ultrasound negative for DVT.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Ventilation/perfusion scan normal
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD   Admission Date: 8/17/2023 Discharge Date: 8/19/2023 Condition on discharge: Improved   DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: Patient is a 84 y.o. female with past medical history of severe profound hearing loss, poor controlled hypertension, CKD stage 4, AFib/prior DVT no longer on anticoagulation, prior GI bleed who had recent admission in August for anemia and left AMA during that admission. She presented to the ER on 8/17/23 as directed by PCP for concern of PE as patient was complaining about pleuritic chest pain in the office.  Upon arrival, found to be severely hypertensive, and COVID-19 positive.  VQ scan with low probability for pulmonary embolism. She is very difficult to provide history as she cannot hear given her severe hearing loss.  Was doing text to talk to communicate with her best I could.   Given patient was not responding to p.r.n. IV meds in ER she was started on nicardipine drip and admitted to ICU as a CC2 hypertensive urgency.  EKG with T wave inversion lead III but otherwise does not show any evidence of new ischemic changes.  Tropes flat x2. Chest x-ray no acute process.  Satting 100% on room air.  Bilateral extremity ultrasound negative for DVT.
Age: 49.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Asthenia, Blindness, Diplopia, Hypoaesthesia, Magnetic resonance imaging
Clinical narrative: Diagnosed with multiple sclerosis. Right side numbness and weakness  from head to toe, loss of vision , double vision
Age: 49.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Multiple sclerosis
Clinical narrative: Diagnosed with multiple sclerosis. Right side numbness and weakness  from head to toe, loss of vision , double vision
Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: No adverse event, Product preparation error
Clinical narrative: Patient received Moderna Spikevax 2023-2024 Formula on 10/30/23.  Our team was given some training before administering the vaccine, but we did not know that the vaccine needed a thaw time and Medical Assistant was applying heat to the frozen vaccine with her hands for up to 15-20 min until it turned into liquid. Patient has been called and stated no symptoms signs or any effects after receiving the vaccine.
Age: 36.0
Sex: F
Vaccine: UNK
Symptoms: Immediate post-injection reaction, Joint range of motion decreased, Pain, Product administered at inappropriate site
Clinical narrative: Flu vaccine. Needle administered high in the arm near the joint. Immediate pain that persisted x2 weeks. Limited ROM. No sign of nerve injury. No signs of infection.   Evaluated at Occ med clinic: will treat conservatively with ice, rest, ibuprofen, gentle ROM MRI ordered to r/o soft tissue injury
Age: 7.0
Sex: F
Vaccine: COVID19
Symptoms: Underdose
Clinical narrative: Patient administered lower than authorized dose. Per table: Interim recommendations for COVID-19 vaccine administration errors and deviations, patient is advised to repeat dose immediately.
Age: 67.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Asthenia, Brain fog, Epistaxis, Hypoaesthesia, Influenza
Clinical narrative: Muscle pain in the left upper arm after the 2nd dose even though my shot was in the right arm. Adverse effects that started this past summer were nose bleeds which I have never had before, tingling in my arms and numbness in my hands. I have brain fog , weakness and reoccurring pain in my left arm.  Some days I do not feel well and have no energy.  I also got sick with the flu  2 months after the vaccination.