chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Blood sodium increased, COVID-19, Hyponatraemia, Laboratory test abnormal, Malaise
Clinical narrative: Admit Date: 2/27/2023 11:18 AM Discharge Date: 3/1/2023  3:44 PM    Admitting Physician: MD Attending Physician: MD Discharge Clinician: MD Primary Care Provider at Discharge: MD   Hospital Course:  Patient is a 62 y.o. female with past medical history significant for seizures on Tegretol, Depression/Anxiety on Zoloft, hypertension presented with abnormal lab results.  Patient reported recent diagnosis with COVID (symptoms since 2/24/23) and was supposed to receive her 1st dose of remdesivir outpatient. Pre infusion labs were abnormal and patient was advised to go to the ER for further evaluation.    Patient reported taking Tegretol and Zoloft for many years and denied any recent changes to her medications.      Workup in the emergency department significant for sodium 150. She was given 500mL of IVF in the ED. Urine and serum osmolality and urine sodium were ordered. ED provider discussed case with Neurology on-call and they felt that Tegretol alone would not cause this significant hyponatremia. Patient was offered Keppra in the short term as an alternative but she refused switching to Keppra.  So patient was continued on Tegretol and Zoloft.  Serial BMPs per monitored.  As patient's sodium level was correcting too fast patient was started on a D5 water to slow down the correction of sodium levels.  As sodium levels continue to improve off IV fluids patient was felt comfortable with plans for discharge.  Patient also received 3 doses of IV remdesivir.  Patient oxygen saturations remained stable on room air.   Patient was discharged to Home without services in stable condition.
Age: 1.0
Sex: F
Vaccine: MMRV
Symptoms: Immunisation reaction, Rash erythematous, Rash macular
Clinical narrative: Five days post vaccination the child broke out in an erythematous, macular rash.  The Doctor does believe the rash was a reaction to the ProQuad.
Age: 14.0
Sex: F
Vaccine: COVID19-2
Symptoms: Extra dose administered
Clinical narrative: Staff followed correct policy & workflow for reconciling vaccines & manually checking Data for any recent bivalent covid booster. Mom provided a picture of the patients current covid vaccine card. Both workflows provided proof that patients last covid vaccine was 3/2022 therefore staff administered a bivalent booster 3/2/2023. When parent got home, her husband reminded her that patient had already received a bivalent booster 11/2022. This reminded mom that she had 2 pictures of the patients covid vaccine card in her phone, an old covid vaccine card & a more recent one that listed the 11/2022 vaccine. Staff failed to enter 11/2022 covid vaccine manually into Data. Patient, parent & PCP are aware of the this.
Age: 89.0
Sex: F
Vaccine: VARZOS
Symptoms: Erythema, Pain, Skin warm
Clinical narrative: She had a lot of pain that started the night of the dose, which is now gone. However, now she has redness which is hot to the touch and extends from point of vaccine down to the elbow.
Age: 5.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: got regular Covid vaccine rather than bivalent
Age: 72.0
Sex: F
Vaccine: COVID19-2
Symptoms: Extra dose administered
Clinical narrative: Patient was mistakenly administered with Pfizer Bivalent Vaccine on day of this report. Patient had previously received Pfizer Bivalent Vaccine on 10/24/2022. Patient showed no signs or symptoms at time of administration.
Age: 59.0
Sex: F
Vaccine: VARZOS
Symptoms: Abdominal pain, Diarrhoea, Dizziness, Headache, Nausea
Clinical narrative: Systemic: Abdominal Pain-Mild, Systemic: Diarrhea-Medium, Systemic: Dizziness / Lightheadness-Medium, Systemic: Fever-Mild, Systemic: Headache-Medium, Systemic: Nausea-Medium, Systemic: Vomiting-Medium
Age: 59.0
Sex: F
Vaccine: VARZOS
Symptoms: Pyrexia, Vomiting
Clinical narrative: Systemic: Abdominal Pain-Mild, Systemic: Diarrhea-Medium, Systemic: Dizziness / Lightheadness-Medium, Systemic: Fever-Mild, Systemic: Headache-Medium, Systemic: Nausea-Medium, Systemic: Vomiting-Medium
Age: 52.0
Sex: F
Vaccine: COVID19-2
Symptoms: Syringe issue
Clinical narrative: Error: Leaking from Syringe-
Age: 75.0
Sex: F
Vaccine: COVID19-2
Symptoms: Expired product administered
Clinical narrative: Error: Expired Product Administered-
Age: 78.0
Sex: M
Vaccine: PNC20
Symptoms: Injection site erythema, Injection site swelling
Clinical narrative: Site: Redness at Injection Site-Severe, Site: Swelling at Injection Site-Medium, Additional Details: redness large from injection area spreading to insid of arm down to elbow. pt advised over the phone to seek medical care to determine if cellulitis or just a localized reaction
Age: 52.0
Sex: F
Vaccine: COVID19
Symptoms: Aneurysm, Cardiac disorder, Cerebrovascular accident
Clinical narrative: Systemic: Cardiac Disorder (diagnosed by MD)-Medium, Systemic: Stroke-Medium, Additional Details: Suffered from stroke and aneurysm on May 13, 2022. Unsure of severity.
Age: 67.0
Sex: F
Vaccine: PPV
Symptoms: Expired product administered
Clinical narrative: I GAVE AN EXPIRED DOSE
Age: 80.0
Sex: F
Vaccine: VARZOS
Symptoms: Injection site erythema, Injection site pruritus
Clinical narrative: Site: Itching at Injection Site-Medium, Site: Redness at Injection Site-Medium
Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Mechanical urticaria, Pruritus, Scratch, Skin swelling
Clinical narrative: I experienced a severe form of itchiness all over my body with no rash. I would get raises from the scratching. I'd take Zyrtec and it would last forty-eight hours and then I'd experience itchiness on the forty-nineth hour.
Age: 1.75
Sex: M
Vaccine: COVID19-2
Symptoms: Wrong product administered
Clinical narrative: Error: Wrong Vaccine/Product Administered-
Age: 50.0
Sex: M
Vaccine: VARZOS
Symptoms: Chills, Fatigue, Feeling abnormal, Injection site pain, Myalgia
Clinical narrative: Sore injection site Tiredness, muscle aches and pain, chills, mental fogginess
Age: 50.0
Sex: M
Vaccine: VARZOS
Symptoms: Pain
Clinical narrative: Sore injection site Tiredness, muscle aches and pain, chills, mental fogginess
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Basal ganglia infarction, Basophil count decreased
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Basophil percentage, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium normal
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Blood chloride normal, Blood creatinine, Blood creatinine increased, Blood glucose normal, Blood potassium normal
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Blood sodium normal, Blood urea nitrogen/creatinine ratio, Blood urea normal, Carbon dioxide normal, Cerebral atrophy
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Chest X-ray normal, Chest pain, Chronic kidney disease, Computerised tomogram head abnormal, Differential white blood cell count
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Electrocardiogram, Eosinophil count normal, Eosinophil percentage, Full blood count, Glomerular filtration rate decreased
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Granulocyte percentage, Grip strength decreased, Haematocrit decreased, Haemoglobin, Haemoglobin decreased
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Hemiparesis, Hypoaesthesia, Immature granulocyte count, International normalised ratio normal, Lacunar infarction
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Lymphocyte count normal, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Mean platelet volume normal, Metabolic function test, Monocyte count increased, Monocyte percentage increased, Muscular weakness
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Neutrophil count normal, Neutrophil percentage increased, Normocytic anaemia, Paraesthesia, Platelet count normal
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Protein total normal, Prothrombin time normal, Red blood cell count decreased, Red cell distribution width normal, SARS-CoV-2 test negative
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 82.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Subdural haematoma, Troponin I increased, White blood cell count normal, White matter lesion
Clinical narrative: ED note by Dr. 10/16/22: "Chief Complaint Patient presents with ? Numbness     HISTORY OF PRESENT ILLNESS   Patient, is a 82 y.o.male who presents to the Emergency Department with numbness tingling his left arm hand.  He also has weakness in his left grip.  He states this started occurring around 6:00 p.m. yesterday.  He says he was watching football on could hold onto the remote causing him to have concern why he may be weak.  He had no difficulty with speech trouble walking.  He had no trauma associated with this change in sensation and grip strength.  He says entire left arm feels weak as well as somewhat on his left leg but is able to ambulate without difficulty.  Does not take any blood thinners, had a history of stroke, have any chest pain or shortness of breath.     REVIEW OF SYSTEMS   The pertinent positive and negative symptoms are as per HPI. All other systems reviewed and are negative." "CLINICAL IMPRESSION   1. Atraumatic subdural hematoma  2. Left arm weakness   DISPOSITION/PLAN   Admitted"  H&P by Dr. on 10/16/22: "PCP: MD Chief Complaint:  Left hand weakness and numbness   HPI: Patient is a 82 y.o., male with a history of essential hypertension, CKD who presents with left hand weakness and numbness that began yesterday around 6:00 p.m.; this morning when he woke up his symptoms continued.  He denies hitting his head or falling down, denies any difficulty with walking, talking.  No headaches, blurry vision, nausea/vomiting, chest pain, shortness of breath, diarrhea, dysuria.     In the ED, CT brain suggestive of mixed density subdural hematoma over right frontal and parietal convexity without midline shift.  ED physician discussed these findings with Neurosurgery, who recommended admission for observation and repeat imaging in the morning.   COVID-19 vaccination status:  Received vaccine x2 and booster x2. COVID-19 test:  Negative today." "Assessment/Plan:  Patient is a 82 y.o., male who presents with the following:   1. Subdural hematoma, nontraumatic -CT findings as above; neurosurgery consulted by ED, recommend MRI tomorrow to rule out underlying CVA as well. -hold off aspirin, neuro checks q.4 hours. -fall precautions.   2. Essential hypertension  -resume lisinopril, metoprolol with holding parameters.   3. Hyperlipidemia  -resume statin.   4. COPD without exacerbation  -resume home inhaler regimen.   5. Chronic GERD  -resume PPI.   6. CKD stage IIIA -serum creatinine currently around baseline, will continue to monitor and avoid nephrotoxic agents.     7. Normocytic anemia  -hemoglobin currently stable, will order iron panel, vitamin B12 and folate levels. "
Age: 18.0
Sex: M
Vaccine: MENB
Symptoms: Fall, Syncope, Unresponsive to stimuli
Clinical narrative: Systemic: Fainting / Unresponsive-Medium, Additional Details: about 5 minutes after vaccine, patient was waiting in the waiting room, fell to the floor, and seized up for about 5 seconds before coming to. Patient alert and stable. EMS not activated. Patient accompanied home by family member
Age: 79.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Amnesia, Angiogram normal, Asthenia, COVID-19, Computerised tomogram head normal
Clinical narrative: Discharge Provider: MD Primary Care Provider: MD Admission Date: 2/18/2023 Discharge Date: 3/1/2023  PRESENTING PROBLEM: Weakness [R53.1] Generalized weakness [R53.1] COVID [U07.1]   HOSPITAL COURSE: Patient is an 80 year old female with hx of dementia, CVA w residual R sided weakness who presented with dizziness and intermittent confusion/memory loss. She was brought to the ER due to concern for acute CVA. Workup including CTH, CTP, CTA HN, and MRI negative. Given the memory loss, underwent EEG which showed nonspecific encephalopathy. Neurology was consulted. Patient was found to be positive for COVID and if was felt to be the reason for patient's confusion. PT/OT saw patient during her hospital stay. PMR consulted and recommended SAR. Patient stayed in the hospital until out of COVID precautions. She received supportive care for COVID 19. She was started on ASA 81mg daily. She was discharged in stable condition on 3/1/2023.
Age: 79.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Confusional state, Dizziness, Electroencephalogram abnormal, Encephalopathy, Magnetic resonance imaging head normal
Clinical narrative: Discharge Provider: MD Primary Care Provider: MD Admission Date: 2/18/2023 Discharge Date: 3/1/2023  PRESENTING PROBLEM: Weakness [R53.1] Generalized weakness [R53.1] COVID [U07.1]   HOSPITAL COURSE: Patient is an 80 year old female with hx of dementia, CVA w residual R sided weakness who presented with dizziness and intermittent confusion/memory loss. She was brought to the ER due to concern for acute CVA. Workup including CTH, CTP, CTA HN, and MRI negative. Given the memory loss, underwent EEG which showed nonspecific encephalopathy. Neurology was consulted. Patient was found to be positive for COVID and if was felt to be the reason for patient's confusion. PT/OT saw patient during her hospital stay. PMR consulted and recommended SAR. Patient stayed in the hospital until out of COVID precautions. She received supportive care for COVID 19. She was started on ASA 81mg daily. She was discharged in stable condition on 3/1/2023.
Age: 79.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Perfusion brain scan normal, SARS-CoV-2 test positive
Clinical narrative: Discharge Provider: MD Primary Care Provider: MD Admission Date: 2/18/2023 Discharge Date: 3/1/2023  PRESENTING PROBLEM: Weakness [R53.1] Generalized weakness [R53.1] COVID [U07.1]   HOSPITAL COURSE: Patient is an 80 year old female with hx of dementia, CVA w residual R sided weakness who presented with dizziness and intermittent confusion/memory loss. She was brought to the ER due to concern for acute CVA. Workup including CTH, CTP, CTA HN, and MRI negative. Given the memory loss, underwent EEG which showed nonspecific encephalopathy. Neurology was consulted. Patient was found to be positive for COVID and if was felt to be the reason for patient's confusion. PT/OT saw patient during her hospital stay. PMR consulted and recommended SAR. Patient stayed in the hospital until out of COVID precautions. She received supportive care for COVID 19. She was started on ASA 81mg daily. She was discharged in stable condition on 3/1/2023.
Age: 57.0
Sex: M
Vaccine: COVID19-2, COVID19-2, COVID19
Symptoms: Alopecia
Clinical narrative: alopecia involving the scalp, beard, eyebrows, eyelashes & body hair
Age: 57.0
Sex: M
Vaccine: COVID19-2, COVID19-2, COVID19
Symptoms: Alopecia, Hypotrichosis, Madarosis
Clinical narrative: alopecia involving the scalp, beard, eyebrows, eyelashes & body hair
Age: 57.0
Sex: M
Vaccine: COVID19-2, COVID19-2, COVID19
Symptoms: Alopecia, Dizziness, Hypotrichosis, Inappropriate schedule of product administration, Injection site pain
Clinical narrative: alopecia involving the scalp, beard, eyebrows, eyelashes & body hair
Age: 57.0
Sex: M
Vaccine: COVID19-2, COVID19-2, COVID19
Symptoms: Loss of consciousness, Nasopharyngitis, SARS-CoV-2 test negative, Suspected COVID-19
Clinical narrative: alopecia involving the scalp, beard, eyebrows, eyelashes & body hair