chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 51.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect dose administered, Incorrect product formulation administered, Product preparation issue
Clinical narrative: Patient arrived for COVID Pfizer booster in clinic. I had grabbed the vial that was in the adult bin for covid boosters without looking to verify correct vial. I had put the orders in and personally draw the medication up. An employee offered to help, to which I gave her the drew up syringe and said that orders were in. The co-worker went to administer the vaccine into the right deltoid. Co-worker came back to desk to scan medication and noticed the lot numbers were not matching with the orders. I had drawn up the child's vaccine age 5-12 monovalent without dilution. The incident was immediately reported to direct supervisor and patient. Patient did wait for 20 minutes for any adverse reactions. None was reported. Provider was notified by supervisor. Variance report was completed. Patient was asymptomatic and was instructed to call if the patient had any reactions.
Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Electric shock sensation, Erythema, Pain, Pain in extremity, Peripheral swelling
Clinical narrative: Starting in September of 2022 I experienced foot pain with a shocking sensation, causing things to swell and get red.  Stepping on the foot caused it to be too sore to walk on.  This was right foot.  Doctor consulted.  Doctor X-rayed the foot and referred to podiatrist.  Podiatrist examined foot and provided shoe inserts.  and asked to review in 6 weeks, which has not happened at time of report.
Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: X-ray normal
Clinical narrative: Starting in September of 2022 I experienced foot pain with a shocking sensation, causing things to swell and get red.  Stepping on the foot caused it to be too sore to walk on.  This was right foot.  Doctor consulted.  Doctor X-rayed the foot and referred to podiatrist.  Podiatrist examined foot and provided shoe inserts.  and asked to review in 6 weeks, which has not happened at time of report.
Age: 22.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: PT RECEIVED MONOVALENT INSTEAD OF BIVALENT, NO ADVERSE EVENTS AT ALL, PT WILL GET VACCINATED WITH BIVALENT IN 8 WEEKS.
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal discomfort, Arthralgia, Chills, Chromaturia, Diarrhoea
Clinical narrative: I had chills, a temperature of 99.5 degrees, my feet upper and lower legs were in severe pain. I had a cough start and coughed up a mucous plug in addition shortness of breath with achy joints and muscles my urine was amber in color with abdominal discomfort and a loose stool. My Co2 stat was at 94%.
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Epstein-Barr virus test, Full blood count, Metabolic function test, Myalgia
Clinical narrative: I had chills, a temperature of 99.5 degrees, my feet upper and lower legs were in severe pain. I had a cough start and coughed up a mucous plug in addition shortness of breath with achy joints and muscles my urine was amber in color with abdominal discomfort and a loose stool. My Co2 stat was at 94%.
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Pain in extremity, Productive cough
Clinical narrative: I had chills, a temperature of 99.5 degrees, my feet upper and lower legs were in severe pain. I had a cough start and coughed up a mucous plug in addition shortness of breath with achy joints and muscles my urine was amber in color with abdominal discomfort and a loose stool. My Co2 stat was at 94%.
Age: 69.0
Sex: M
Vaccine: COVID19-2
Symptoms: COVID-19, Nasal congestion, Oropharyngeal pain, Pyrexia, SARS-CoV-2 test negative
Clinical narrative: Around 11/17/2022 I had a high temperature (101.8 degrees), nasal congestion, sore throat, it lasted 5 days, I contacted my doctor and prescribed Paxlovid, I took it for 5 days and symptoms improved, and I have been fine since then, I tested Positive on 11/17 at home COVID-19 and on the 11/18 I had a PCR COVID-19 test and test ed positive. on 11/23 I had another home test, and it was Negative.
Age: 69.0
Sex: M
Vaccine: COVID19-2
Symptoms: SARS-CoV-2 test positive
Clinical narrative: Around 11/17/2022 I had a high temperature (101.8 degrees), nasal congestion, sore throat, it lasted 5 days, I contacted my doctor and prescribed Paxlovid, I took it for 5 days and symptoms improved, and I have been fine since then, I tested Positive on 11/17 at home COVID-19 and on the 11/18 I had a PCR COVID-19 test and test ed positive. on 11/23 I had another home test, and it was Negative.
Age: 42.0
Sex: M
Vaccine: COVID19-2
Symptoms: Chest discomfort, Chest pain
Clinical narrative: Chest pains/tightness. Constant for 4 days. Went to ER.
Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: PT RECEIVED MONOVALENT INSTEAD OF BIVALENT, NO ADVERSE EVENTS AT ALL, PT WILL GET VACCINATED WITH BIVALENT IN 8 WEEKS.
Age: 73.0
Sex: M
Vaccine: UNK, UNK
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Got Covid 19 on or about Dcembet 8,2022
Age: 60.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: COVID-19, Exposure to SARS-CoV-2, Headache, Influenza virus test, Pain
Clinical narrative: On 12/14/2022, I started to experience symptoms of wheezing, head congestion, body aches and a headache. I received a call from a friend, that I had been around, and she tested positive. I did not test, for COVID-19, until 12/15/2022. I contacted my GP, because I had an expired test. I went into the doctors off and had a blood test ran and it came back positive as well. I was prescribed PAXLOVID and I feel that it did not help. I tested negative on 12/18/2022.
Age: 60.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Respiratory tract congestion, SARS-CoV-2 test negative, SARS-CoV-2 test positive, Wheezing
Clinical narrative: On 12/14/2022, I started to experience symptoms of wheezing, head congestion, body aches and a headache. I received a call from a friend, that I had been around, and she tested positive. I did not test, for COVID-19, until 12/15/2022. I contacted my GP, because I had an expired test. I went into the doctors off and had a blood test ran and it came back positive as well. I was prescribed PAXLOVID and I feel that it did not help. I tested negative on 12/18/2022.
Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: PT RECEIVED MONOVALENT INSTEAD OF BIVALENT, NO ADVERSE EVENTS AT ALL, PT WILL GET VACCINATED WITH BIVALENT IN 8 WEEKS.
Age: 28.0
Sex: M
Vaccine: COVID19-2
Symptoms: No adverse event, Underdose
Clinical narrative: Patient who is an adult was given 0.25mL of the Moderna Bivalent COVID booster vaccine, which is less than the authorized dose of 0.50mL.  No adverse events were noted at the time of the administration.
Age: 26.0
Sex: M
Vaccine: COVID19-2
Symptoms: No adverse event, Underdose
Clinical narrative: Patient who is an adult was given 0.25mL of the Moderna Bivalent COVID booster vaccine, which is less than the authorized dose of 0.50mL.  No adverse events were noted at the time of the administration.
Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: PT RECEIVED MONOVALENT INSTEAD OF BIVALENT, NO ADVERSE EVENTS AT ALL, PT WILL GET VACCINATED WITH BIVALENT IN 8 WEEKS.
Age: 76.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Acute kidney injury, Bacteriuria, COVID-19, Comminuted fracture, Fall
Clinical narrative: This is a 78y.o. female with a pmh of IDDM,  pAfib (on warfarin), HTN, HLD, and s/p mitral valve replacement (2018) presents to the hospital after a fall. Xrays on admission significant for mildly displaced superior and inferior left rami fractures with comminuted left sacral fracture. Orthopedic surgery was consulted and is not recommending surgical intervention with just outpatient follow up. Patient is weight bearing as tolerated. Pain was managed with Ultram 50 mg q6h PRN and Tylenol PRN. Patient was also diagnosed with severe lumbar spinal stenosis 2/2 chronic degenerative lumbar spine disease. Patient did not have any concerning neurologic symptoms, loss of bowel or bladder, or saddle anesthesia. Patient is to follow up with ortho spine as needed as an outpatient for further evaluation. Patient was found to be incidental COVID positive, initially not symptomatic, however patient became septic and subsequently symptomatic with fever, chills and an AKI. Given IVF bolus and maintenance fluids for 24 hours with resolution of AKI. ID consulted and patient completed 3 day course of Remdesivir. In addition, patient also got one dose of Ceftriaxone in ED for asymptomatic bacteriuria and subsequently developed a diffuse full body erythematous itchy rash. Improved with 2 doses of steroids, PO Benedryl, and Triamcinolone cream. Patients insulin regimen was adjusted while admitted as having gotten two doses of steroids caused her BG to go up into the 400s. This improved after being taken off steroids. Patient was determined not to be an IPR candidate as she is COVID positive and will need to got to a SAR facility upon discharge. Patient is stable for discharge to SAR facility at this time with the following discharge instructions.
Age: 76.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Feeling cold, Fracture displacement, Fractured sacrum, Lumbar spinal stenosis, Pelvic fracture
Clinical narrative: This is a 78y.o. female with a pmh of IDDM,  pAfib (on warfarin), HTN, HLD, and s/p mitral valve replacement (2018) presents to the hospital after a fall. Xrays on admission significant for mildly displaced superior and inferior left rami fractures with comminuted left sacral fracture. Orthopedic surgery was consulted and is not recommending surgical intervention with just outpatient follow up. Patient is weight bearing as tolerated. Pain was managed with Ultram 50 mg q6h PRN and Tylenol PRN. Patient was also diagnosed with severe lumbar spinal stenosis 2/2 chronic degenerative lumbar spine disease. Patient did not have any concerning neurologic symptoms, loss of bowel or bladder, or saddle anesthesia. Patient is to follow up with ortho spine as needed as an outpatient for further evaluation. Patient was found to be incidental COVID positive, initially not symptomatic, however patient became septic and subsequently symptomatic with fever, chills and an AKI. Given IVF bolus and maintenance fluids for 24 hours with resolution of AKI. ID consulted and patient completed 3 day course of Remdesivir. In addition, patient also got one dose of Ceftriaxone in ED for asymptomatic bacteriuria and subsequently developed a diffuse full body erythematous itchy rash. Improved with 2 doses of steroids, PO Benedryl, and Triamcinolone cream. Patients insulin regimen was adjusted while admitted as having gotten two doses of steroids caused her BG to go up into the 400s. This improved after being taken off steroids. Patient was determined not to be an IPR candidate as she is COVID positive and will need to got to a SAR facility upon discharge. Patient is stable for discharge to SAR facility at this time with the following discharge instructions.
Age: 76.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Pyrexia, Rash erythematous, Rash pruritic, SARS-CoV-2 test positive, Sepsis
Clinical narrative: This is a 78y.o. female with a pmh of IDDM,  pAfib (on warfarin), HTN, HLD, and s/p mitral valve replacement (2018) presents to the hospital after a fall. Xrays on admission significant for mildly displaced superior and inferior left rami fractures with comminuted left sacral fracture. Orthopedic surgery was consulted and is not recommending surgical intervention with just outpatient follow up. Patient is weight bearing as tolerated. Pain was managed with Ultram 50 mg q6h PRN and Tylenol PRN. Patient was also diagnosed with severe lumbar spinal stenosis 2/2 chronic degenerative lumbar spine disease. Patient did not have any concerning neurologic symptoms, loss of bowel or bladder, or saddle anesthesia. Patient is to follow up with ortho spine as needed as an outpatient for further evaluation. Patient was found to be incidental COVID positive, initially not symptomatic, however patient became septic and subsequently symptomatic with fever, chills and an AKI. Given IVF bolus and maintenance fluids for 24 hours with resolution of AKI. ID consulted and patient completed 3 day course of Remdesivir. In addition, patient also got one dose of Ceftriaxone in ED for asymptomatic bacteriuria and subsequently developed a diffuse full body erythematous itchy rash. Improved with 2 doses of steroids, PO Benedryl, and Triamcinolone cream. Patients insulin regimen was adjusted while admitted as having gotten two doses of steroids caused her BG to go up into the 400s. This improved after being taken off steroids. Patient was determined not to be an IPR candidate as she is COVID positive and will need to got to a SAR facility upon discharge. Patient is stable for discharge to SAR facility at this time with the following discharge instructions.
Age: 76.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Spinal osteoarthritis, X-ray abnormal
Clinical narrative: This is a 78y.o. female with a pmh of IDDM,  pAfib (on warfarin), HTN, HLD, and s/p mitral valve replacement (2018) presents to the hospital after a fall. Xrays on admission significant for mildly displaced superior and inferior left rami fractures with comminuted left sacral fracture. Orthopedic surgery was consulted and is not recommending surgical intervention with just outpatient follow up. Patient is weight bearing as tolerated. Pain was managed with Ultram 50 mg q6h PRN and Tylenol PRN. Patient was also diagnosed with severe lumbar spinal stenosis 2/2 chronic degenerative lumbar spine disease. Patient did not have any concerning neurologic symptoms, loss of bowel or bladder, or saddle anesthesia. Patient is to follow up with ortho spine as needed as an outpatient for further evaluation. Patient was found to be incidental COVID positive, initially not symptomatic, however patient became septic and subsequently symptomatic with fever, chills and an AKI. Given IVF bolus and maintenance fluids for 24 hours with resolution of AKI. ID consulted and patient completed 3 day course of Remdesivir. In addition, patient also got one dose of Ceftriaxone in ED for asymptomatic bacteriuria and subsequently developed a diffuse full body erythematous itchy rash. Improved with 2 doses of steroids, PO Benedryl, and Triamcinolone cream. Patients insulin regimen was adjusted while admitted as having gotten two doses of steroids caused her BG to go up into the 400s. This improved after being taken off steroids. Patient was determined not to be an IPR candidate as she is COVID positive and will need to got to a SAR facility upon discharge. Patient is stable for discharge to SAR facility at this time with the following discharge instructions.
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Cough, Respiratory tract congestion, SARS-CoV-2 test positive
Clinical narrative: 11/06/22 presents to EC ED for "cough, chest congestion". PMHx of "SLE, seizures, CAD with CABG, htn, CHF (EF 35%), ESRD on dialysis"
Age: 84.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Bacterial test negative, COVID-19, Chest X-ray abnormal, Computerised tomogram head normal, Computerised tomogram spine
Clinical narrative: This is a 85y.o. female with PMH significant for dementia, alzheimers, depression, hypothyroidism who presents to hospital for fall and head injury. History gathered for paramedics and family. Patient from SKLD, baseline A&Ox1-2. Had unwitnessed fall with bleeding in the back of head. She was placed on C collar. During ED eval, COVID positive, placed in isolation. UA + WBC, negative for bacteria. Was started on IV rocephin in EC. Cervical CT showed no acute fracture. Chest xray showed left sided patchy opacity. Head CT showed no acute hemorrhage. Patient was RRT due to lethargy. And her night time risperidone dose was reduced with good improvement. Met with hospice and will follow up with community hospice needs. Patient also tested positive for COVID, was seen by ID, and no txt needed since respiratory status is stable. Discharged in a stable condition.
Age: 84.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Fall, Haemorrhage, Head injury, Lethargy, Lung opacity
Clinical narrative: This is a 85y.o. female with PMH significant for dementia, alzheimers, depression, hypothyroidism who presents to hospital for fall and head injury. History gathered for paramedics and family. Patient from SKLD, baseline A&Ox1-2. Had unwitnessed fall with bleeding in the back of head. She was placed on C collar. During ED eval, COVID positive, placed in isolation. UA + WBC, negative for bacteria. Was started on IV rocephin in EC. Cervical CT showed no acute fracture. Chest xray showed left sided patchy opacity. Head CT showed no acute hemorrhage. Patient was RRT due to lethargy. And her night time risperidone dose was reduced with good improvement. Met with hospice and will follow up with community hospice needs. Patient also tested positive for COVID, was seen by ID, and no txt needed since respiratory status is stable. Discharged in a stable condition.
Age: 84.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Urine analysis normal, White blood cell count normal
Clinical narrative: This is a 85y.o. female with PMH significant for dementia, alzheimers, depression, hypothyroidism who presents to hospital for fall and head injury. History gathered for paramedics and family. Patient from SKLD, baseline A&Ox1-2. Had unwitnessed fall with bleeding in the back of head. She was placed on C collar. During ED eval, COVID positive, placed in isolation. UA + WBC, negative for bacteria. Was started on IV rocephin in EC. Cervical CT showed no acute fracture. Chest xray showed left sided patchy opacity. Head CT showed no acute hemorrhage. Patient was RRT due to lethargy. And her night time risperidone dose was reduced with good improvement. Met with hospice and will follow up with community hospice needs. Patient also tested positive for COVID, was seen by ID, and no txt needed since respiratory status is stable. Discharged in a stable condition.
Age: 72.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Debridement, Iliac artery occlusion, Pain, Peripheral artery stenosis, SARS-CoV-2 test
Clinical narrative: This is a 74y.o. female with history of COPD, a-fib on xeralto, who presented on 9/25/2022 with occlusion at the level of the bilateral external iliac arteries and severe luminal caliber narrowing of the SFAs to the level of the mid popliteal arteries bilaterally..  Pt underwent procedure listed above which they tolerated well without complication, see operative report for full details.  Patient recovered well. Hospital course significant for left wound that required operative groin washout and debridement.  On HD#33, pain controlled, pt tolerating diet, voiding and ambulating independently, ready for discharge to home care with instruction to follow up as indicated below. Pt was educated on pain expectations.
Age: 72.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Surgery, Wound, Wound treatment
Clinical narrative: This is a 74y.o. female with history of COPD, a-fib on xeralto, who presented on 9/25/2022 with occlusion at the level of the bilateral external iliac arteries and severe luminal caliber narrowing of the SFAs to the level of the mid popliteal arteries bilaterally..  Pt underwent procedure listed above which they tolerated well without complication, see operative report for full details.  Patient recovered well. Hospital course significant for left wound that required operative groin washout and debridement.  On HD#33, pain controlled, pt tolerating diet, voiding and ambulating independently, ready for discharge to home care with instruction to follow up as indicated below. Pt was educated on pain expectations.
Age: 79.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Asthenia, COVID-19, Cough, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: Patient is a 80y.o.male  with h/o Afib and MVR on warfarin, CKDIII, HTN who lives at home w/ 24h caregivers presents with weakness. Tested positive for COVID in EC so symptoms attributed to acute COVID but on further investigation patient had COVID several weeks prior so +test did not represent acute infection.  Unclear cause of patient's symptoms but possibly different virus as he did have mild fever and cough. He was quite weak on admission but over next few days he regained strength and was able to be d/c'd home w/ his usual 24h care.
Age: 56.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Confusional state, Constipation, Dizziness, Ear discomfort
Clinical narrative: She presented with dizziness and confusion. Her dizziness and migraine are improved but occ symptoms -we did not find a discrete etiology for fogginess and dizziness, likely multifactorial She will follow with neuro and ENT and psychiatry Of note her MRI did not have clear stroke but there are some similar white matter changes in the cerebellum compared to previous studies - there were no signs of acute stroke. Her MRI have variable mentioned stroke in the past but not always. Aspirin and statin will be continued at this point -COVID may have been a cause of her more recent dizziness and fogginess and ear fullness  -ENT did see her -she will follow cardiology OP  -she is considering to see a new psychiatrist -she wants to stay off the prozac, of note she is still on trazodone and topamax is on too -she did have constipation this admit(?from hypercalcemia but that is better) and responded to meds -she had intermittent urinary retention - it improved with bowel program  -she was seen by urology and will follow with them OP    She will be DC home with home care
Age: 56.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Feeling abnormal, Hypercalcaemia, Magnetic resonance imaging head abnormal, Migraine, SARS-CoV-2 test positive
Clinical narrative: She presented with dizziness and confusion. Her dizziness and migraine are improved but occ symptoms -we did not find a discrete etiology for fogginess and dizziness, likely multifactorial She will follow with neuro and ENT and psychiatry Of note her MRI did not have clear stroke but there are some similar white matter changes in the cerebellum compared to previous studies - there were no signs of acute stroke. Her MRI have variable mentioned stroke in the past but not always. Aspirin and statin will be continued at this point -COVID may have been a cause of her more recent dizziness and fogginess and ear fullness  -ENT did see her -she will follow cardiology OP  -she is considering to see a new psychiatrist -she wants to stay off the prozac, of note she is still on trazodone and topamax is on too -she did have constipation this admit(?from hypercalcemia but that is better) and responded to meds -she had intermittent urinary retention - it improved with bowel program  -she was seen by urology and will follow with them OP    She will be DC home with home care
Age: 56.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Urinary retention, White matter lesion
Clinical narrative: She presented with dizziness and confusion. Her dizziness and migraine are improved but occ symptoms -we did not find a discrete etiology for fogginess and dizziness, likely multifactorial She will follow with neuro and ENT and psychiatry Of note her MRI did not have clear stroke but there are some similar white matter changes in the cerebellum compared to previous studies - there were no signs of acute stroke. Her MRI have variable mentioned stroke in the past but not always. Aspirin and statin will be continued at this point -COVID may have been a cause of her more recent dizziness and fogginess and ear fullness  -ENT did see her -she will follow cardiology OP  -she is considering to see a new psychiatrist -she wants to stay off the prozac, of note she is still on trazodone and topamax is on too -she did have constipation this admit(?from hypercalcemia but that is better) and responded to meds -she had intermittent urinary retention - it improved with bowel program  -she was seen by urology and will follow with them OP    She will be DC home with home care
Age: 90.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Asthenia, Blood culture, Blood lactic acid, COVID-19, Chest X-ray abnormal
Clinical narrative: 92y.o. male with a PMHx significant for bladder cancer, CKD (Stage 4), HTN, CAD, dementia. Pt presents to facility  from SAR after patient was found to have multiple days of fever and generalized weakness. He had received tylenol with some relief, but fever persisted, according to family. Family had noticed that patient had cloudy urine in his urostomy bad and they had concern for infection. In the ED, patient was worked up for sepsis and covid-19 test was positive. He received IVF bolus, started on Vancomycin and Merrem, labs drawn and blood/urine cultures sent. Troponins were negative, Lactic acid 2.0, UA positive for bacteria, chest xray shows small pleural effusion. Upon arrival to the unit, patient had some difficulty with communication due to language barrier. He is not in acute distress, denies chest pain, shortness of breath, headache, dizziness, nausea, abdominal pain, diarrhea. Spoke with patient's son and daughter over the phone to discuss patient's home medications and history. Disposition - Pt stable for dc today home. Daughter refused home care . Pt to continue home meds except lasix. F/u with specialists
Age: 90.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Culture urine, Laboratory test, Pleural effusion, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 92y.o. male with a PMHx significant for bladder cancer, CKD (Stage 4), HTN, CAD, dementia. Pt presents to facility  from SAR after patient was found to have multiple days of fever and generalized weakness. He had received tylenol with some relief, but fever persisted, according to family. Family had noticed that patient had cloudy urine in his urostomy bad and they had concern for infection. In the ED, patient was worked up for sepsis and covid-19 test was positive. He received IVF bolus, started on Vancomycin and Merrem, labs drawn and blood/urine cultures sent. Troponins were negative, Lactic acid 2.0, UA positive for bacteria, chest xray shows small pleural effusion. Upon arrival to the unit, patient had some difficulty with communication due to language barrier. He is not in acute distress, denies chest pain, shortness of breath, headache, dizziness, nausea, abdominal pain, diarrhea. Spoke with patient's son and daughter over the phone to discuss patient's home medications and history. Disposition - Pt stable for dc today home. Daughter refused home care . Pt to continue home meds except lasix. F/u with specialists
Age: 90.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Sepsis, Troponin normal, Urine abnormality, Urine analysis abnormal, Urostomy
Clinical narrative: 92y.o. male with a PMHx significant for bladder cancer, CKD (Stage 4), HTN, CAD, dementia. Pt presents to facility  from SAR after patient was found to have multiple days of fever and generalized weakness. He had received tylenol with some relief, but fever persisted, according to family. Family had noticed that patient had cloudy urine in his urostomy bad and they had concern for infection. In the ED, patient was worked up for sepsis and covid-19 test was positive. He received IVF bolus, started on Vancomycin and Merrem, labs drawn and blood/urine cultures sent. Troponins were negative, Lactic acid 2.0, UA positive for bacteria, chest xray shows small pleural effusion. Upon arrival to the unit, patient had some difficulty with communication due to language barrier. He is not in acute distress, denies chest pain, shortness of breath, headache, dizziness, nausea, abdominal pain, diarrhea. Spoke with patient's son and daughter over the phone to discuss patient's home medications and history. Disposition - Pt stable for dc today home. Daughter refused home care . Pt to continue home meds except lasix. F/u with specialists
Age: 80.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Ataxia, Balance disorder, Body temperature increased, COVID-19, Fall
Clinical narrative: Patient is a 82y.o. year old female with past medical history of acoustic neuroma with resection and residual Bell's palsy past, atrial fibrillation on Xarelto presented for fall and ataxia on 9/25.  Per patient and the daughter she has been off balance since noon yesterday and was seeming to be leaning on her right side.  Lost her balance, fell and hit her head yesterday at 5 PM.  Denies headache, dizziness or neck pain but does endorse some upper respiratory tract symptoms that started earlier last week which are now resolved per her recollection.  She did test COVID-positive in the ER, had one-time temperature of 100.9F and desaturation to 88% on room air.  Infectious diseases consulted for COVID.
Age: 80.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Head injury, Oxygen saturation decreased, Posture abnormal, Respiratory symptom, SARS-CoV-2 test positive
Clinical narrative: Patient is a 82y.o. year old female with past medical history of acoustic neuroma with resection and residual Bell's palsy past, atrial fibrillation on Xarelto presented for fall and ataxia on 9/25.  Per patient and the daughter she has been off balance since noon yesterday and was seeming to be leaning on her right side.  Lost her balance, fell and hit her head yesterday at 5 PM.  Denies headache, dizziness or neck pain but does endorse some upper respiratory tract symptoms that started earlier last week which are now resolved per her recollection.  She did test COVID-positive in the ER, had one-time temperature of 100.9F and desaturation to 88% on room air.  Infectious diseases consulted for COVID.
Age: 34.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Caesarean section, Maternal exposure before pregnancy, SARS-CoV-2 test
Clinical narrative: Discharge after C/S of newborn baby. Vitals WNL, pain controlled with oral pain meds, scripts given. Incision C/D/I. Tol reg diet, ambulating without difficulty. Baby Boy.
Age: 81.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Acute myocardial infarction, Anticoagulant therapy, COVID-19, Chest X-ray abnormal, Electrocardiogram T wave abnormal
Clinical narrative: This is a 83y.o. male with PMH of CAD s/p CABG (1982, redo in 1992), CHF, ICM s/p ICD, T2DM, HLD, hypothyroidism, BPH who presented as a transfer from emergency room for management of NSTEMI and COVID-19 infection. He also has BLE pain after a fall three days prior. Pelvis XR was unremarkable. He tested positive for COVID-19.  Workup revealed NSTEMI with troponin of 2.20. Of note, EKG revealed nonspecific t wave abnormalities however no evidence of St elevations or reciprocals. He received heparin bolus and started on heparin gtt. He was found to be hypoxic on room air which improved to 95% on 2L O2 NC. Patient was transferred to hospital for further management. In the ED, patient noted to be tachycardic in 120s, febrile (Tmax 100.5F), tachypneic, hypoxic in 80s. SpO2 currently maintained on 6L O2 NC. CXR shows mild coarsening of pulmonary interstitium - acute vs chronic. Labs significant for hgb 10.9, lymphocytes 0.8, INR 1.3. troponin 2.20 -- > 4.19. COVID-19 PCR detected. Patient was started on drcadron and remdesevir for 5 days. Patient was weaned off oxygen and passed home oxygen eval. Cleared by endocrine and pulmonary and discharged in a stable condition. Patient lives wife who can assist at home. Resume home Dm regimen per endo and follow up as outpatient. rx sent to pharmacy. Discussed with nursing staff.
Age: 81.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Fall, Haemoglobin decreased, Hypoxia, International normalised ratio increased, Lung disorder
Clinical narrative: This is a 83y.o. male with PMH of CAD s/p CABG (1982, redo in 1992), CHF, ICM s/p ICD, T2DM, HLD, hypothyroidism, BPH who presented as a transfer from emergency room for management of NSTEMI and COVID-19 infection. He also has BLE pain after a fall three days prior. Pelvis XR was unremarkable. He tested positive for COVID-19.  Workup revealed NSTEMI with troponin of 2.20. Of note, EKG revealed nonspecific t wave abnormalities however no evidence of St elevations or reciprocals. He received heparin bolus and started on heparin gtt. He was found to be hypoxic on room air which improved to 95% on 2L O2 NC. Patient was transferred to hospital for further management. In the ED, patient noted to be tachycardic in 120s, febrile (Tmax 100.5F), tachypneic, hypoxic in 80s. SpO2 currently maintained on 6L O2 NC. CXR shows mild coarsening of pulmonary interstitium - acute vs chronic. Labs significant for hgb 10.9, lymphocytes 0.8, INR 1.3. troponin 2.20 -- > 4.19. COVID-19 PCR detected. Patient was started on drcadron and remdesevir for 5 days. Patient was weaned off oxygen and passed home oxygen eval. Cleared by endocrine and pulmonary and discharged in a stable condition. Patient lives wife who can assist at home. Resume home Dm regimen per endo and follow up as outpatient. rx sent to pharmacy. Discussed with nursing staff.
Age: 81.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Lymphocyte count decreased, Pain in extremity, Pyrexia, SARS-CoV-2 test positive, Tachycardia
Clinical narrative: This is a 83y.o. male with PMH of CAD s/p CABG (1982, redo in 1992), CHF, ICM s/p ICD, T2DM, HLD, hypothyroidism, BPH who presented as a transfer from emergency room for management of NSTEMI and COVID-19 infection. He also has BLE pain after a fall three days prior. Pelvis XR was unremarkable. He tested positive for COVID-19.  Workup revealed NSTEMI with troponin of 2.20. Of note, EKG revealed nonspecific t wave abnormalities however no evidence of St elevations or reciprocals. He received heparin bolus and started on heparin gtt. He was found to be hypoxic on room air which improved to 95% on 2L O2 NC. Patient was transferred to hospital for further management. In the ED, patient noted to be tachycardic in 120s, febrile (Tmax 100.5F), tachypneic, hypoxic in 80s. SpO2 currently maintained on 6L O2 NC. CXR shows mild coarsening of pulmonary interstitium - acute vs chronic. Labs significant for hgb 10.9, lymphocytes 0.8, INR 1.3. troponin 2.20 -- > 4.19. COVID-19 PCR detected. Patient was started on drcadron and remdesevir for 5 days. Patient was weaned off oxygen and passed home oxygen eval. Cleared by endocrine and pulmonary and discharged in a stable condition. Patient lives wife who can assist at home. Resume home Dm regimen per endo and follow up as outpatient. rx sent to pharmacy. Discussed with nursing staff.
Age: 81.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Tachypnoea, Troponin, X-ray of pelvis and hip normal
Clinical narrative: This is a 83y.o. male with PMH of CAD s/p CABG (1982, redo in 1992), CHF, ICM s/p ICD, T2DM, HLD, hypothyroidism, BPH who presented as a transfer from emergency room for management of NSTEMI and COVID-19 infection. He also has BLE pain after a fall three days prior. Pelvis XR was unremarkable. He tested positive for COVID-19.  Workup revealed NSTEMI with troponin of 2.20. Of note, EKG revealed nonspecific t wave abnormalities however no evidence of St elevations or reciprocals. He received heparin bolus and started on heparin gtt. He was found to be hypoxic on room air which improved to 95% on 2L O2 NC. Patient was transferred to hospital for further management. In the ED, patient noted to be tachycardic in 120s, febrile (Tmax 100.5F), tachypneic, hypoxic in 80s. SpO2 currently maintained on 6L O2 NC. CXR shows mild coarsening of pulmonary interstitium - acute vs chronic. Labs significant for hgb 10.9, lymphocytes 0.8, INR 1.3. troponin 2.20 -- > 4.19. COVID-19 PCR detected. Patient was started on drcadron and remdesevir for 5 days. Patient was weaned off oxygen and passed home oxygen eval. Cleared by endocrine and pulmonary and discharged in a stable condition. Patient lives wife who can assist at home. Resume home Dm regimen per endo and follow up as outpatient. rx sent to pharmacy. Discussed with nursing staff.
Age: 18.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: PT RECEIVED MONOVALENT INSTEAD OF BIVALENT, NO ADVERSE EVENTS AT ALL, PT WILL GET VACCINATED WITH BIVALENT IN 8 WEEKS.
Age: 68.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Atrial fibrillation, COVID-19, Chest pain, Dyspnoea, Flatulence
Clinical narrative: This is a 70y.o. female who presented for the above procedure. Postoperative course was complicated by COVID diagnosis discovered given respiratory insufficiency, SOB and CP. ID was consulted and she was determined to not be a candidate for COVID tx. She additionally had afib and was placed on amiodarone gtt which was transitioned to PO metoprolol with Cardiology following. Cardiology eventually requested CTA to assess for coronary disease requiring intervention without evidence of obstructive CAD and she was deemed stable for discharge with outpatient follow up for discussion of anticoagulation resumption. Diet was advanced to full liquids. Diet education given. Pain was controlled on PO medications. Patient was passing flatus, having bowel movements, ambulating. The patient was deemed stable for discharge on POD8. Please see record for further details on care.
Age: 68.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Respiratory failure, SARS-CoV-2 test positive
Clinical narrative: This is a 70y.o. female who presented for the above procedure. Postoperative course was complicated by COVID diagnosis discovered given respiratory insufficiency, SOB and CP. ID was consulted and she was determined to not be a candidate for COVID tx. She additionally had afib and was placed on amiodarone gtt which was transitioned to PO metoprolol with Cardiology following. Cardiology eventually requested CTA to assess for coronary disease requiring intervention without evidence of obstructive CAD and she was deemed stable for discharge with outpatient follow up for discussion of anticoagulation resumption. Diet was advanced to full liquids. Diet education given. Pain was controlled on PO medications. Patient was passing flatus, having bowel movements, ambulating. The patient was deemed stable for discharge on POD8. Please see record for further details on care.
Age: 70.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Abdominal lymphadenopathy, COVID-19, Cardiac stress test normal, Computerised tomogram thorax abnormal, Cough
Clinical narrative: This is a 72y.o. female with PMHx significant for CAD prior PCI, HTN, sarcoidosis, CHF diastolic dysfunction who presented for shortness of breath progressively worsening over the last few weeks. She endorses mild SOB at baseline and does not use supplemental O2 or CPAP at home. Endorses a dry cough. She is vaccinated against COVID and did not test positive in the past until 9/26. Recently hospitalized for HTN. States she has a hx Pulmonary embolism from early 2000s. Denies chest pain, abdominal pain, nausea, vomiting, paresthesia, fever, chills. During ED eval, chest CT showed no PE, but a bulky calcified lymphadenopathy in the hila and upper abd. Trop negative, COVID positive. procalcitonin 7.32. Admit for further eval and management. covid precautions removed 10/6 and sats stable on RA now. She completed IV decadron and Remdesivir 10/1. ID was following and completed ceftin . She has hx of Dysphagia S/p dilation on 7/21 via EGD. Esophagram showing no evidence of obstruction and Esophageal dysmotility and she is tolerating reg diet. Per cardio, CP likely due to MS in nature. ECHO with EF 55% and stress test neg with EF 70%. Psych was following and trazadone increased, continue xanax.  PT/OT recommending SAR and pt agreeable. She is stable for d/c with close Op follow up
Age: 70.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Dyspnoea, Echocardiogram normal, Ejection fraction normal, Hilar lymphadenopathy, Hypertension
Clinical narrative: This is a 72y.o. female with PMHx significant for CAD prior PCI, HTN, sarcoidosis, CHF diastolic dysfunction who presented for shortness of breath progressively worsening over the last few weeks. She endorses mild SOB at baseline and does not use supplemental O2 or CPAP at home. Endorses a dry cough. She is vaccinated against COVID and did not test positive in the past until 9/26. Recently hospitalized for HTN. States she has a hx Pulmonary embolism from early 2000s. Denies chest pain, abdominal pain, nausea, vomiting, paresthesia, fever, chills. During ED eval, chest CT showed no PE, but a bulky calcified lymphadenopathy in the hila and upper abd. Trop negative, COVID positive. procalcitonin 7.32. Admit for further eval and management. covid precautions removed 10/6 and sats stable on RA now. She completed IV decadron and Remdesivir 10/1. ID was following and completed ceftin . She has hx of Dysphagia S/p dilation on 7/21 via EGD. Esophagram showing no evidence of obstruction and Esophageal dysmotility and she is tolerating reg diet. Per cardio, CP likely due to MS in nature. ECHO with EF 55% and stress test neg with EF 70%. Psych was following and trazadone increased, continue xanax.  PT/OT recommending SAR and pt agreeable. She is stable for d/c with close Op follow up
Age: 70.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Lymph node calcification, Oesophagram, Procalcitonin, SARS-CoV-2 test positive, Troponin normal
Clinical narrative: This is a 72y.o. female with PMHx significant for CAD prior PCI, HTN, sarcoidosis, CHF diastolic dysfunction who presented for shortness of breath progressively worsening over the last few weeks. She endorses mild SOB at baseline and does not use supplemental O2 or CPAP at home. Endorses a dry cough. She is vaccinated against COVID and did not test positive in the past until 9/26. Recently hospitalized for HTN. States she has a hx Pulmonary embolism from early 2000s. Denies chest pain, abdominal pain, nausea, vomiting, paresthesia, fever, chills. During ED eval, chest CT showed no PE, but a bulky calcified lymphadenopathy in the hila and upper abd. Trop negative, COVID positive. procalcitonin 7.32. Admit for further eval and management. covid precautions removed 10/6 and sats stable on RA now. She completed IV decadron and Remdesivir 10/1. ID was following and completed ceftin . She has hx of Dysphagia S/p dilation on 7/21 via EGD. Esophagram showing no evidence of obstruction and Esophageal dysmotility and she is tolerating reg diet. Per cardio, CP likely due to MS in nature. ECHO with EF 55% and stress test neg with EF 70%. Psych was following and trazadone increased, continue xanax.  PT/OT recommending SAR and pt agreeable. She is stable for d/c with close Op follow up
Age: 77.0
Sex: F
Vaccine: VARZOS
Symptoms: Product preparation error
Clinical narrative: patient was given diluent only and not the active portion of the vaccine. medication was not mixed.
Age: 75.0
Sex: M
Vaccine: COVID19-2
Symptoms: Asthenia, COVID-19, Cough, Feeling abnormal, Malaise
Clinical narrative: After receiving the vaccine, I felt bad for 24 hours with body aches and feeling weak. On 12/19/2022 I did not feel well with congestion, runny nose and a slight cough. On 12/20/2022, I tested positive for COVID-19 with a home test. I am taking doxylamine-DM-acetaminophen to help with my symptoms.
Age: 75.0
Sex: M
Vaccine: COVID19-2
Symptoms: Pain, Respiratory tract congestion, Rhinorrhoea, SARS-CoV-2 test positive
Clinical narrative: After receiving the vaccine, I felt bad for 24 hours with body aches and feeling weak. On 12/19/2022 I did not feel well with congestion, runny nose and a slight cough. On 12/20/2022, I tested positive for COVID-19 with a home test. I am taking doxylamine-DM-acetaminophen to help with my symptoms.
Age: 46.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Cough, Dyspnoea, Pleuritic pain, SARS-CoV-2 test positive
Clinical narrative: 48 y.o. male with PMHx of Muscular dystrophy, Scoliosis, Chronic Hypercarbic Hypoxic Respiratory Failure 2/2 restrictive lung disease on 2-3L home O2, HFpEF, and OSA not on BPAP presented on 9/26/2022 with c/o dyspnea with associated nonproductive cough and pleuritic chest pain. Prior to presentation, tested positive for COVID-19 by PCR.
Age: 70.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Abdominal pain, Acute respiratory failure, Asthenia, Blood loss anaemia, COVID-19
Clinical narrative: 71y.o. male with multiple medical problems including BPH, chronic LBP with LLE radicular pain, DMII and PPN who was admitted to the hospital on 9/5/2022 for N/V and abdominal pain. Upon admission, lexiscan MPI showed a reversible perfusion defect. Cardiovascular surgery was consulted and performed CABG x3 on 9/13. Pts hospital course has been c/b acute hypoxic respiratory failure, post-op acute blood loss anemia, dysphagia and right forearm cellulitis with completion of abx courses. Corpak was pulled on 9/21 by the pt. SLP is following and have the pt on mechanical soft diet with thickened liquids. Psych was consulted for depression and started the pt on Wellbutrin. Pt with recent hx of (7/27/2022) lumbar laminectomy with medial facetectomy and foraminotomy with fusion at L4-5 on  by Dr., post-op course complicated by lethargy and confusion. Patient with unwitnessed fall with RRT activated on 9/26- no head trauma and no head CT required. He was transferred to the med ward for a dx of COVID with fever and anorexia.  He was treated with remdesivir - he did not have hypoxia. He had quite some anorexia and asthenia and some depressed mood.  He has been recovering and is now showing signs of resolution of these problems and we anticipated return to HCF, but he was denied by insurance, including a peer to peer.  Evaluation on Day of Discharge: Last night he had nausea and vomiting and could not eat dinner. Also did not eat lunch. This morning he felt good and ate the entire BKF. He has had multiple stools (constipation was an issue in the past days and received plenty of stool softners) - stool sfotners will be held now. Suspect component of gastroparesis - this should improve as he becomes more active.
Age: 70.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Cardiac perfusion defect, Cellulitis, Confusion postoperative, Constipation, Coronary artery bypass
Clinical narrative: 71y.o. male with multiple medical problems including BPH, chronic LBP with LLE radicular pain, DMII and PPN who was admitted to the hospital on 9/5/2022 for N/V and abdominal pain. Upon admission, lexiscan MPI showed a reversible perfusion defect. Cardiovascular surgery was consulted and performed CABG x3 on 9/13. Pts hospital course has been c/b acute hypoxic respiratory failure, post-op acute blood loss anemia, dysphagia and right forearm cellulitis with completion of abx courses. Corpak was pulled on 9/21 by the pt. SLP is following and have the pt on mechanical soft diet with thickened liquids. Psych was consulted for depression and started the pt on Wellbutrin. Pt with recent hx of (7/27/2022) lumbar laminectomy with medial facetectomy and foraminotomy with fusion at L4-5 on  by Dr., post-op course complicated by lethargy and confusion. Patient with unwitnessed fall with RRT activated on 9/26- no head trauma and no head CT required. He was transferred to the med ward for a dx of COVID with fever and anorexia.  He was treated with remdesivir - he did not have hypoxia. He had quite some anorexia and asthenia and some depressed mood.  He has been recovering and is now showing signs of resolution of these problems and we anticipated return to HCF, but he was denied by insurance, including a peer to peer.  Evaluation on Day of Discharge: Last night he had nausea and vomiting and could not eat dinner. Also did not eat lunch. This morning he felt good and ate the entire BKF. He has had multiple stools (constipation was an issue in the past days and received plenty of stool softners) - stool sfotners will be held now. Suspect component of gastroparesis - this should improve as he becomes more active.