chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Sex: M
Vaccine: PPV
Symptoms: Pneumonia pneumococcal
Clinical narrative: Pneumonia; This spontaneous report has been downloaded from regulatory authority, concerning an adult male patient between 30-34 years old. Their concurrent conditions, medical history, drug reactions/allergies, and concomitant medications were not provided.   On an unspecified date, the patient was vaccinated with the second dose of pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, administered as prophylaxis (dosage regimen, route of administration, lot number and expiration date were not reported).   On an unknown date in 2018, the patient experienced an Pneumonia (Streptococcus pneumoniae pneumonia) and streptococcus pneumoniae serotyping was not available. At the time of the report, outcome of the event was not reported.   Causal relationship between suspect vaccine and the event was not reported. Upon internal review, the event Streptococcus pneumoniae pneumonia was determined to be medically significant.
Sex: F
Vaccine: PPV
Symptoms: Pneumococcal infection
Clinical narrative: No data provided; This spontaneous report has been downloaded from Regulatory Authority and referring to an adult female patient (age: 25-29). The patient's medical history, concurrent conditions and concomitant therapies were not reported.  On unknown dates, the patient was vaccinated with pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, 2 times, for prophylaxis (strength, dose, lot #, expiry date, and route of administration were not provided).   On an unknown date in 2021, the patient experienced Pneumococcal infection (reported as No data provided). On an unknown date in 2021, streptococcus pneumoniae serotyping was not available. At the time of reporting, the outcome of the event was not known.    The causal relationship between the event and pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) was unknown.  Upon internal review, the event of Pneumococcal infection was determined to be medically significant
Sex: F
Vaccine: PPV
Symptoms: Pneumococcal bacteraemia
Clinical narrative: Bacteraemia; This spontaneous report has been downloaded from National Notifiable Diseases Surveillance System (NNDSS)", concerning an adult female patient around 25 to 29 years old. Their concurrent conditions, medical history, drug reactions/allergies, and concomitant medications were not provided.   On an unspecified date, the patient was vaccinated with the first dose of pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, administered as prophylaxis (dosage regimen, route of administration, lot number and expiration date were not reported).   On an unknown date in 2014, the patient experienced  Bacteremia (Pneumococcal bacteraemia) and streptococcus pneumoniae serotyping was not available. At the time of the report, outcome of the event was not reported.   Causal relationship between suspect vaccine and the event was not reported. Upon internal review, the event Pneumococcal bacteraemia was determined to be medically significant.
Sex: F
Vaccine: PPV
Symptoms: Pneumonia pneumococcal
Clinical narrative: Pneumonia; This spontaneous report has been downloaded from the National Notifiable Diseases Surveillance System (NNDSS) concerning to an elderly (age: 65-69 years old) female patient. The patient's historical vaccines (unspecified) did not have available serotypes. The patient's medical history, historical drugs, known drug allergies, concurrent conditions and concomitant therapies were not reported.   On an unknown date, the patient was vaccinated with the first dose of pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, administered for prophylaxis (strength, volume of injection, lot #, expiry date, anatomical location and route of administration was not provided).   On an unknown date in 2021, the patient experienced pneumonia (Pneumonia pneumococcal). The streptococcus pneumoniae serotyping was not available. At the time of reporting, the outcome of the event had not been provided.  The causal relationship between pneumonia pneumococcal and pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) was not provided.   Upon internal review pneumonia pneumococcal  was determined to be medically significant
Sex: M
Vaccine: PNC, PPV
Symptoms: Pneumonia pneumococcal
Clinical narrative: Pneumonia; This spontaneous report has been downloaded from National Notifiable Diseases Surveillance System (NNDSS), concerning a child male patient between 02-04 years old. Their concurrent conditions, medical history, drug reactions/allergies, and concomitant medications were not provided.   On an unspecified date, the patient was vaccinated with the first dose of pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, administered as prophylaxis (dosage regimen, route of administration, lot number and expiration date were not reported). The patient was also vaccinated with 3 doses of pneumococcal vaccine conj 7v (crm197) (PREVENAR) (dosage regimen, indication, route of administration, lot number and expiration date were not reported).   On an unknown date in 2014, the patient experienced pneumonia (Pneumonia pneumococcal) and streptococcus pneumoniae serotyping not available. At the time of the report, outcome of the event was not reported.   Causal relationship between suspect vaccines and the event was not reported. Upon internal review, the event pneumonia pneumococcal was determined to be medically significant.
Sex: M
Vaccine: PPV
Symptoms: Pneumonia pneumococcal
Clinical narrative: Pneumonia; This spontaneous report has been downloaded from Surveillance System, concerning an adult male patient between 50-54 years old. Their concurrent conditions, medical history, drug reactions/allergies, and concomitant medications were not provided.   On an unspecified date, the patient was vaccinated with the first dose of pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, administered as prophylaxis (dosage regimen, route of administration, lot number and expiration date were not reported).   On an unknown date in 2014, the patient experienced pneumonia (Pneumonia pneumococcal) and streptococcus pneumoniae serotyping was not available. At the time of the report, outcome of the event was not reported.   Causal relationship between suspect vaccine and the event was not reported. Upon internal review, the event pneumonia pneumococcal was determined to be medically significant.
Sex: F
Vaccine: PPV
Symptoms: Pneumonia pneumococcal
Clinical narrative: Pneumonia; This spontaneous report has been downloaded from Regulatory Authority, concerning an elderly female patient of 85+ years old. Their concurrent conditions, medical history, drug reactions/allergies, and concomitant medications were not provided.   On an unspecified date, the patient was vaccinated with the first and second dose of pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, administered as prophylaxis (dosage regimen, route of administration, lot number and expiration date were not reported).   On an unknown date in 2014, the patient experienced pneumonia (Pneumonia pneumococcal) and streptococcus pneumoniae serotyping was not available. At the time of the report, outcome of the event was not reported.   Causal relationship between suspect vaccine and the event was not reported. Upon internal review, the event pneumonia pneumococcal was determined to be medically significant.
Sex: F
Vaccine: PPV
Symptoms: Pneumonia pneumococcal
Clinical narrative: Pneumonia; This spontaneous report has been downloaded from regulatory authority, concerning an adult female patient between 60-64 years old. Their concurrent conditions, medical history, drug reactions/allergies, and concomitant medications were not provided.   On an unspecified date, the patient was vaccinated with the first, second and third dose of pneumococcal 23v polysaccharide vaccine (PNEUMOVAX23) injection, administered as prophylaxis (dosage regimen, route of administration, lot number and expiration date were not reported).   On an unknown date in 2014, the patient experienced pneumonia (Pneumonia pneumococcal) and streptococcus pneumoniae serotyping was not available. At the time of the report, outcome of the event was not reported.   Causal relationship between suspect vaccine and the event was not reported. Upon internal review, the event pneumonia pneumococcal was determined to be medically significant.
Age: 6.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered, Malaise
Clinical narrative: The vaccine administered was in the refrigerator few days past vaccine refrigerator expiration date. Upon discovering and calling the patient's mother she mentioned that the patient was sick. She did not expand on the symptoms upon asking. Patient's mother was upset. She did not intend to deal with us and said she does not trust us anymore and said she would be communicating with the patient's pediatrician herself. I was unable to retrieve any other information as she was really upset.  It's unknown if the patient recovered from the adverse event.  It's unknown if the adverse event is because of the vaccine. The Result or outcome of adverse event(s) are unknown as well. Checking Doctor or Other Healthcare Professional Office visit box as patient's mother said she will contact the pediatrician, and as unknown box is unavailable.
Age: 50.0
Sex: M
Vaccine: COVID19
Symptoms: Chest discomfort, Fatigue, Headache, Nausea, Vitiligo
Clinical narrative: This is the 2nd Pfizer Covid vaccine received.  Within one day of the injection, felt heaviness and pressure on my chest, especially when relaxed and laying down.  This feeling comes and goes even now at two years later.  Nausea and tired, and headaches. On December 26, 2022, I started to develop non segmented Vitiligo on my face, chest and arms.
Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Angiogram pulmonary normal, Blood creatinine increased, COVID-19, Chest pain
Clinical narrative: Admit date: 1/17/2024  Discharge date:  01/19/2024  Admitting Physician: DO   Attending Physician at the Time of Discharge: DO  Primary Care Physician: MD  Reason for Admission:  Dyspnea  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) patient is an 81-year-old female presented for chest pain dyspnea progressing over the last several days.  Patient notes recent upper respiratory infection.  Endorses poor oral intake prior to admission.  Patient initially presented to one campus emergency department was transferred to other campus for admission.  Upon presentation she was hypertensive vitals stable.  Initially hypoxic placed on 2 L nasal cannula with improvement of oxygen saturation.  Patient tested positive for COVID.  CTA was obtained and negative for PE findings of interstitial prominence no consolidations.  Labs are notable for elevated creatinine consistent with AKI and hyponatremia.  She was started on to IV fluids with improvement of hyponatremia.  She was started on Decadron remdesivir for hypoxia and COVID diagnosis.  Patient was slowly titrated to room air.  Acute kidney injury hyponatremia improved.  Patient's home thiazide diuretic was held.  She will be discharged home.  Patient has been concern over confusion while in the hospital.  Suspect some encephalopathy multifactorial from home benzodiazepine use, hyponatremia, AKI.  Patient may be having early signs of dementia should be further evaluated following resolution of acute infection. Discharged to Home
Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Encephalopathy, Hypertension, Hyponatraemia, Hyponatraemic encephalopathy
Clinical narrative: Admit date: 1/17/2024  Discharge date:  01/19/2024  Admitting Physician: DO   Attending Physician at the Time of Discharge: DO  Primary Care Physician: MD  Reason for Admission:  Dyspnea  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) patient is an 81-year-old female presented for chest pain dyspnea progressing over the last several days.  Patient notes recent upper respiratory infection.  Endorses poor oral intake prior to admission.  Patient initially presented to one campus emergency department was transferred to other campus for admission.  Upon presentation she was hypertensive vitals stable.  Initially hypoxic placed on 2 L nasal cannula with improvement of oxygen saturation.  Patient tested positive for COVID.  CTA was obtained and negative for PE findings of interstitial prominence no consolidations.  Labs are notable for elevated creatinine consistent with AKI and hyponatremia.  She was started on to IV fluids with improvement of hyponatremia.  She was started on Decadron remdesivir for hypoxia and COVID diagnosis.  Patient was slowly titrated to room air.  Acute kidney injury hyponatremia improved.  Patient's home thiazide diuretic was held.  She will be discharged home.  Patient has been concern over confusion while in the hospital.  Suspect some encephalopathy multifactorial from home benzodiazepine use, hyponatremia, AKI.  Patient may be having early signs of dementia should be further evaluated following resolution of acute infection. Discharged to Home
Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Hypophagia, Hypoxia, Infection, SARS-CoV-2 test positive, Toxic encephalopathy
Clinical narrative: Admit date: 1/17/2024  Discharge date:  01/19/2024  Admitting Physician: DO   Attending Physician at the Time of Discharge: DO  Primary Care Physician: MD  Reason for Admission:  Dyspnea  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) patient is an 81-year-old female presented for chest pain dyspnea progressing over the last several days.  Patient notes recent upper respiratory infection.  Endorses poor oral intake prior to admission.  Patient initially presented to one campus emergency department was transferred to other campus for admission.  Upon presentation she was hypertensive vitals stable.  Initially hypoxic placed on 2 L nasal cannula with improvement of oxygen saturation.  Patient tested positive for COVID.  CTA was obtained and negative for PE findings of interstitial prominence no consolidations.  Labs are notable for elevated creatinine consistent with AKI and hyponatremia.  She was started on to IV fluids with improvement of hyponatremia.  She was started on Decadron remdesivir for hypoxia and COVID diagnosis.  Patient was slowly titrated to room air.  Acute kidney injury hyponatremia improved.  Patient's home thiazide diuretic was held.  She will be discharged home.  Patient has been concern over confusion while in the hospital.  Suspect some encephalopathy multifactorial from home benzodiazepine use, hyponatremia, AKI.  Patient may be having early signs of dementia should be further evaluated following resolution of acute infection. Discharged to Home
Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Upper respiratory tract infection
Clinical narrative: Admit date: 1/17/2024  Discharge date:  01/19/2024  Admitting Physician: DO   Attending Physician at the Time of Discharge: DO  Primary Care Physician: MD  Reason for Admission:  Dyspnea  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) patient is an 81-year-old female presented for chest pain dyspnea progressing over the last several days.  Patient notes recent upper respiratory infection.  Endorses poor oral intake prior to admission.  Patient initially presented to one campus emergency department was transferred to other campus for admission.  Upon presentation she was hypertensive vitals stable.  Initially hypoxic placed on 2 L nasal cannula with improvement of oxygen saturation.  Patient tested positive for COVID.  CTA was obtained and negative for PE findings of interstitial prominence no consolidations.  Labs are notable for elevated creatinine consistent with AKI and hyponatremia.  She was started on to IV fluids with improvement of hyponatremia.  She was started on Decadron remdesivir for hypoxia and COVID diagnosis.  Patient was slowly titrated to room air.  Acute kidney injury hyponatremia improved.  Patient's home thiazide diuretic was held.  She will be discharged home.  Patient has been concern over confusion while in the hospital.  Suspect some encephalopathy multifactorial from home benzodiazepine use, hyponatremia, AKI.  Patient may be having early signs of dementia should be further evaluated following resolution of acute infection. Discharged to Home
Age: 31.0
Sex: F
Vaccine: FLUC4, RSV
Symptoms: Delivery, Exposure during pregnancy
Clinical narrative: Patient received the arexvy and flucelvax vaccine on this 09/21/23. patient was pregnant at the time of vaccine. patient delivered in novermber. states the child was fine in december. In january child experienced earing loss in the right ear. patient is concerned if the Arexvy vaccine can lead to this effect on the child
Age: 50.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hypoaesthesia, Immediate post-injection reaction, Mobility decreased, Pain
Clinical narrative: Immediate pain, now with numbness in fingers and limited shoulder range of motion
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Blood albumin decreased, Blood culture negative, COVID-19, COVID-19 pneumonia
Clinical narrative: Admitting Provider  MD Discharge Provider  MD Primary Care Physician MD Admission Date  1/20/2024  Discharge Date  1/24/2024   Discharge Diagnosis  COVID 19 PNA Discharge Destination  SNF Brief Hospital Course 71 YO female Past medical history significant for hypothyroidism in addition to brain aneurysm status post clip in April 2023 and former smoker more than 50 years.   She presented from nursing facility due to increased requirement of oxygen and placed on non-rebreather.  Complaining from cough and fever and fatigue. There is COVID outbreak at the nursing facility 1 week ago.  Respiratory culture negative except for COVID-19  She is DNR/DNI, but would want aggressive care including bipap and pressors if needed. She was admited to ICU/PCU for severe COIVD management.  Patient received steroids, tocilizumab and remdesivir.  Patient improved her vital signs and oxygen requirement currently on room air.  Problem Oriented Hospital Course # Acute hypoxic respiratory failure  # COVID-19 virus pneumonia, improving:   -Received steroids on presentation, now discontinued as patient currently on room air -Legionella urine negative  -Respiratory panel negative except for COVID-19  -s/p 1 dose of Tocilizumab  -Remdesivir x 5 days.    # Ecoli due to UTI -Susceptible to Cefazoline, currently on cefepime IV continue for now, upon DC DC with Vantin 200 mg bid total 5 days,  # Septic shock likely related to COVID-19 virus infection/improving:  Treatment as above # Lactic acidosis, resolved  # Leukocytosis: resolved -Blood cultures no growth   # Chronic dysphagia -Speech therapy consulted, Pureed diet   # Hypoalbuminemia with albumin level 2.9 likely related to malnutrition:    # Bacterial conjunctivitis b/l mostly on the right eye:  - Start erythromycin ophthalmic ointment bid for 5 days started 1/21/24.  # Hypothyroidism  Diet: Diet Order General; 2.5 gm Na; Level 1:  Pureed DVT prophylaxis: Heparin SQ Code:   Code Status: No CPR/DNI Additional Care Limitations confirmed DNR/DNI with patient grand-daughter at bedside on admission  Disposition: pending RMDV completion   Post-Discharge Follow-Up Labs pending at discharge:None   Incidental findings:None   Follow-up items for PCP:None  Discharged to SNF
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Conjunctivitis bacterial, Cough, Dysphagia, Escherichia infection, Exposure to SARS-CoV-2
Clinical narrative: Admitting Provider  MD Discharge Provider  MD Primary Care Physician MD Admission Date  1/20/2024  Discharge Date  1/24/2024   Discharge Diagnosis  COVID 19 PNA Discharge Destination  SNF Brief Hospital Course 71 YO female Past medical history significant for hypothyroidism in addition to brain aneurysm status post clip in April 2023 and former smoker more than 50 years.   She presented from nursing facility due to increased requirement of oxygen and placed on non-rebreather.  Complaining from cough and fever and fatigue. There is COVID outbreak at the nursing facility 1 week ago.  Respiratory culture negative except for COVID-19  She is DNR/DNI, but would want aggressive care including bipap and pressors if needed. She was admited to ICU/PCU for severe COIVD management.  Patient received steroids, tocilizumab and remdesivir.  Patient improved her vital signs and oxygen requirement currently on room air.  Problem Oriented Hospital Course # Acute hypoxic respiratory failure  # COVID-19 virus pneumonia, improving:   -Received steroids on presentation, now discontinued as patient currently on room air -Legionella urine negative  -Respiratory panel negative except for COVID-19  -s/p 1 dose of Tocilizumab  -Remdesivir x 5 days.    # Ecoli due to UTI -Susceptible to Cefazoline, currently on cefepime IV continue for now, upon DC DC with Vantin 200 mg bid total 5 days,  # Septic shock likely related to COVID-19 virus infection/improving:  Treatment as above # Lactic acidosis, resolved  # Leukocytosis: resolved -Blood cultures no growth   # Chronic dysphagia -Speech therapy consulted, Pureed diet   # Hypoalbuminemia with albumin level 2.9 likely related to malnutrition:    # Bacterial conjunctivitis b/l mostly on the right eye:  - Start erythromycin ophthalmic ointment bid for 5 days started 1/21/24.  # Hypothyroidism  Diet: Diet Order General; 2.5 gm Na; Level 1:  Pureed DVT prophylaxis: Heparin SQ Code:   Code Status: No CPR/DNI Additional Care Limitations confirmed DNR/DNI with patient grand-daughter at bedside on admission  Disposition: pending RMDV completion   Post-Discharge Follow-Up Labs pending at discharge:None   Incidental findings:None   Follow-up items for PCP:None  Discharged to SNF
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Hypoalbuminaemia, Intensive care, Intra-cerebral aneurysm operation, Intracranial aneurysm
Clinical narrative: Admitting Provider  MD Discharge Provider  MD Primary Care Physician MD Admission Date  1/20/2024  Discharge Date  1/24/2024   Discharge Diagnosis  COVID 19 PNA Discharge Destination  SNF Brief Hospital Course 71 YO female Past medical history significant for hypothyroidism in addition to brain aneurysm status post clip in April 2023 and former smoker more than 50 years.   She presented from nursing facility due to increased requirement of oxygen and placed on non-rebreather.  Complaining from cough and fever and fatigue. There is COVID outbreak at the nursing facility 1 week ago.  Respiratory culture negative except for COVID-19  She is DNR/DNI, but would want aggressive care including bipap and pressors if needed. She was admited to ICU/PCU for severe COIVD management.  Patient received steroids, tocilizumab and remdesivir.  Patient improved her vital signs and oxygen requirement currently on room air.  Problem Oriented Hospital Course # Acute hypoxic respiratory failure  # COVID-19 virus pneumonia, improving:   -Received steroids on presentation, now discontinued as patient currently on room air -Legionella urine negative  -Respiratory panel negative except for COVID-19  -s/p 1 dose of Tocilizumab  -Remdesivir x 5 days.    # Ecoli due to UTI -Susceptible to Cefazoline, currently on cefepime IV continue for now, upon DC DC with Vantin 200 mg bid total 5 days,  # Septic shock likely related to COVID-19 virus infection/improving:  Treatment as above # Lactic acidosis, resolved  # Leukocytosis: resolved -Blood cultures no growth   # Chronic dysphagia -Speech therapy consulted, Pureed diet   # Hypoalbuminemia with albumin level 2.9 likely related to malnutrition:    # Bacterial conjunctivitis b/l mostly on the right eye:  - Start erythromycin ophthalmic ointment bid for 5 days started 1/21/24.  # Hypothyroidism  Diet: Diet Order General; 2.5 gm Na; Level 1:  Pureed DVT prophylaxis: Heparin SQ Code:   Code Status: No CPR/DNI Additional Care Limitations confirmed DNR/DNI with patient grand-daughter at bedside on admission  Disposition: pending RMDV completion   Post-Discharge Follow-Up Labs pending at discharge:None   Incidental findings:None   Follow-up items for PCP:None  Discharged to SNF
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Lactic acidosis, Legionella test, Leukocytosis, Malnutrition, Pyrexia
Clinical narrative: Admitting Provider  MD Discharge Provider  MD Primary Care Physician MD Admission Date  1/20/2024  Discharge Date  1/24/2024   Discharge Diagnosis  COVID 19 PNA Discharge Destination  SNF Brief Hospital Course 71 YO female Past medical history significant for hypothyroidism in addition to brain aneurysm status post clip in April 2023 and former smoker more than 50 years.   She presented from nursing facility due to increased requirement of oxygen and placed on non-rebreather.  Complaining from cough and fever and fatigue. There is COVID outbreak at the nursing facility 1 week ago.  Respiratory culture negative except for COVID-19  She is DNR/DNI, but would want aggressive care including bipap and pressors if needed. She was admited to ICU/PCU for severe COIVD management.  Patient received steroids, tocilizumab and remdesivir.  Patient improved her vital signs and oxygen requirement currently on room air.  Problem Oriented Hospital Course # Acute hypoxic respiratory failure  # COVID-19 virus pneumonia, improving:   -Received steroids on presentation, now discontinued as patient currently on room air -Legionella urine negative  -Respiratory panel negative except for COVID-19  -s/p 1 dose of Tocilizumab  -Remdesivir x 5 days.    # Ecoli due to UTI -Susceptible to Cefazoline, currently on cefepime IV continue for now, upon DC DC with Vantin 200 mg bid total 5 days,  # Septic shock likely related to COVID-19 virus infection/improving:  Treatment as above # Lactic acidosis, resolved  # Leukocytosis: resolved -Blood cultures no growth   # Chronic dysphagia -Speech therapy consulted, Pureed diet   # Hypoalbuminemia with albumin level 2.9 likely related to malnutrition:    # Bacterial conjunctivitis b/l mostly on the right eye:  - Start erythromycin ophthalmic ointment bid for 5 days started 1/21/24.  # Hypothyroidism  Diet: Diet Order General; 2.5 gm Na; Level 1:  Pureed DVT prophylaxis: Heparin SQ Code:   Code Status: No CPR/DNI Additional Care Limitations confirmed DNR/DNI with patient grand-daughter at bedside on admission  Disposition: pending RMDV completion   Post-Discharge Follow-Up Labs pending at discharge:None   Incidental findings:None   Follow-up items for PCP:None  Discharged to SNF
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Septic shock, Sputum culture positive, Urinary tract infection
Clinical narrative: Admitting Provider  MD Discharge Provider  MD Primary Care Physician MD Admission Date  1/20/2024  Discharge Date  1/24/2024   Discharge Diagnosis  COVID 19 PNA Discharge Destination  SNF Brief Hospital Course 71 YO female Past medical history significant for hypothyroidism in addition to brain aneurysm status post clip in April 2023 and former smoker more than 50 years.   She presented from nursing facility due to increased requirement of oxygen and placed on non-rebreather.  Complaining from cough and fever and fatigue. There is COVID outbreak at the nursing facility 1 week ago.  Respiratory culture negative except for COVID-19  She is DNR/DNI, but would want aggressive care including bipap and pressors if needed. She was admited to ICU/PCU for severe COIVD management.  Patient received steroids, tocilizumab and remdesivir.  Patient improved her vital signs and oxygen requirement currently on room air.  Problem Oriented Hospital Course # Acute hypoxic respiratory failure  # COVID-19 virus pneumonia, improving:   -Received steroids on presentation, now discontinued as patient currently on room air -Legionella urine negative  -Respiratory panel negative except for COVID-19  -s/p 1 dose of Tocilizumab  -Remdesivir x 5 days.    # Ecoli due to UTI -Susceptible to Cefazoline, currently on cefepime IV continue for now, upon DC DC with Vantin 200 mg bid total 5 days,  # Septic shock likely related to COVID-19 virus infection/improving:  Treatment as above # Lactic acidosis, resolved  # Leukocytosis: resolved -Blood cultures no growth   # Chronic dysphagia -Speech therapy consulted, Pureed diet   # Hypoalbuminemia with albumin level 2.9 likely related to malnutrition:    # Bacterial conjunctivitis b/l mostly on the right eye:  - Start erythromycin ophthalmic ointment bid for 5 days started 1/21/24.  # Hypothyroidism  Diet: Diet Order General; 2.5 gm Na; Level 1:  Pureed DVT prophylaxis: Heparin SQ Code:   Code Status: No CPR/DNI Additional Care Limitations confirmed DNR/DNI with patient grand-daughter at bedside on admission  Disposition: pending RMDV completion   Post-Discharge Follow-Up Labs pending at discharge:None   Incidental findings:None   Follow-up items for PCP:None  Discharged to SNF
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Asthenia, Blood lactic acid increased, Blood thyroid stimulating hormone increased, COVID-19
Clinical narrative: Admit date: 1/21/2024  Discharge date: 01/24/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: DO Reason for Admission: Dizziness  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 60 YO male presented to ED with progressive weakness and dizziness.  Notes 2 weeks of cough and dyspnea, with poor appetite.  Lightheadedness is much worse with sitting up or standing, no vertigo.  Notes intermittent difficulty urinating, better when he takes his flomax.  Denies dysuria, pelvic pain, flank pain. Denies bleeding or diarrhea. Chronic black stools on iron.  ED noted firm prostate mass on rectal exam, Urology consulted. (HPI per Dr)  Hospital Course: No notes on file patient is a 60yr old male with a history of HTN, CAD, Hypothyroidism, LUTS, Nasopharyngeal cancer (head and neck), Anxiety, GERD, Smoker who presented with weakness, SOB and falling. He says he has been getting progressively worsening SOB with mild to moderate exertion like walking to the bathroom. Also he has been falling lately - he says while ambulating he would just notice his legs will start shaking, he will get a "head rush" and legs would give way. Today he is seen ambulating in room. PT evaluated and recommended Home with assist.  Sepsis secondary to UTI - Based on leukocytosis, elevated lactate, Urine culture E.coli x2strains. Unsure if there was complete urinary obstruction.  Voiding pretty well at this time.  Improving on antibiotics IV ceftriaxone day#3 based on resolution of leukocytosis and clinical improvement. Will discharge home on keflex  COVID - Assymptomatic  Urinary retention Enlarged prostate.  Increase PSA, unsure significance with the current UTI.  F/u with urology continue flomax.  Syncope/Falls - Could be cardiac or orthostatic.  Echo normal.  Plan is for Event monitor on discharge. Order placed and CM to notify cards office.  AKI likely from volume depletion and sepsis.  Improving with fluids.  Frequent falls with lower ext weakness -  Rule out cervical stenosis. MRI revealed Multilevel spondylosis, most notably at C4-C5 where there is mild central spinal stenosis and moderate bilateral foraminal stenosis. Per NS curbside, findings of mild to moderate foraminal stenosis will not explain his symtoms.   History of head and neck cancer status post radiation and chemotherapy.  No obvious recurrence or metastatic disease could contribute to thyroid changes.  TSH high but T4 OK will need to follow up in2-3 months.  May have subclinical hypothyroid and should be monitored for progression Discharged to Home
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Cervical spinal stenosis, Cough, Culture urine positive, Decreased appetite, Dizziness
Clinical narrative: Admit date: 1/21/2024  Discharge date: 01/24/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: DO Reason for Admission: Dizziness  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 60 YO male presented to ED with progressive weakness and dizziness.  Notes 2 weeks of cough and dyspnea, with poor appetite.  Lightheadedness is much worse with sitting up or standing, no vertigo.  Notes intermittent difficulty urinating, better when he takes his flomax.  Denies dysuria, pelvic pain, flank pain. Denies bleeding or diarrhea. Chronic black stools on iron.  ED noted firm prostate mass on rectal exam, Urology consulted. (HPI per Dr)  Hospital Course: No notes on file patient is a 60yr old male with a history of HTN, CAD, Hypothyroidism, LUTS, Nasopharyngeal cancer (head and neck), Anxiety, GERD, Smoker who presented with weakness, SOB and falling. He says he has been getting progressively worsening SOB with mild to moderate exertion like walking to the bathroom. Also he has been falling lately - he says while ambulating he would just notice his legs will start shaking, he will get a "head rush" and legs would give way. Today he is seen ambulating in room. PT evaluated and recommended Home with assist.  Sepsis secondary to UTI - Based on leukocytosis, elevated lactate, Urine culture E.coli x2strains. Unsure if there was complete urinary obstruction.  Voiding pretty well at this time.  Improving on antibiotics IV ceftriaxone day#3 based on resolution of leukocytosis and clinical improvement. Will discharge home on keflex  COVID - Assymptomatic  Urinary retention Enlarged prostate.  Increase PSA, unsure significance with the current UTI.  F/u with urology continue flomax.  Syncope/Falls - Could be cardiac or orthostatic.  Echo normal.  Plan is for Event monitor on discharge. Order placed and CM to notify cards office.  AKI likely from volume depletion and sepsis.  Improving with fluids.  Frequent falls with lower ext weakness -  Rule out cervical stenosis. MRI revealed Multilevel spondylosis, most notably at C4-C5 where there is mild central spinal stenosis and moderate bilateral foraminal stenosis. Per NS curbside, findings of mild to moderate foraminal stenosis will not explain his symtoms.   History of head and neck cancer status post radiation and chemotherapy.  No obvious recurrence or metastatic disease could contribute to thyroid changes.  TSH high but T4 OK will need to follow up in2-3 months.  May have subclinical hypothyroid and should be monitored for progression Discharged to Home
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Dizziness postural, Dyspnoea, Dyspnoea exertional, Dysuria, Echocardiogram normal
Clinical narrative: Admit date: 1/21/2024  Discharge date: 01/24/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: DO Reason for Admission: Dizziness  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 60 YO male presented to ED with progressive weakness and dizziness.  Notes 2 weeks of cough and dyspnea, with poor appetite.  Lightheadedness is much worse with sitting up or standing, no vertigo.  Notes intermittent difficulty urinating, better when he takes his flomax.  Denies dysuria, pelvic pain, flank pain. Denies bleeding or diarrhea. Chronic black stools on iron.  ED noted firm prostate mass on rectal exam, Urology consulted. (HPI per Dr)  Hospital Course: No notes on file patient is a 60yr old male with a history of HTN, CAD, Hypothyroidism, LUTS, Nasopharyngeal cancer (head and neck), Anxiety, GERD, Smoker who presented with weakness, SOB and falling. He says he has been getting progressively worsening SOB with mild to moderate exertion like walking to the bathroom. Also he has been falling lately - he says while ambulating he would just notice his legs will start shaking, he will get a "head rush" and legs would give way. Today he is seen ambulating in room. PT evaluated and recommended Home with assist.  Sepsis secondary to UTI - Based on leukocytosis, elevated lactate, Urine culture E.coli x2strains. Unsure if there was complete urinary obstruction.  Voiding pretty well at this time.  Improving on antibiotics IV ceftriaxone day#3 based on resolution of leukocytosis and clinical improvement. Will discharge home on keflex  COVID - Assymptomatic  Urinary retention Enlarged prostate.  Increase PSA, unsure significance with the current UTI.  F/u with urology continue flomax.  Syncope/Falls - Could be cardiac or orthostatic.  Echo normal.  Plan is for Event monitor on discharge. Order placed and CM to notify cards office.  AKI likely from volume depletion and sepsis.  Improving with fluids.  Frequent falls with lower ext weakness -  Rule out cervical stenosis. MRI revealed Multilevel spondylosis, most notably at C4-C5 where there is mild central spinal stenosis and moderate bilateral foraminal stenosis. Per NS curbside, findings of mild to moderate foraminal stenosis will not explain his symtoms.   History of head and neck cancer status post radiation and chemotherapy.  No obvious recurrence or metastatic disease could contribute to thyroid changes.  TSH high but T4 OK will need to follow up in2-3 months.  May have subclinical hypothyroid and should be monitored for progression Discharged to Home
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Escherichia test positive, Faeces discoloured, Fall, Hypovolaemia, Leukocytosis
Clinical narrative: Admit date: 1/21/2024  Discharge date: 01/24/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: DO Reason for Admission: Dizziness  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 60 YO male presented to ED with progressive weakness and dizziness.  Notes 2 weeks of cough and dyspnea, with poor appetite.  Lightheadedness is much worse with sitting up or standing, no vertigo.  Notes intermittent difficulty urinating, better when he takes his flomax.  Denies dysuria, pelvic pain, flank pain. Denies bleeding or diarrhea. Chronic black stools on iron.  ED noted firm prostate mass on rectal exam, Urology consulted. (HPI per Dr)  Hospital Course: No notes on file patient is a 60yr old male with a history of HTN, CAD, Hypothyroidism, LUTS, Nasopharyngeal cancer (head and neck), Anxiety, GERD, Smoker who presented with weakness, SOB and falling. He says he has been getting progressively worsening SOB with mild to moderate exertion like walking to the bathroom. Also he has been falling lately - he says while ambulating he would just notice his legs will start shaking, he will get a "head rush" and legs would give way. Today he is seen ambulating in room. PT evaluated and recommended Home with assist.  Sepsis secondary to UTI - Based on leukocytosis, elevated lactate, Urine culture E.coli x2strains. Unsure if there was complete urinary obstruction.  Voiding pretty well at this time.  Improving on antibiotics IV ceftriaxone day#3 based on resolution of leukocytosis and clinical improvement. Will discharge home on keflex  COVID - Assymptomatic  Urinary retention Enlarged prostate.  Increase PSA, unsure significance with the current UTI.  F/u with urology continue flomax.  Syncope/Falls - Could be cardiac or orthostatic.  Echo normal.  Plan is for Event monitor on discharge. Order placed and CM to notify cards office.  AKI likely from volume depletion and sepsis.  Improving with fluids.  Frequent falls with lower ext weakness -  Rule out cervical stenosis. MRI revealed Multilevel spondylosis, most notably at C4-C5 where there is mild central spinal stenosis and moderate bilateral foraminal stenosis. Per NS curbside, findings of mild to moderate foraminal stenosis will not explain his symtoms.   History of head and neck cancer status post radiation and chemotherapy.  No obvious recurrence or metastatic disease could contribute to thyroid changes.  TSH high but T4 OK will need to follow up in2-3 months.  May have subclinical hypothyroid and should be monitored for progression Discharged to Home
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Magnetic resonance imaging spinal abnormal, Muscular weakness, Musculoskeletal disorder, Orthostatic hypotension, Prostatic mass
Clinical narrative: Admit date: 1/21/2024  Discharge date: 01/24/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: DO Reason for Admission: Dizziness  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 60 YO male presented to ED with progressive weakness and dizziness.  Notes 2 weeks of cough and dyspnea, with poor appetite.  Lightheadedness is much worse with sitting up or standing, no vertigo.  Notes intermittent difficulty urinating, better when he takes his flomax.  Denies dysuria, pelvic pain, flank pain. Denies bleeding or diarrhea. Chronic black stools on iron.  ED noted firm prostate mass on rectal exam, Urology consulted. (HPI per Dr)  Hospital Course: No notes on file patient is a 60yr old male with a history of HTN, CAD, Hypothyroidism, LUTS, Nasopharyngeal cancer (head and neck), Anxiety, GERD, Smoker who presented with weakness, SOB and falling. He says he has been getting progressively worsening SOB with mild to moderate exertion like walking to the bathroom. Also he has been falling lately - he says while ambulating he would just notice his legs will start shaking, he will get a "head rush" and legs would give way. Today he is seen ambulating in room. PT evaluated and recommended Home with assist.  Sepsis secondary to UTI - Based on leukocytosis, elevated lactate, Urine culture E.coli x2strains. Unsure if there was complete urinary obstruction.  Voiding pretty well at this time.  Improving on antibiotics IV ceftriaxone day#3 based on resolution of leukocytosis and clinical improvement. Will discharge home on keflex  COVID - Assymptomatic  Urinary retention Enlarged prostate.  Increase PSA, unsure significance with the current UTI.  F/u with urology continue flomax.  Syncope/Falls - Could be cardiac or orthostatic.  Echo normal.  Plan is for Event monitor on discharge. Order placed and CM to notify cards office.  AKI likely from volume depletion and sepsis.  Improving with fluids.  Frequent falls with lower ext weakness -  Rule out cervical stenosis. MRI revealed Multilevel spondylosis, most notably at C4-C5 where there is mild central spinal stenosis and moderate bilateral foraminal stenosis. Per NS curbside, findings of mild to moderate foraminal stenosis will not explain his symtoms.   History of head and neck cancer status post radiation and chemotherapy.  No obvious recurrence or metastatic disease could contribute to thyroid changes.  TSH high but T4 OK will need to follow up in2-3 months.  May have subclinical hypothyroid and should be monitored for progression Discharged to Home
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Prostatic specific antigen increased, Prostatomegaly, Sepsis, Spinal osteoarthritis, Syncope
Clinical narrative: Admit date: 1/21/2024  Discharge date: 01/24/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: DO Reason for Admission: Dizziness  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 60 YO male presented to ED with progressive weakness and dizziness.  Notes 2 weeks of cough and dyspnea, with poor appetite.  Lightheadedness is much worse with sitting up or standing, no vertigo.  Notes intermittent difficulty urinating, better when he takes his flomax.  Denies dysuria, pelvic pain, flank pain. Denies bleeding or diarrhea. Chronic black stools on iron.  ED noted firm prostate mass on rectal exam, Urology consulted. (HPI per Dr)  Hospital Course: No notes on file patient is a 60yr old male with a history of HTN, CAD, Hypothyroidism, LUTS, Nasopharyngeal cancer (head and neck), Anxiety, GERD, Smoker who presented with weakness, SOB and falling. He says he has been getting progressively worsening SOB with mild to moderate exertion like walking to the bathroom. Also he has been falling lately - he says while ambulating he would just notice his legs will start shaking, he will get a "head rush" and legs would give way. Today he is seen ambulating in room. PT evaluated and recommended Home with assist.  Sepsis secondary to UTI - Based on leukocytosis, elevated lactate, Urine culture E.coli x2strains. Unsure if there was complete urinary obstruction.  Voiding pretty well at this time.  Improving on antibiotics IV ceftriaxone day#3 based on resolution of leukocytosis and clinical improvement. Will discharge home on keflex  COVID - Assymptomatic  Urinary retention Enlarged prostate.  Increase PSA, unsure significance with the current UTI.  F/u with urology continue flomax.  Syncope/Falls - Could be cardiac or orthostatic.  Echo normal.  Plan is for Event monitor on discharge. Order placed and CM to notify cards office.  AKI likely from volume depletion and sepsis.  Improving with fluids.  Frequent falls with lower ext weakness -  Rule out cervical stenosis. MRI revealed Multilevel spondylosis, most notably at C4-C5 where there is mild central spinal stenosis and moderate bilateral foraminal stenosis. Per NS curbside, findings of mild to moderate foraminal stenosis will not explain his symtoms.   History of head and neck cancer status post radiation and chemotherapy.  No obvious recurrence or metastatic disease could contribute to thyroid changes.  TSH high but T4 OK will need to follow up in2-3 months.  May have subclinical hypothyroid and should be monitored for progression Discharged to Home
Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Thyroid disorder, Thyroxine normal, Tremor, Urinary retention, Urinary tract infection
Clinical narrative: Admit date: 1/21/2024  Discharge date: 01/24/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: DO Reason for Admission: Dizziness  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 60 YO male presented to ED with progressive weakness and dizziness.  Notes 2 weeks of cough and dyspnea, with poor appetite.  Lightheadedness is much worse with sitting up or standing, no vertigo.  Notes intermittent difficulty urinating, better when he takes his flomax.  Denies dysuria, pelvic pain, flank pain. Denies bleeding or diarrhea. Chronic black stools on iron.  ED noted firm prostate mass on rectal exam, Urology consulted. (HPI per Dr)  Hospital Course: No notes on file patient is a 60yr old male with a history of HTN, CAD, Hypothyroidism, LUTS, Nasopharyngeal cancer (head and neck), Anxiety, GERD, Smoker who presented with weakness, SOB and falling. He says he has been getting progressively worsening SOB with mild to moderate exertion like walking to the bathroom. Also he has been falling lately - he says while ambulating he would just notice his legs will start shaking, he will get a "head rush" and legs would give way. Today he is seen ambulating in room. PT evaluated and recommended Home with assist.  Sepsis secondary to UTI - Based on leukocytosis, elevated lactate, Urine culture E.coli x2strains. Unsure if there was complete urinary obstruction.  Voiding pretty well at this time.  Improving on antibiotics IV ceftriaxone day#3 based on resolution of leukocytosis and clinical improvement. Will discharge home on keflex  COVID - Assymptomatic  Urinary retention Enlarged prostate.  Increase PSA, unsure significance with the current UTI.  F/u with urology continue flomax.  Syncope/Falls - Could be cardiac or orthostatic.  Echo normal.  Plan is for Event monitor on discharge. Order placed and CM to notify cards office.  AKI likely from volume depletion and sepsis.  Improving with fluids.  Frequent falls with lower ext weakness -  Rule out cervical stenosis. MRI revealed Multilevel spondylosis, most notably at C4-C5 where there is mild central spinal stenosis and moderate bilateral foraminal stenosis. Per NS curbside, findings of mild to moderate foraminal stenosis will not explain his symtoms.   History of head and neck cancer status post radiation and chemotherapy.  No obvious recurrence or metastatic disease could contribute to thyroid changes.  TSH high but T4 OK will need to follow up in2-3 months.  May have subclinical hypothyroid and should be monitored for progression Discharged to Home