chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 87.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertensive urgency, Magnetic resonance imaging head abnormal, Mental status changes, Renal impairment, SARS-CoV-2 test positive
Clinical narrative: 88y.o. female presenting with altered mental status. Upon presentation she was found to be COVID-positive which was likely source of her altered mental status. MRI brain demonstrated remote left parietal infarct with possible small acute infarcts in left occipital lobe. This was likely secondary to longstanding hypertension. Additionally, was found to have hypertensive urgency. She does have element of CKD with acutely elevated creatinine. Creatinine resolved to previous level with IV fluids. In terms of her blood pressure, metoprolol and clonidine were increased. Once her renal function resolved to baseline, losartan was resumed. Blood pressure was still elevated, and calcium channel blocker was added. This achieved acceptable control of her blood pressure. Following this, she was stable for discharge home. Family is able to provide care for her. She was discharged home accordingly to follow-up expediently with her primary care physician. Patient's daughter had already been in discussion with primary care to set up follow-up appointment.
Age: 73.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Bronchoscopy, COVID-19, COVID-19 pneumonia, Candida test positive, Culture positive
Clinical narrative: 74 yo M PMH CKD 2/2 chronic glomerulonephritis s/p renal transplant in 2008, COVID-19 pneumonia 7/27, HTN, OSA, paroxysmal afib, possible COPD vs asthma and extensive occupational exposure in cement production plant who presented 8/21 as a transfer for evaluation of persistent fevers. Patient tested positive for COVID pneumonia on 7/27 and afterwards he had shingles on his left arm that was treated with acyclovir for 1 week. After treatment, his fever persisted along with diarrhea and loss of appetite with a 23 pound weight loss. He also has worsening acute on chronic dyspnea with mildly productive cough. Patient was taken for bronchoscopy with BAL and transferred to MICU 8/25 for postprocedure management s/p intubation for bronchoscopy. Treated empirically with Cefepime, doxy, azithromycin, Rocephin and IV steroids decadron 10mg BID for suspected persistent COVID-19 PNA. Respiratory culture +Klebsiella and rare Candida. He was extubated 8/27 to nasal cannula and tolerating well since that time.  Spoke with patient's wife re: home care services. States she is not sure they will be needing at this time. States they will be staying in nearby condo for a few days and then travel back home. Verbalizes unsure if they will go to outpatient therapy vs home care. States she will look into it once home.
Age: 73.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Decreased appetite, Diarrhoea, Dyspnoea, Endotracheal intubation, Herpes zoster
Clinical narrative: 74 yo M PMH CKD 2/2 chronic glomerulonephritis s/p renal transplant in 2008, COVID-19 pneumonia 7/27, HTN, OSA, paroxysmal afib, possible COPD vs asthma and extensive occupational exposure in cement production plant who presented 8/21 as a transfer for evaluation of persistent fevers. Patient tested positive for COVID pneumonia on 7/27 and afterwards he had shingles on his left arm that was treated with acyclovir for 1 week. After treatment, his fever persisted along with diarrhea and loss of appetite with a 23 pound weight loss. He also has worsening acute on chronic dyspnea with mildly productive cough. Patient was taken for bronchoscopy with BAL and transferred to MICU 8/25 for postprocedure management s/p intubation for bronchoscopy. Treated empirically with Cefepime, doxy, azithromycin, Rocephin and IV steroids decadron 10mg BID for suspected persistent COVID-19 PNA. Respiratory culture +Klebsiella and rare Candida. He was extubated 8/27 to nasal cannula and tolerating well since that time.  Spoke with patient's wife re: home care services. States she is not sure they will be needing at this time. States they will be staying in nearby condo for a few days and then travel back home. Verbalizes unsure if they will go to outpatient therapy vs home care. States she will look into it once home.
Age: 73.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Intensive care, Klebsiella test positive, Productive cough, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 74 yo M PMH CKD 2/2 chronic glomerulonephritis s/p renal transplant in 2008, COVID-19 pneumonia 7/27, HTN, OSA, paroxysmal afib, possible COPD vs asthma and extensive occupational exposure in cement production plant who presented 8/21 as a transfer for evaluation of persistent fevers. Patient tested positive for COVID pneumonia on 7/27 and afterwards he had shingles on his left arm that was treated with acyclovir for 1 week. After treatment, his fever persisted along with diarrhea and loss of appetite with a 23 pound weight loss. He also has worsening acute on chronic dyspnea with mildly productive cough. Patient was taken for bronchoscopy with BAL and transferred to MICU 8/25 for postprocedure management s/p intubation for bronchoscopy. Treated empirically with Cefepime, doxy, azithromycin, Rocephin and IV steroids decadron 10mg BID for suspected persistent COVID-19 PNA. Respiratory culture +Klebsiella and rare Candida. He was extubated 8/27 to nasal cannula and tolerating well since that time.  Spoke with patient's wife re: home care services. States she is not sure they will be needing at this time. States they will be staying in nearby condo for a few days and then travel back home. Verbalizes unsure if they will go to outpatient therapy vs home care. States she will look into it once home.
Age: 73.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Weight decreased
Clinical narrative: 74 yo M PMH CKD 2/2 chronic glomerulonephritis s/p renal transplant in 2008, COVID-19 pneumonia 7/27, HTN, OSA, paroxysmal afib, possible COPD vs asthma and extensive occupational exposure in cement production plant who presented 8/21 as a transfer for evaluation of persistent fevers. Patient tested positive for COVID pneumonia on 7/27 and afterwards he had shingles on his left arm that was treated with acyclovir for 1 week. After treatment, his fever persisted along with diarrhea and loss of appetite with a 23 pound weight loss. He also has worsening acute on chronic dyspnea with mildly productive cough. Patient was taken for bronchoscopy with BAL and transferred to MICU 8/25 for postprocedure management s/p intubation for bronchoscopy. Treated empirically with Cefepime, doxy, azithromycin, Rocephin and IV steroids decadron 10mg BID for suspected persistent COVID-19 PNA. Respiratory culture +Klebsiella and rare Candida. He was extubated 8/27 to nasal cannula and tolerating well since that time.  Spoke with patient's wife re: home care services. States she is not sure they will be needing at this time. States they will be staying in nearby condo for a few days and then travel back home. Verbalizes unsure if they will go to outpatient therapy vs home care. States she will look into it once home.
Age: 75.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Antiplatelet therapy, Blood glucose normal, COVID-19, Dizziness, Head injury
Clinical narrative: Patient is a 77 yo male with a pmhx of DM, CAD who presents after syncopal episode. Per EMS, patient woke up this morning and felt dizzy. Went to restroom and after using bathroom, syncopized and hit his head on the bathtub. States his wife said he was unconscious for about 30-40 seconds. Patient does take plavix daily for previous TIA. No other blood thinners. Patient's wife thought he might be hypoglycemic and gave his BG, when EMS checked was in the 70s and they had him eat a sandwich. Patient takes glimepiride daily, no insulin. Did test positive for covid on Saturday and started Paxlovid yesterday. No headache, nausea, vomiting, CP, SOB. Still feeling dizziness when moving his head. Pt requesting to leave, does not want to be admitted. Dr. aware. Pt is leaving AMA
Age: 75.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Loss of consciousness, SARS-CoV-2 test positive, Syncope
Clinical narrative: Patient is a 77 yo male with a pmhx of DM, CAD who presents after syncopal episode. Per EMS, patient woke up this morning and felt dizzy. Went to restroom and after using bathroom, syncopized and hit his head on the bathtub. States his wife said he was unconscious for about 30-40 seconds. Patient does take plavix daily for previous TIA. No other blood thinners. Patient's wife thought he might be hypoglycemic and gave his BG, when EMS checked was in the 70s and they had him eat a sandwich. Patient takes glimepiride daily, no insulin. Did test positive for covid on Saturday and started Paxlovid yesterday. No headache, nausea, vomiting, CP, SOB. Still feeling dizziness when moving his head. Pt requesting to leave, does not want to be admitted. Dr. aware. Pt is leaving AMA
Age: 78.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Ankle fracture, COVID-19, Cast application, Open reduction of fracture, SARS-CoV-2 test positive
Clinical narrative: Acute malleoli ankle fractures status post casting by orthopedic surgery.  Nonweightbearing with use of crutches.  PT/OT consulted.  Patient does not own a wheelchair.  Pain currently controlled.  Management per orthopedic surgery. -Surgical repair ORIF of right ankle on 8/24/22 - discussed with ortho resident. Follow up with orthopedic surgery outpatient. Patient is being discharged.
Age: 78.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Walking aid user, Weight bearing difficulty
Clinical narrative: Acute malleoli ankle fractures status post casting by orthopedic surgery.  Nonweightbearing with use of crutches.  PT/OT consulted.  Patient does not own a wheelchair.  Pain currently controlled.  Management per orthopedic surgery. -Surgical repair ORIF of right ankle on 8/24/22 - discussed with ortho resident. Follow up with orthopedic surgery outpatient. Patient is being discharged.
Age: 24.0
Sex: F
Vaccine: COVID19
Symptoms: Deafness, Tinnitus, Vertigo
Clinical narrative: Hearing loss, tinnitus and vertigo.
Age: 86.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Hypotension, SARS-CoV-2 test positive
Clinical narrative: 08/23/22 presents to EC ED for "low blood pressure". PMHx of "HTN, HLD, CKD Stage 3"
Age: 86.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: Anticoagulant therapy, Bladder catheterisation, Bladder mass, COVID-19, Hydronephrosis
Clinical narrative: 08/23/22 presents to EC ED for "low blood pressure". PMHx of "HTN, HLD, CKD Stage 3"
Age: 86.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: Mental status changes, SARS-CoV-2 test positive, Ureteral stent insertion
Clinical narrative: 08/23/22 presents to EC ED for "low blood pressure". PMHx of "HTN, HLD, CKD Stage 3"
Age: 86.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Chest pain, SARS-CoV-2 test positive
Clinical narrative: 08/23/22 presents to EC ED for "chest pain". PMHx of "CAD s/p stenting in 2021 and cardiomyopathy"
Age: 55.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Dyspnoea, SARS-CoV-2 test positive
Clinical narrative: 08/23/22 presents to ED for "shortness of breath". PMHx of "hypertension"
Age: 75.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Blood glucose decreased, COVID-19, Heart rate increased, SARS-CoV-2 test positive
Clinical narrative: 08/23/22 presents to EC ED for "rapid heart rate and low blood sugar". PMHx of "diabetes mellitus type 2, hypertension"
Age: 74.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Fall, SARS-CoV-2 test positive
Clinical narrative: 08/23/22 presents to ED for "fall". PMHx of "diabetes, hypertension"
Age: 90.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Abdominal pain, COVID-19, Chest pain, Dyspnoea, SARS-CoV-2 test positive
Clinical narrative: 08/23/22 presents to EC ED for "chest pain, abdominal pain, dyspnea". PMHx of "SVT, DVT on eliquis" "etastatic prostate cancer"
Age: 68.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Mania, SARS-CoV-2 test positive
Clinical narrative: 08/24/22 presents to ED for "manic behavior". PMHx of "depression and hypertension".
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive, Urinary tract stoma complication
Clinical narrative: 08/24/22 presents to ED for "Perc nephrostomy tube malfunction". PMHx of "CAD, hypothyroidism, diverticulosis, CKD stage IV, prostate cancer"
Age: 92.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Fall, SARS-CoV-2 test positive
Clinical narrative: 08/24/22 presents to EC ED for "Fall/COVID". PMHx of "HTN, breast Ca, diverticular bleed, dementia"
Age: 71.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Abdominal pain, COVID-19, Dyspnoea, SARS-CoV-2 test positive
Clinical narrative: 08/24/22 presents to EC ED for "abdominal pain, shortness of breath". PMHx of "MS, CVA, recent fall and left rib fracture"
Age: 75.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Heart rate increased, Imaging procedure abnormal
Clinical narrative: 08/24/22 presents to EC ED for "abnormal imaging and rapid heart rate". PMHx of "Ischemic stroke L parietal lobe with small superimposed hemorrhage 07/22, Afib, IDDM s/p RBKA and L toe amputation, HTN, HLD, PVD "
Age: 77.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Fall, Mental status changes, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 08/24/22 presents to EC ED for "altered mental status, fall, fever". PMHx of "HTN, HLD, AAA, and a pacemaker"
Age: 66.0
Sex: U
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Dyspnoea, SARS-CoV-2 test positive
Clinical narrative: 08/24/22 presents to ED for "SOB". PMHx of "breast cancer, COPD, asthma, bronchitis, hypertension, diabetes, OSA"
Age: 60.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood creatinine increased, COVID-19, SARS-CoV-2 test positive
Clinical narrative: 8/24/22 presents to EC ED for "elevated creatinine all". PMHx of "pancreatic adenocarcinoma with peritoneal carcinomatosis s/p loop colostomy, on chemotherapy, obstructive uropathy s/p bilateral ureteral stents, left PCN placement, CAD, emphysema, pulmonary nodule, hypertension, hyperlipidemia"
Age: 69.0
Sex: U
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Fatigue, Hypophagia, SARS-CoV-2 test positive
Clinical narrative: 08/24/22 presents to ED for "fatigue, not eating". PMHx of "anemia, Hep C, lymphoma, HTN"
Age: 48.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Migraine, SARS-CoV-2 test positive
Clinical narrative: 08/25/22 presents to EC ED for "migraine". PMHx of "colon cancer s/p resection".
Age: 75.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: 08/25/22 presents to ED for "COVID". PMHx of "dementia, aortic valve replacement on coumadin, spinal stenosis with recent rhizotomy"
Age: 90.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Muscular weakness, Pain in extremity, SARS-CoV-2 test positive
Clinical narrative: 08/25/22 presents to ED for "leg pain, extremity weakness". PMHx of "hypertension, HLD, arthritis, obesity, and right lower extremity DVT status post IVC filter".
Age: 16.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive, Vomiting
Clinical narrative: 08/25/22 presents to ED for "vomiting". PMHx of "COVID, ADHD, Panic attacks, and haluciniations"
Age: 53.0
Sex: F
Vaccine: COVID19
Symptoms: Nausea, Pyrexia, Urticaria, Vomiting
Clinical narrative: I experienced fever, nausea, throwing up and hives.
Age: 75.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Nephrostomy tube removal, SARS-CoV-2 test positive
Clinical narrative: 08/25/22 presents to ED for "Nephrostomy tube dislodged". PMHx of "L-sided perinephric abscess, CVA, HTN, hypothyroidism, overactive bladder, and HLD"
Age: 87.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Cough, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 08/25/22 presents to EC ED for "fever, cough". PMHx of "TAA, HTN, aortic valve replacement, depression, COPD, Alzheimer's"
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19-2
Symptoms: COVID-19, Respiratory failure, SARS-CoV-2 test positive, Syncope
Clinical narrative: 08/22/22 presents to EC ED for "syncope, respiratory failure". PMHx of "diagnosed with COvid about 1 week ago" "HLD, HTN, DM2"
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19-2
Symptoms: COVID-19, Catheterisation cardiac abnormal, Confusional state, Hypoxia, Lethargy
Clinical narrative: 08/22/22 presents to EC ED for "syncope, respiratory failure". PMHx of "diagnosed with COvid about 1 week ago" "HLD, HTN, DM2"
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19-2
Symptoms: Pulmonary embolism, SARS-CoV-2 test positive, Syncope, Thrombectomy
Clinical narrative: 08/22/22 presents to EC ED for "syncope, respiratory failure". PMHx of "diagnosed with COvid about 1 week ago" "HLD, HTN, DM2"
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19-2
Symptoms: COVID-19, Respiratory failure, SARS-CoV-2 test positive, Syncope
Clinical narrative: 62y.o. male who recently traveled and was diagnosed with COvid about 1 week ago, treated with zithromax/ amoxicillin then atovaquone and proguanil presents with acut syncope.  EMS found him quite hypoxic put on NRB and brought to ER where massive PE found. He was taken urgently to cath lab for thrombectomy- 5-6 thrombectomies were performed in both left and right sides.  After, Right heart pressures were much improved.  Oxygen has been weaned to room air. Evaluation on Day of Discharge: Feeling great, denies any dyspnea chest pain or bleeding, no overnight events. No lower extremity edema, lungs clear to auscultation, patient is eager to go home as soon as possible. is very lethargic and confused. Attempts to follow directions.
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19-2
Symptoms: COVID-19, Catheterisation cardiac abnormal, Confusional state, Hypoxia, Lethargy
Clinical narrative: 62y.o. male who recently traveled and was diagnosed with COvid about 1 week ago, treated with zithromax/ amoxicillin then atovaquone and proguanil presents with acut syncope.  EMS found him quite hypoxic put on NRB and brought to ER where massive PE found. He was taken urgently to cath lab for thrombectomy- 5-6 thrombectomies were performed in both left and right sides.  After, Right heart pressures were much improved.  Oxygen has been weaned to room air. Evaluation on Day of Discharge: Feeling great, denies any dyspnea chest pain or bleeding, no overnight events. No lower extremity edema, lungs clear to auscultation, patient is eager to go home as soon as possible. is very lethargic and confused. Attempts to follow directions.
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19-2
Symptoms: Pulmonary embolism, SARS-CoV-2 test positive, Syncope, Thrombectomy
Clinical narrative: 62y.o. male who recently traveled and was diagnosed with COvid about 1 week ago, treated with zithromax/ amoxicillin then atovaquone and proguanil presents with acut syncope.  EMS found him quite hypoxic put on NRB and brought to ER where massive PE found. He was taken urgently to cath lab for thrombectomy- 5-6 thrombectomies were performed in both left and right sides.  After, Right heart pressures were much improved.  Oxygen has been weaned to room air. Evaluation on Day of Discharge: Feeling great, denies any dyspnea chest pain or bleeding, no overnight events. No lower extremity edema, lungs clear to auscultation, patient is eager to go home as soon as possible. is very lethargic and confused. Attempts to follow directions.
Age: 42.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Chest discomfort, Palpitations, SARS-CoV-2 test positive
Clinical narrative: 08/25/22 presents to ED for "palpitations and chest pressue". PMHx of "WPW, HTN, anxiety, GERD"
Age: 80.0
Sex: U
Vaccine: COVID19, COVID19, COVID19
Symptoms: Asthenia, COVID-19, SARS-CoV-2 test positive
Clinical narrative: 08/26/22 presents to ED for "generalized weakness". PMHx of "CABG, DMII, CAD, HTN"
Age: 38.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Delivery, Maternal exposure before pregnancy, Pregnancy, SARS-CoV-2 test positive
Clinical narrative: 08/26/22 presents to EC ED for "SVD (spontaneous vaginal delivery)". PMHx of "fibromyalgia and fatigue"
Age: 60.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Fatigue, SARS-CoV-2 test positive
Clinical narrative: 08/26/22 presents to EC ED for "fatigue". PMHx of "HTN, protein malnutrition, infected pancreatic pseudocyst"
Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Cough, Hypoglycaemia, SARS-CoV-2 test positive
Clinical narrative: 08/26/2022 presented to ED for cough and hypoglycemia. PMHx of CAD, CKD and dementia.
Age: 81.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Fatigue, Laboratory test abnormal, SARS-CoV-2 test positive
Clinical narrative: 08/26/22 presents to ED for "Fatigue, abnormal labs". PMHx of " hypertension, hyperlipidemia, sick sinus syndrome status post pacemaker, bladder cancer and CKD 3"
Age: 94.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Hypoglycaemia, SARS-CoV-2 test positive
Clinical narrative: 08/26/22 presents to ED due to "hypoglycemia".  "no significant PMH"
Age: 21.0
Sex: U
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Labour induction, SARS-CoV-2 test positive
Clinical narrative: 08/26/22 presents to Triage for "planned induction of labor". PMHx of "anxiety disorder, depression"
Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Chest pain, Nausea, SARS-CoV-2 test positive, Vomiting
Clinical narrative: 08/26/22 presents to ED for "chest pain" "nausea and vomiting". PMHx of "GERD and HTN"
Age: 80.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Fall, SARS-CoV-2 test positive
Clinical narrative: 08/27/22 presents to ED for "fall". PMHx of "a-fib, DVT/PE on Eliquis, upper and lower spinal stenosis"
Age: 90.0
Sex: U
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Chest pain, SARS-CoV-2 test positive
Clinical narrative: 08/27/22 presents to EC ED for "chest pain". PMHx of "CAD, DM, lower extremity edema, and arthritis"
Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, COVID-19, SARS-CoV-2 test positive
Clinical narrative: 08/27/22 presents to  ED for "generalized weakness". PMHx of "Anemia, Dyslipidemia (high LDL; low HDL), CABG, Hyperlipidemia, Hypertension, Kidney disease, and Osteoporosis"
Age: 89.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Fall, SARS-CoV-2 test positive
Clinical narrative: 08/27/22 presents to EC ED for "fall". PMHx of "advanced chronic systolic congestive heart failure, dementia, chronic kidney disease (stage unknown ),  mechanical mitral valve, on anticoagulation with Coumadin"
Age: 56.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Dizziness, SARS-CoV-2 test positive, Wound infection
Clinical narrative: 08/27/22 presents to EC ED for "wound infection, dizziness". PMHx of "Bipolar disorder"
Age: 48.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Mental status changes, SARS-CoV-2 test positive
Clinical narrative: 08/27/22 presents to EC ED for "AMS". PMHx of "cirrhosis secondary to autoimmune hepatitis and chronic peritoneal effusion"
Age: 34.0
Sex: M
Vaccine: COVID19
Symptoms: Depression, Headache, Injection site reaction, Rash erythematous, Rash pruritic
Clinical narrative: Headaches for two weeks after injection; Tinnitus,  depression,  and red itchy rash near injection site.
Age: 34.0
Sex: M
Vaccine: COVID19
Symptoms: Tinnitus
Clinical narrative: Headaches for two weeks after injection; Tinnitus,  depression,  and red itchy rash near injection site.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Tested COVID + in preparation FOR D/C FROM HOSPITAL.
Age: 62.0
Sex: M
Vaccine: SMALLMNK
Symptoms: Incorrect dose administered, No adverse event, Product preparation issue
Clinical narrative: On August 22, 2022, in the afternoon (approximately 1:00 p.m.), a vial was opened from which a 0.1ml ID dose was obtained and from which, due to confusion and error, 3 doses were administered the following day. After this I realize that the vial exceeds the stipulated duration time (8 hours) and proceeds to discard it. This situation was discussed with personnel from the health department who told us that this incident report should be completed. Immediately afterwards and after talking with our Medical Director, Dr., we have decided to make an appointment with our patients for the administration of vaccines in order to complete the number of doses and avoid losses. In this email I include the information of the 3 vaccinated patients. Any doubt, question or recommendation, do not hesitate to communicate I remain on the lookout. Patient does not present adverse reaction to incident.
Age: 56.0
Sex: F
Vaccine: TDAP
Symptoms: Erythema, Induration, Pain, Skin warm, Swelling
Clinical narrative: warm, redness, swelling,  large induration area, pain 4/10
Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
Clinical narrative: Death on 08/29/2022
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Respiratory tract congestion
Clinical narrative: COUGH, CONGESTION
Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Biopsy bone marrow abnormal, Blood test abnormal, Chronic myeloid leukaemia, Platelet count increased, Postmenopausal haemorrhage
Clinical narrative: A few weeks after getting 3rd dose I got a random freak period. I was already in menopause which was also confirmed thru blood testing. I hadn't had a period in 14 months prior to vaccine shot. I was checked for other issues like cancer or abnormal pap smear but was cleared. I Never got another period after the only random one in November. Then in mid January of 2022 my primary doctor recommended a complete routine blood workup because it hadn't been done since May of 2020. I wasn't sick and had zero symptoms. My results from blood test in mid January of 2022 showed a  very high blood platelet count. I was sent to a blood specialist and thru more blood testing and a bone marrow biopsy  was diagnosed with Chronic Myelogenous Leukemia stage 1 on February 17 2022.
Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Smear cervix normal
Clinical narrative: A few weeks after getting 3rd dose I got a random freak period. I was already in menopause which was also confirmed thru blood testing. I hadn't had a period in 14 months prior to vaccine shot. I was checked for other issues like cancer or abnormal pap smear but was cleared. I Never got another period after the only random one in November. Then in mid January of 2022 my primary doctor recommended a complete routine blood workup because it hadn't been done since May of 2020. I wasn't sick and had zero symptoms. My results from blood test in mid January of 2022 showed a  very high blood platelet count. I was sent to a blood specialist and thru more blood testing and a bone marrow biopsy  was diagnosed with Chronic Myelogenous Leukemia stage 1 on February 17 2022.
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Was admitted to the hospital for another reason.  Tested COVID positive
Age: 52.0
Sex: F
Vaccine: COVID19
Symptoms: Pain, Vomiting
Clinical narrative: VOMITING, ACHES
Age: 70.0
Sex: F
Vaccine: COVID19-2
Symptoms: Back pain, Dysstasia, Gait disturbance, Injection site erythema, Injection site induration
Clinical narrative: I still have extreme pain in my lower back since 9/6/2022 after receiving the Moderna bivalent COVID-19 vaccine on 9/4/2022.  I have difficulty walking standing up straight, and I could not bend at all for 2 days. I am still slowly recovering. In the past, I had 3 Pfizer vaccine shots and 1 Moderna booster shot administered. I never had problems with shots previously.  I also have a severe reaction around the injection site that measures about 5 inches and is red, swollen, hot to the touch, and hardened. I am taking the maximum dose of ibuprofen everyday in order to recover.
Age: 70.0
Sex: F
Vaccine: COVID19-2
Symptoms: Injection site swelling, Injection site warmth, Interchange of vaccine products, Mobility decreased
Clinical narrative: I still have extreme pain in my lower back since 9/6/2022 after receiving the Moderna bivalent COVID-19 vaccine on 9/4/2022.  I have difficulty walking standing up straight, and I could not bend at all for 2 days. I am still slowly recovering. In the past, I had 3 Pfizer vaccine shots and 1 Moderna booster shot administered. I never had problems with shots previously.  I also have a severe reaction around the injection site that measures about 5 inches and is red, swollen, hot to the touch, and hardened. I am taking the maximum dose of ibuprofen everyday in order to recover.
Age: 80.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: Pfizer 11/3/21, 11/24/21. Positive on 9/7/22
Age: 45.0
Sex: M
Vaccine: VARCEL
Symptoms: No adverse event, Wrong product administered
Clinical narrative: Pt reported to Immunizations Clinic to receive one vaccine, meningococcal, but received varicella. A system indicated that pt required varicella. Titers were not drawn to confirm necessity,  Pt has had no adverse physical effects. Discrepancy was discovered on 8 Sep22 when pt inquired about meningococcal date.
Age: 53.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: 9/7/2022 Moderna Monovalent was given not Bivalent. We advised patient in 2 months they can return for a Bivalent shot. Patient tolerated well. No Adverse reactions
Age: 37.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to Birth Center Triage for "ctx".  PMHx of "Crohn's disease Bowel resection 2015"
Age: 24.0
Sex: F
Vaccine: COVID19, VARCEL
Symptoms: Generalised tonic-clonic seizure, Interchange of vaccine products, Sleep disorder
Clinical narrative: My first vaccine dose was Moderna and two weeks later I had a localized rash and giant lump on my arm. For my second dose I did Pfizer and had a grand mal seizure in my sleep at 4 am 6 months later.
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, COVID-19, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to ED for "left elbow pain". PMHx of "bilateral lower extremity amputation, left olecranon bursitis status post incision and drainage on 8/24 for possible septic bursitis"
Age: 20.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: 9/7/2022 Moderna monovalent given not bivalent. We advised patient in 2 months they can return for a bivalent shot. Patient tolerated well. No adverse reaction.
Age: 92.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Fall, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to ED for "fall". PMHx of "CKD, dementia, HTN, HLD"
Age: 68.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Coronary artery bypass, Dyspnoea, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to EC ED for "shortness of breath". PMHx of "CABG x3 8/13/2022, HTN, Hep C, HPL, Hepatocellular carcinoma s/p Liver transplant (2015), Chronic back pain"
Age: 78.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Abdominal pain, COVID-19, Nausea, SARS-CoV-2 test positive, Vomiting
Clinical narrative: 08/29/22 presents to ED for "nausea and vomiting as well as abdominal pain". PMHx of "Crohn's disease, CKD stage III, aortic sclerosis, mitral valve regurgitation, and diastolic dysfunction"
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Mental status changes, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to EC ED for "altered mental status". PMHx of "type 2 diabetes, coronary artery disease, stage II as of CKD"
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Fatigue, Laboratory test abnormal, SARS-CoV-2 test positive
Clinical narrative: 08/29/2022 presented to ED for abnormal lab values and fatigue. PMHx of breast cancer and multiple myeloma.
Age: 80.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Dyspnoea, Oedema peripheral, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to ED for "shortness of breath and bilateral lower extremity edema". PMHx of "atrial fibrillation, hypertension, congestive heart failure"
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Abdominal pain, COVID-19, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to ED for "abdominal pain". PMHx of "GERD, gastric ulcers, HTN, and HLD"
Age: 46.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: 9/7/2022 Moderna monovalent given not bivalent. We advised patient in 2 months they can return for a bivalent shot. Patient tolerated well. No adverse reaction.
Age: 73.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Device occlusion, Gastrostomy
Clinical narrative: 08/29/22 presents to EC ED for "Blocked J tube". PMHx of "esophageal cancer s/p chemotherapy and G-tube placement on 8/17" "HTN, recent COVID infection 8/21/2022"
Age: 71.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Cough, Pain, SARS-CoV-2 test positive
Clinical narrative: 08/29/22 presents to EC ED for "cough/aches". PMHx of "HTN and GERD" "urgent care on 8/27 where she tested positive for COVID"
Age: 83.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive, Syncope
Clinical narrative: 08/28/22 presents to EC ED for "Synocope". PMHx of "falls with intracranial hemorrhage, CVA, CAD, and orthostatic hypotension"
Age: 38.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive, Uterine contractions during pregnancy
Clinical narrative: 08/28/22 presents to Birth Center Triage for "contractions". PMHx of "no past medical history on file"
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Fatigue, SARS-CoV-2 test positive
Clinical narrative: 08/28/22 presents to ED for "fatigue". PMHx of "CAD s/p remote stenting, HTN, HLD, BPH, right inguinal hernia s/p repair 8/15"
Age: 28.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: 9/7/2022 Moderna monovalent given not bivalent. We advised patient in 2 months they can return for a bivalent shot. Patient tolerated well. No adverse reaction.
Age: 37.0
Sex: F
Vaccine: UNK
Symptoms: Vaccination error
Clinical narrative: JYNNEOS EUA Received a patient complaint that the Jynneos vaccine was supposed to be administered intradermally but was administered subcutaneously because there was no visible "wheal" and concerned she would not receive the full protection since the dose administered was 0.1mL. Per provider the vaccine is recommended to be repeated via intradermal route immediately.
Age: 77.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Chest pain, SARS-CoV-2 test positive
Clinical narrative: 08/28/22 presents to EC ED for "right chest pain". PMHx of "right lung transplant on chronic immunosuppression, GERD, hypothyroidism, prior bladder cancer, osteoporosis, CKD, MDD/GAD"
Age: 67.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19-2
Symptoms: COVID-19 pneumonia, Chest tube insertion, Death, Dyspnoea, Endotracheal intubation
Clinical narrative: 68y.o. female with PMH pertinent for seronegative RA on chronic prednisone recent COVID PNA presented for worsening SOB. In the ER, patient was hypoxic requiring HFNC 100% FiO2/50 L and a nonrebreather maintaining SPO2 in the early 90s.  Significant increase in work of breathing.  Patient was intubated. On 8/28, the patient developed resp distress. Patient had a needle decompression and then chest tube placement for right sided tension pneumothorax. Patient was unable to be weaned off ventilator and on 9/5 had a drop in SpO2 with increased WOB. Patient required multiple pressors for hemodynamic instability. Patient transitioned to comfort care, and passed peacefully that evening.
Age: 67.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19-2
Symptoms: Haemodynamic instability, Hypoxia, Mechanical ventilation, Oxygen saturation decreased, Pneumothorax
Clinical narrative: 68y.o. female with PMH pertinent for seronegative RA on chronic prednisone recent COVID PNA presented for worsening SOB. In the ER, patient was hypoxic requiring HFNC 100% FiO2/50 L and a nonrebreather maintaining SPO2 in the early 90s.  Significant increase in work of breathing.  Patient was intubated. On 8/28, the patient developed resp distress. Patient had a needle decompression and then chest tube placement for right sided tension pneumothorax. Patient was unable to be weaned off ventilator and on 9/5 had a drop in SpO2 with increased WOB. Patient required multiple pressors for hemodynamic instability. Patient transitioned to comfort care, and passed peacefully that evening.
Age: 67.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19-2
Symptoms: Respiratory distress, SARS-CoV-2 antibody test, SARS-CoV-2 antibody test positive
Clinical narrative: 68y.o. female with PMH pertinent for seronegative RA on chronic prednisone recent COVID PNA presented for worsening SOB. In the ER, patient was hypoxic requiring HFNC 100% FiO2/50 L and a nonrebreather maintaining SPO2 in the early 90s.  Significant increase in work of breathing.  Patient was intubated. On 8/28, the patient developed resp distress. Patient had a needle decompression and then chest tube placement for right sided tension pneumothorax. Patient was unable to be weaned off ventilator and on 9/5 had a drop in SpO2 with increased WOB. Patient required multiple pressors for hemodynamic instability. Patient transitioned to comfort care, and passed peacefully that evening.
Age: 59.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19-2
Symptoms: Acute kidney injury, Alcohol use, COVID-19, Central venous catheterisation, Chest pain
Clinical narrative: 61y.o. male who presents  on 8/22 with history of CABG, Hypertension, SBP, significant for alcoholic cirrhosis complicated by ascites and hydrothorax, and end-stage renal disease requiring dialysis M W F, presented to the ER from dialysis due to chest pain right-sided associated with dizziness.  Found to be COVID positive, no indication for Remdesivir. Remained in isolation for 10 days, isolation precautions are removed.  He reports that he began consuming alcohol in his 20s until April 9, 2022, when he stopped consumption due to symptoms. HRS with progressive AKI- initiated on hemodialysis July 8, 2022 -undergoing Intermittent HD 3 x week MWF via RIJ permacath- under care of Dr  Upon exam, pt
Age: 59.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19-2
Symptoms: Confusional state, Dizziness, Ex-alcohol user, Haemodialysis, Hepatorenal syndrome
Clinical narrative: 61y.o. male who presents  on 8/22 with history of CABG, Hypertension, SBP, significant for alcoholic cirrhosis complicated by ascites and hydrothorax, and end-stage renal disease requiring dialysis M W F, presented to the ER from dialysis due to chest pain right-sided associated with dizziness.  Found to be COVID positive, no indication for Remdesivir. Remained in isolation for 10 days, isolation precautions are removed.  He reports that he began consuming alcohol in his 20s until April 9, 2022, when he stopped consumption due to symptoms. HRS with progressive AKI- initiated on hemodialysis July 8, 2022 -undergoing Intermittent HD 3 x week MWF via RIJ permacath- under care of Dr  Upon exam, pt
Age: 59.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19-2
Symptoms: Lethargy, SARS-CoV-2 test positive
Clinical narrative: 61y.o. male who presents  on 8/22 with history of CABG, Hypertension, SBP, significant for alcoholic cirrhosis complicated by ascites and hydrothorax, and end-stage renal disease requiring dialysis M W F, presented to the ER from dialysis due to chest pain right-sided associated with dizziness.  Found to be COVID positive, no indication for Remdesivir. Remained in isolation for 10 days, isolation precautions are removed.  He reports that he began consuming alcohol in his 20s until April 9, 2022, when he stopped consumption due to symptoms. HRS with progressive AKI- initiated on hemodialysis July 8, 2022 -undergoing Intermittent HD 3 x week MWF via RIJ permacath- under care of Dr  Upon exam, pt
Age: 14.0
Sex: M
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: HOSPITALIZATION
Age: 77.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute kidney injury, COVID-19, Decreased appetite, Haemoglobin decreased, Mental status changes
Clinical narrative: 78-year-old man with past medical history of hypothyroidism, dementia, and mood disorder who came to the emergency department with altered mental status, decreased appetite, and acute kidney injury.  Given fluid hydration, procalcitonin was positive, renal function improved with IV fluids, started on ceftriaxone and azithromycin for diagnosis of community-acquired pneumonia, remains on room air.  He was COVID-positive but he did not have COVID-19 pneumonia, therefore after discussion with ID he did not require remdesivir or Paxlovid.  Hemoglobin baseline is probably between 1011.  It was 12.2 upon admission but probably hemoconcentrated.  No signs of gastroenterologic bleeding.  Discharged home with daughter in stable condition.  Discharged with Augmentin to complete total of 5 days for CAP
Age: 77.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Pneumonia, Procalcitonin abnormal, SARS-CoV-2 test positive
Clinical narrative: 78-year-old man with past medical history of hypothyroidism, dementia, and mood disorder who came to the emergency department with altered mental status, decreased appetite, and acute kidney injury.  Given fluid hydration, procalcitonin was positive, renal function improved with IV fluids, started on ceftriaxone and azithromycin for diagnosis of community-acquired pneumonia, remains on room air.  He was COVID-positive but he did not have COVID-19 pneumonia, therefore after discussion with ID he did not require remdesivir or Paxlovid.  Hemoglobin baseline is probably between 1011.  It was 12.2 upon admission but probably hemoconcentrated.  No signs of gastroenterologic bleeding.  Discharged home with daughter in stable condition.  Discharged with Augmentin to complete total of 5 days for CAP
Age: 67.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Anaemia, COVID-19, Chest X-ray abnormal, Chest discomfort, Chills
Clinical narrative: 69y.o. female who presents for dyspnea. She has known history of gallbladder cancer and prior cholecystectomy, COPD on chronic home oxygen at 2-3L, and recent admission for right intertrochanteric femur fracture status post intramedullary nail placement. She started feeling short of breathing about 3 days prior to arrival. Denies any sick contacts. Has been vaccinated for covid-19. She was having productive cough. She was having chest discomfort with coughing. No fevers noted. She had chills. Denies nausea or vomiting. She presented to the ER for further evaluation. Covid testing returned positive. Chest x-ray showed infiltrates. Mild troponin elevation noted. Mild anemia and leukopenia noted. DC today to home. stable condition.  Discharged with Augmentin to complete total of 5 days for CAP
Age: 67.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Dyspnoea, Femur fracture, Leukopenia, Lung infiltration, Pneumonia
Clinical narrative: 69y.o. female who presents for dyspnea. She has known history of gallbladder cancer and prior cholecystectomy, COPD on chronic home oxygen at 2-3L, and recent admission for right intertrochanteric femur fracture status post intramedullary nail placement. She started feeling short of breathing about 3 days prior to arrival. Denies any sick contacts. Has been vaccinated for covid-19. She was having productive cough. She was having chest discomfort with coughing. No fevers noted. She had chills. Denies nausea or vomiting. She presented to the ER for further evaluation. Covid testing returned positive. Chest x-ray showed infiltrates. Mild troponin elevation noted. Mild anemia and leukopenia noted. DC today to home. stable condition.  Discharged with Augmentin to complete total of 5 days for CAP
Age: 67.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Productive cough, SARS-CoV-2 test positive, Troponin increased
Clinical narrative: 69y.o. female who presents for dyspnea. She has known history of gallbladder cancer and prior cholecystectomy, COPD on chronic home oxygen at 2-3L, and recent admission for right intertrochanteric femur fracture status post intramedullary nail placement. She started feeling short of breathing about 3 days prior to arrival. Denies any sick contacts. Has been vaccinated for covid-19. She was having productive cough. She was having chest discomfort with coughing. No fevers noted. She had chills. Denies nausea or vomiting. She presented to the ER for further evaluation. Covid testing returned positive. Chest x-ray showed infiltrates. Mild troponin elevation noted. Mild anemia and leukopenia noted. DC today to home. stable condition.  Discharged with Augmentin to complete total of 5 days for CAP
Age: 84.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Bladder catheterisation, COVID-19, Cerebral mass effect, Computerised tomogram head abnormal, Constipation
Clinical narrative: 85y.o. male who per ER with significant past medical history of CAD, CVA, dementia, HLD, HTN and MI  who presents to Hospital on 0823 with a chief complaint of fall.  History was collected from patient and EMS. Reports that he was taking his morning walk, when he passed out and woke up in a pool of blood. Pt does not remember events of incident, and notes that he is not taking any thinners except for baby aspirin. Patient denies any fevers, chills, cough, nausea, vomiting, abdominal pain, dysuria, increased urinary frequency, melena, hematochezia, chest pain, or shortness of breath. The patient has deterioration of neurological status and evidence of an enlarging acute subdural hematoma with worsening midline shift on CT scan of the head. Pt has remained with elevated WBC count and fever started 0902 with Tmax 100.4F. He denies any changes. Feels constipated past several days and foley remains indwelling.
Age: 84.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Fall, Haemorrhage, Loss of consciousness, Memory impairment, Neurological decompensation
Clinical narrative: 85y.o. male who per ER with significant past medical history of CAD, CVA, dementia, HLD, HTN and MI  who presents to Hospital on 0823 with a chief complaint of fall.  History was collected from patient and EMS. Reports that he was taking his morning walk, when he passed out and woke up in a pool of blood. Pt does not remember events of incident, and notes that he is not taking any thinners except for baby aspirin. Patient denies any fevers, chills, cough, nausea, vomiting, abdominal pain, dysuria, increased urinary frequency, melena, hematochezia, chest pain, or shortness of breath. The patient has deterioration of neurological status and evidence of an enlarging acute subdural hematoma with worsening midline shift on CT scan of the head. Pt has remained with elevated WBC count and fever started 0902 with Tmax 100.4F. He denies any changes. Feels constipated past several days and foley remains indwelling.