chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Anaphylactic reaction, Chest discomfort, Dyspnoea, Pain
Clinical narrative: Patient had an anaphylactic reaction. She experienced tightness in her chest and had was having difficulty breathing. She even looked like she was gasping for air. An epipen was administered and within seconds she was able to breathe. 911 was contacted upon initiation of the reaction. EMS arrived within minutes after administering the epipen. She was assessed by paramedics and it was determined that the patient would be ok. I called husband in the afternoon to check on patient and he stated that she was good. I also followed up on 03/05/2021 with the patient and she stated that other than soreness that she was fine. I let patient know that since she had a reaction to the first dose, that she would not be able to receive the second dose.
Age: 54.0
Sex: M
Vaccine: COVID19
Symptoms: Blood test normal, Seizure
Clinical narrative: Seizure 3/4
Age: 42.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect dose administered
Clinical narrative: covid vaccine was mixed with 0.8ml instead of1.8ml
Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: Respiratory tract congestion, Sneezing
Clinical narrative: COVID arm and slight allergies like sneezing and congestion
Age: 51.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Injection site erythema, Injection site pain, Injection site warmth, Lymphadenopathy
Clinical narrative: Headaches, underarm glands swollen, body aches, soreness, redness of arm, fever near area
Age: 51.0
Sex: F
Vaccine: COVID19
Symptoms: Pain
Clinical narrative: Headaches, underarm glands swollen, body aches, soreness, redness of arm, fever near area
Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Chills, Injection site pain, Musculoskeletal stiffness, Pyrexia
Clinical narrative: Pt. called clinic today at 8:22am to report overnight fever and chills, as well as neck, left shoulder and left arm stiffness and pain at the injection site (left deltoid).   Pt. advised that she may alternate acetaminophen with ibuprofen for fever/pain  relief as well as heat/ice to help with muscle stiffness and pain.  Clinic will call patient on Monday to re-evaluate the condition of the patient.
Age: 41.0
Sex: F
Vaccine: COVID19
Symptoms: Pruritus, Skin reaction
Clinical narrative: 12/30 vaccination 10 days later, I had itching and noticed a spreading 4" diameter. After 3 days it went away.  1/8/2021 Contacted Dr. office that morning in case it was cellulitis, virtual visit. Monitor and several days later, it was gone.  *Dr stated 'skin reaction seen many times with vaccine'.
Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Contusion, Headache, Injection site pain, Injection site swelling, Lymphadenopathy
Clinical narrative: after receiving shot i had an headache later that day about 3pm. I took ibuprofen 800mg a,d went to sleep. I woke up about 10:30pm that night feeling sluggish. That Sunday I woke up with the same headache not as bad and i took another ibuprofen 800. My arm was very sore and swollen at the injection site. On Monday, when i woke up my right armpit had swollen up and bruised rally bad. My lymph nodes in my armpits had also swollen and very tender to touch. I went to SCS clinic and they gave me some Cyclobenzaprine for muscle relaxation and told me to follow up with my PCP. I went to my PCP on 3/4/2021 and she prescribed me some Prednisone for swelling.
Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Sluggishness, Tenderness
Clinical narrative: after receiving shot i had an headache later that day about 3pm. I took ibuprofen 800mg a,d went to sleep. I woke up about 10:30pm that night feeling sluggish. That Sunday I woke up with the same headache not as bad and i took another ibuprofen 800. My arm was very sore and swollen at the injection site. On Monday, when i woke up my right armpit had swollen up and bruised rally bad. My lymph nodes in my armpits had also swollen and very tender to touch. I went to SCS clinic and they gave me some Cyclobenzaprine for muscle relaxation and told me to follow up with my PCP. I went to my PCP on 3/4/2021 and she prescribed me some Prednisone for swelling.
Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Amnesia, Asthenia, Chills, Dizziness, Eye movement disorder
Clinical narrative: 6:30am 3/4/2021 She called for her husband, sat down on the toilet as she became dizzy, he reported that her eyes rolled back and her body became stiff. This lasted approximately 10 seconds. She does not remember what happened. She was weak the rest of the day. 3/4/21 She reports whole body chills without fever, aching, headache, vomiting, and dizziness. 3/5 she sent me a picture of "COVID arm". She is still slightly dizzy.
Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Musculoskeletal stiffness, Vaccination complication
Clinical narrative: 6:30am 3/4/2021 She called for her husband, sat down on the toilet as she became dizzy, he reported that her eyes rolled back and her body became stiff. This lasted approximately 10 seconds. She does not remember what happened. She was weak the rest of the day. 3/4/21 She reports whole body chills without fever, aching, headache, vomiting, and dizziness. 3/5 she sent me a picture of "COVID arm". She is still slightly dizzy.
Age: 28.0
Sex: M
Vaccine: COVID19
Symptoms: Dizziness, Dysphemia, Hemiparesis, Joint stiffness, Migraine
Clinical narrative: 18 days after Covid Vaccine Dose 1, patient started to present with symptoms of a frontal lobe migraine along with nausea, dizziness, and L Sided Weakness. As time continued to pass while en route to local hospital, patient began to stutter harshly, saying every other word in a sentence, complained of a stiff jaw, and began to panic.
Age: 28.0
Sex: M
Vaccine: COVID19
Symptoms: Nausea, Panic reaction
Clinical narrative: 18 days after Covid Vaccine Dose 1, patient started to present with symptoms of a frontal lobe migraine along with nausea, dizziness, and L Sided Weakness. As time continued to pass while en route to local hospital, patient began to stutter harshly, saying every other word in a sentence, complained of a stiff jaw, and began to panic.
Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Influenza like illness
Clinical narrative: The following morning, I felt like I had the flu, but symptoms disappeared within 3 hours.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site induration, Injection site mass, Injection site pain, Injection site pruritus, Injection site swelling
Clinical narrative: Normal soreness and swelling at injection site. Within  4 days  developed a hard mass about 3" x 2" with soreness and itching at site.
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site erythema, Injection site pain, Injection site swelling, Injection site warmth, Myalgia
Clinical narrative: "Covid Arm", left arm red, warm to touch, swollen. Soft ball size erythema tender and warm to touch. Striae distal to this. Localized myalgia. Temp 99.1.
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Skin striae
Clinical narrative: "Covid Arm", left arm red, warm to touch, swollen. Soft ball size erythema tender and warm to touch. Striae distal to this. Localized myalgia. Temp 99.1.
Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Blood creatine phosphokinase increased, COVID-19, Colitis, Computerised tomogram abnormal
Clinical narrative: Pt presented for generalized weakness, altered mental status, severe diarrhea. Determined COVID positive on 2/14/2021. Patient was found to have elevated CPKs severe hyponatremia bilateral groundglass opacities on CT scan and mild colitis.  Patient was given hypertonic saline and admitted to intensive care unit where she was placed on mechanical ventilation. Patient currently still admitted.
Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Diarrhoea, Hyponatraemia, Lung opacity, Mental disorder, SARS-CoV-2 test positive
Clinical narrative: Pt presented for generalized weakness, altered mental status, severe diarrhea. Determined COVID positive on 2/14/2021. Patient was found to have elevated CPKs severe hyponatremia bilateral groundglass opacities on CT scan and mild colitis.  Patient was given hypertonic saline and admitted to intensive care unit where she was placed on mechanical ventilation. Patient currently still admitted.
Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site induration, Injection site mass, Rash, Rash pruritic
Clinical narrative: Arm rash plus  hard lump  just below the injection site. Rash  started six or seven days after the injection and lasted  5 or 6 days.  Itchy entire time.
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Erythema, Pruritus, Skin warm
Clinical narrative: Within the first day of shot left arm was red, warm to touch, itchy. (First dose of Moderna received on 01-29-21 had a smaller reaction after 7 days)
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Chills, Dizziness, Fatigue, Feeling abnormal, Feeling cold
Clinical narrative: Dizziness, Hot flash starting at the base of my neck & spreading up through my head followed by sweating hands/palms followed by feeling very cold and then cycling back to hot flash, more sweaty palms, & back to chills. Minor nausea.  Lasted from 8:15am til 11:30am.  I called my care team at clinic they suggested that I call "911", but I did not call "911".  My daughter who is a nurse came over to my house & stayed with me until 11:30am.  On 03/05/2021 I woke up at 8:00am with a mild headache, minor muscle aches, tired, a little brain fog, & minor nausea which is continuing as of 10:35am as I am completing this form.
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Hot flush, Hyperhidrosis, Myalgia, Nausea
Clinical narrative: Dizziness, Hot flash starting at the base of my neck & spreading up through my head followed by sweating hands/palms followed by feeling very cold and then cycling back to hot flash, more sweaty palms, & back to chills. Minor nausea.  Lasted from 8:15am til 11:30am.  I called my care team at clinic they suggested that I call "911", but I did not call "911".  My daughter who is a nurse came over to my house & stayed with me until 11:30am.  On 03/05/2021 I woke up at 8:00am with a mild headache, minor muscle aches, tired, a little brain fog, & minor nausea which is continuing as of 10:35am as I am completing this form.
Age: 33.0
Sex: M
Vaccine: COVID19
Symptoms: Paraesthesia oral, Vaccine positive rechallenge
Clinical narrative: REPORTS TINGLING SENSATION TO TONGUE (SIMILAR TO PREVIOUS REACTION WHEN GIVEN FIRST DOSE)
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Balance disorder, Chills, Headache, Pain
Clinical narrative: Felt like the flu that night & all the next day.  Achey, painful joints, off-balance slightly, chills, no fever that i know of, headache, extremely painful left arm up & down, into shoulder & scapula. .  Stayed home all day., took Tyleno, benedril dye free the day after injection when feeling so bad
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Pain in extremity
Clinical narrative: Felt like the flu that night & all the next day.  Achey, painful joints, off-balance slightly, chills, no fever that i know of, headache, extremely painful left arm up & down, into shoulder & scapula. .  Stayed home all day., took Tyleno, benedril dye free the day after injection when feeling so bad
Age: 51.0
Sex: F
Vaccine: COVID19
Symptoms: Lymphadenopathy
Clinical narrative: Swollen lymph nodes in left arm (same arm that I received the shot)
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Feeling abnormal, Paraesthesia oral, Tongue disorder
Clinical narrative: The patient was at the end of her 30 minuet observation post IM injection. Patient stated, "I feel funny, my lips and tongue are tingling. My tongue is starting to feel thick." Patient was taken to a private room where vitals were taken ( stable vital signs), patient stated, "I feel like it is getting worse." Patient was given IM EPI. EMS was called and patient was transported to the ED.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Erythema, Feeling abnormal, Pruritus
Clinical narrative: Erythema, itching, dizziness, feeling "wierd". She was given IM Benadryl 25mg 12 minutes after her IM injection of the Moderna vaccine (12:15) and that was repeated 25 minutes later (12:40). The patient was feeling better after each injection but after her 2nd dose of Benadryl she was still feeling dizzy and "wierd". She was transported to the ED by ambulance  further treated there.
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site pruritus, Injection site rash, Injection site swelling
Clinical narrative: pt states that about 14 days after taking the covid vax that she noticed a lump on her left arm around the injection site.  Today 3/5/2021 she had developed a a 3 x 5 itchy red rash on left arm where the lump was at the day before.  Pt has not put any medicine on it or contacted her PCP at this time.
Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Body temperature increased
Clinical narrative: Began running a temperature of 103 the evening of the vaccine 3/4/2021
Age: 33.0
Sex: F
Vaccine: TYP
Symptoms: Immediate post-injection reaction, Urticaria
Clinical narrative: Immediately after injection, wheal formed. Patient denied pain or feeling uneasy and waited about 10 minutes after injection.. Provider was notified and stated that urticaria characterized by wheals (hives) accompanied by an itching or burning sensation resolves generally within 24 hours and that she should monitor her arm for any issues and if she should have further issues to return to the clinic for further evaluation or go to ER. Patient refused repeat vitals because she had to leave for a meeting.  Will follow up with patient via phone call later today in the afternoon.
Age: 53.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Dizziness, Mass, Pain in extremity, Pruritus
Clinical narrative: After taking my first dose, I felt lightheaded.  It lasted about 10 minutes.  After taking it the next week, my arm was sore and a bump was visible.  It stayed for two days.  Then it would go down, then raise again accompanied by itching.  Then it went away.  No treatment.  I did put lotion on the itching site.
Age: 23.0
Sex: F
Vaccine: HEP
Symptoms: Erythema, Pain, Skin warm, Swelling
Clinical narrative: Employee reported redness, swelling, pain, and heat a few hours after administration of vaccine on 3/3/21
Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Chest pain, Dizziness, Respiratory rate increased, Retching
Clinical narrative: Dizziness, lightheadedness, chest pain, increased respiration, gagging
Age: 40.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site erythema, Injection site pain, Injection site pruritus, Injection site swelling, Injection site warmth
Clinical narrative: One week after the injection I have a large (tennis ball sized) raised red spot on my arm near the injection site. This red spot is tender and warm to the touch. It does itch at times but not consistently. It has grown since I initially noticed it.   I am treating it with topical cortizone cream and ice. Possible antibiotic treatement if symptoms do not improve within the next few days.
Age: 40.0
Sex: F
Vaccine: COVID19
Symptoms: Adverse reaction, Paraesthesia oral
Clinical narrative: During observation period patient reported tingling feeling in lips which progressed to her tongue.  She also was not sure if she had trouble breathing or if she was just feeling anxious.  Gave her 50mg of oral Benadryl, administered an Epipen and called 911.  Paramedics responded and took her to E.R. where she remained under observation for a few hours before being released with a prescription for Epipen.  When paramedics evaluated her they said her condition appeared to be normal.  Hospital instructed her to return if allergic symptoms returned.
Age: 47.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Asthma, Dyspnoea, Paraesthesia oral
Clinical narrative: Lip tingling after 10 minutes from shot. 30 minutes later had difficulty breathing, was induced by Anxiety and Asthma. Went to the ER just to be sure.
Age: 72.0
Sex: F
Vaccine: VARZOS
Symptoms: Cough, Crying, Hallucination, Insomnia, Night sweats
Clinical narrative: night sweats, insomnia, hallucination at night, hot spot on arm which is swollen and sore (tennis ball size), in bed from 3/2/21 until 3/5/21, runny nose, dry cough, fever, body aches, weeping eye (clear mucous)
Age: 72.0
Sex: F
Vaccine: VARZOS
Symptoms: Pain, Pain in extremity, Peripheral swelling, Pyrexia, Rhinorrhoea
Clinical narrative: night sweats, insomnia, hallucination at night, hot spot on arm which is swollen and sore (tennis ball size), in bed from 3/2/21 until 3/5/21, runny nose, dry cough, fever, body aches, weeping eye (clear mucous)
Age: 72.0
Sex: F
Vaccine: VARZOS
Symptoms: Skin warm
Clinical narrative: night sweats, insomnia, hallucination at night, hot spot on arm which is swollen and sore (tennis ball size), in bed from 3/2/21 until 3/5/21, runny nose, dry cough, fever, body aches, weeping eye (clear mucous)
Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Somnolence
Clinical narrative: PATIENT REPORTS DROWSINESS AND FEELING TIRED AFTER VACCINE.  PT WAS MONITORED FOR AN  ADDITIONAL 30 MINS. UPON DISCHARGE REPORTS FEELING BETTER
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site erythema, Injection site pain, Injection site pruritus, Injection site swelling, Injection site warmth
Clinical narrative: Moderna COVID-19 Vaccine EUA; swelling, redness, itchiness, and soreness in the arm that got the shot 7 days after the short. the area is also warm and sensitive to touch
Age: 51.0
Sex: F
Vaccine: COVID19
Symptoms: Aura, Dizziness, Paraesthesia oral, Vitreous floaters
Clinical narrative: PT C/O OF DIZZINESS, PERIORAL PARESTHESIA, EYE FLOATERS WHICH STARTED A FEW MINUTES AFTER RECEIVING THE VACCINATION. PT HAS A HISTORY OF COVID 19 W/CHRONIC "BREATHING PROBLEMS."  10:02 BP 161/82 HR 77 O2 97%  10:05 AM BP 169/79 HR 75  10:09 AM 156/82 HR 75 O2 97% PT WAS MONITORED WITH REPEAT VITALS FOR 15 MIN IN ADDITION TO REQUIRED OBSERVATION TIME. THE REPORTED FLOATERS STARTED TO RESOLVE, BUT PT CONTINUED TO FEEL SHE WAS HAVING A "MIGRAINE LIKE AURA". THE PARESTHESIAS RESOLVED. NO FURTHER ACUTE CHANGES OCCURRED AND PT FELT COMFORTABLE TO LEAVE OBSERVATION SITE. PT WAS ADVISED TO F/U WITH HER PCP.
Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Muscular weakness, Myalgia, Pain in extremity
Clinical narrative: Initial soreness in left arm deltoid muscle lasted about 2 days. Then a few days after that there was muscle weakness and soreness when I tried to use my left deltoid muscle. Pain and weakness has yet to go away and it?s been 2 months.
Age: 42.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Abdominal distension, Abdominal pain upper, Diarrhoea, Gastrointestinal disorder, Haematochezia
Clinical narrative: Sever GI issues. They have continued for 8 days now. I'm allergic to ALL seafood, and the symptoms I'm experiencing remind me of those: bloody sto, diarrhea, nausea, bloating, stomach cramping. The symptoms started about 30 minutes after the vaccine was administered. It took me this long to figure out it may have been the vaccine.   (The above is my main concern. I did also experience a stiff and painful arm which limited my range of motion, and fever.  But I expected those reactions. )
Age: 42.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Joint range of motion decreased, Musculoskeletal stiffness, Nausea, Pain in extremity, Pyrexia
Clinical narrative: Sever GI issues. They have continued for 8 days now. I'm allergic to ALL seafood, and the symptoms I'm experiencing remind me of those: bloody sto, diarrhea, nausea, bloating, stomach cramping. The symptoms started about 30 minutes after the vaccine was administered. It took me this long to figure out it may have been the vaccine.   (The above is my main concern. I did also experience a stiff and painful arm which limited my range of motion, and fever.  But I expected those reactions. )
Age: 42.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Abdominal distension, Abdominal pain upper, Diarrhoea, Haematochezia, Nausea
Clinical narrative: Sever GI issues. They have continued for 8 days now. I'm allergic to ALL seafood, and the symptoms I'm experiencing remind me of those: bloody sto, diarrhea, nausea, bloating, stomach cramping. The symptoms started about 30 minutes after the vaccine was administered. It took me this long to figure out it may have been the vaccine.   (The above is my main concern. I did also experience a stiff and painful arm which limited my range of motion, and fever.  But I expected those reactions. )
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiac monitoring, Chills, Computerised tomogram head, Dizziness, Fatigue
Clinical narrative: Initially there were severe flu like symptoms: chills, shaking, headache & body aches, fatigue starting apx 2 hours following. These continued until apx 24 hours later when additional mental fog set it, difficulty focusing attention, lethargy, trouble walking, dizziness then brief loss of consciousness occurred, extreme difficulty staying awake. I was taken to the emergency room where additional tests were done due to "stroke- like" symptoms.  Tests were okay with hospital staff reporting that likely/only known cause was the COVID  vaccine given the day before. Symptoms have gradually reduced but occasional mental fog, occasional dizzy spells & chronic fatigue persist.
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Feeling abnormal, Gait disturbance, Headache, Influenza like illness, Lethargy
Clinical narrative: Initially there were severe flu like symptoms: chills, shaking, headache & body aches, fatigue starting apx 2 hours following. These continued until apx 24 hours later when additional mental fog set it, difficulty focusing attention, lethargy, trouble walking, dizziness then brief loss of consciousness occurred, extreme difficulty staying awake. I was taken to the emergency room where additional tests were done due to "stroke- like" symptoms.  Tests were okay with hospital staff reporting that likely/only known cause was the COVID  vaccine given the day before. Symptoms have gradually reduced but occasional mental fog, occasional dizzy spells & chronic fatigue persist.
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Loss of consciousness, Pain, Somnolence, Tremor
Clinical narrative: Initially there were severe flu like symptoms: chills, shaking, headache & body aches, fatigue starting apx 2 hours following. These continued until apx 24 hours later when additional mental fog set it, difficulty focusing attention, lethargy, trouble walking, dizziness then brief loss of consciousness occurred, extreme difficulty staying awake. I was taken to the emergency room where additional tests were done due to "stroke- like" symptoms.  Tests were okay with hospital staff reporting that likely/only known cause was the COVID  vaccine given the day before. Symptoms have gradually reduced but occasional mental fog, occasional dizzy spells & chronic fatigue persist.
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal distension, Abdominal pain, Abdominal pain lower, Abdominal pain upper, Abdominal rebound tenderness
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal rigidity, Abdominal tenderness, Alanine aminotransferase normal, Albumin globulin ratio normal, Amylase normal
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Aortic arteriosclerosis, Arteriosclerosis coronary artery, Aspartate aminotransferase normal, Asthenia, Bacterial test
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Bilirubin urine, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin increased, Blood calcium normal
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Blood chloride decreased, Blood creatinine increased, Blood gases, Blood glucose increased, Blood lactic acid
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Blood lactic acid abnormal, Blood potassium normal, Blood sodium decreased, Blood urea increased, Blood urine absent
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Blood urine present, Carbon dioxide abnormal, Chest X-ray abnormal, Cholecystitis acute, Cholelithiasis
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen, Culture urine, Diarrhoea, Differential white blood cell count abnormal, Diverticulum intestinal
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Full blood count abnormal, Gastrointestinal sounds abnormal, Glomerular filtration rate decreased, Glucose urine absent
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Glucose urine present, Haematocrit increased, Haemoglobin increased, Hiatus hernia, Influenza A virus test negative
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital
Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Influenza virus test negative, Lipase normal, Lymphocyte count, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal
Clinical narrative: Office visit - NP Chief Complaint: seen today, 3/4/2021, complaining of or following up for Fever (started today), Nausea (has nausea today), Abdominal Pain (c\o upper and lower abd pain has been constant for the last 3 days started on monday), Diarrhea (states she had diarrhea all day yesterday but has had no bm today), and Fatigue (pt states she is feeling very week today) . HPI Patient comes in to the office complaining of severe abdominal pain.  States the pain started on Monday and was less severe, stating the pain has escalated to a 9/10 today and "unbearable."  Pt. States she had diarrhea for a 24 hour period yesterday, but denies any bowel movement today.  Patient also complains of severe fatigue and states nausea with emesis a "few times over the last 4 days."  Patient states that on Tuesday her pain became "a little better," but states since that time it has worsened and is severe at approximately 1230 this morning."  Patient states she did not go to the ER because she "knew she had an appointment today."   BP 134/84 Pulse 104 Temp 101.6 °F (38.7 °C) Resp 20 SpO2 94% Abdominal:     General: There is distension.     Palpations: Abdomen is rigid.     Tenderness: There is generalized abdominal tenderness. There is guarding and rebound.     Comments: Tinkling bowel sounds noted to RLQ and RUQ with hypoactive bowel sounds to LUQ and LLQ.  Abdomen is rigid and guarding and rebound pain are noted with examination.     triaged to Emergency room:  HPI  75 y.o. female who presents with complaints of right upper quadrant pain since Monday reports is moderate to severe sharp better right upper quadrant without radiation better with rest and worse with movement   FINAL IMPRESSION     ICD-10-CM ICD-9-CM 1. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction  K80.62 574.60 2. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC)  A41.9 038.9     995.91   Final Disposition Transfer to Another Facility current inpatient at Hospital