chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, Dysstasia, Electrocardiogram abnormal, Gastrooesophageal reflux disease, Hyperlipidaemia
Clinical narrative: Patient is a 77 y.o. male patient with history of HTN, HLD, Hypothyroidism, DM2, dementia, MRDD, COPD  presented to Hospital with weakness. Noted to have COVID, no O2 requirement. Started on paxlovid from ID recommendation. Stop statin/fibrate at this time. Complete paxlovid and recommend following with PCP to discus restarting statin/fibrate. Also, recommend stopping glipizde given risk of hypoglycemia especially in elderly. Defer to PCP regarding medication addition for DM. Patient with 24 hour care at home and will resume on DC.    Discharge Diagnoses:   Weakness  Covid-19 Virus Infection COPD, not in exacerbation  Patient with weakness in setting of COVID-19 Per caregiver history, patient usually ambulates with walker however in the ER required 2 person assist just to get up Date of onset of symptoms: 11/10/2023 Symptoms present on admission: Weakness, shortness of breath Date of covid positive test: 11/10/2023 Vaccination status: vaccinated Imaging: CXR?bronchial wall cuffing, consistent with bronchitis or reactive airway disease.  No consolidative pneumonia or other acute pulmonary findings. Oxygen requirements on admission: None Current oxygen requirements: None ID consulted and giving patient paxlovid   Continue inhalers, incentive spirometry, Tessalon for cough, Mucinex for congestion PT/OT consulted, appears to have 24/7 care per nursing. Will likely just go home and continue his health aide   Elevated troponin In setting of COVID-19 Initial troponin 34 then repeat 36 EKG showed NSR with RBBB present on previous  No prior troponin on file Currently denying any chest pain Continue telemetry   Hypothyroidism Continue home levothyroxine TSH WNL Type 2 diabetes On metformin, glipizide at home Recommend likely stopping glipizide at home given risk of hypoglycemia, especially in elderly  Sliding scale insulin while inpatient    GERD Continue home PPI   Anxiety/depression Continue Lexapro   Hyperlipidemia Hold home statin and fenofibrate
Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Hypothyroidism, Respiratory tract congestion, SARS-CoV-2 test positive, Troponin increased, Type 2 diabetes mellitus
Clinical narrative: Patient is a 77 y.o. male patient with history of HTN, HLD, Hypothyroidism, DM2, dementia, MRDD, COPD  presented to Hospital with weakness. Noted to have COVID, no O2 requirement. Started on paxlovid from ID recommendation. Stop statin/fibrate at this time. Complete paxlovid and recommend following with PCP to discus restarting statin/fibrate. Also, recommend stopping glipizde given risk of hypoglycemia especially in elderly. Defer to PCP regarding medication addition for DM. Patient with 24 hour care at home and will resume on DC.    Discharge Diagnoses:   Weakness  Covid-19 Virus Infection COPD, not in exacerbation  Patient with weakness in setting of COVID-19 Per caregiver history, patient usually ambulates with walker however in the ER required 2 person assist just to get up Date of onset of symptoms: 11/10/2023 Symptoms present on admission: Weakness, shortness of breath Date of covid positive test: 11/10/2023 Vaccination status: vaccinated Imaging: CXR?bronchial wall cuffing, consistent with bronchitis or reactive airway disease.  No consolidative pneumonia or other acute pulmonary findings. Oxygen requirements on admission: None Current oxygen requirements: None ID consulted and giving patient paxlovid   Continue inhalers, incentive spirometry, Tessalon for cough, Mucinex for congestion PT/OT consulted, appears to have 24/7 care per nursing. Will likely just go home and continue his health aide   Elevated troponin In setting of COVID-19 Initial troponin 34 then repeat 36 EKG showed NSR with RBBB present on previous  No prior troponin on file Currently denying any chest pain Continue telemetry   Hypothyroidism Continue home levothyroxine TSH WNL Type 2 diabetes On metformin, glipizide at home Recommend likely stopping glipizide at home given risk of hypoglycemia, especially in elderly  Sliding scale insulin while inpatient    GERD Continue home PPI   Anxiety/depression Continue Lexapro   Hyperlipidemia Hold home statin and fenofibrate
Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Walking aid user
Clinical narrative: Patient is a 77 y.o. male patient with history of HTN, HLD, Hypothyroidism, DM2, dementia, MRDD, COPD  presented to Hospital with weakness. Noted to have COVID, no O2 requirement. Started on paxlovid from ID recommendation. Stop statin/fibrate at this time. Complete paxlovid and recommend following with PCP to discus restarting statin/fibrate. Also, recommend stopping glipizde given risk of hypoglycemia especially in elderly. Defer to PCP regarding medication addition for DM. Patient with 24 hour care at home and will resume on DC.    Discharge Diagnoses:   Weakness  Covid-19 Virus Infection COPD, not in exacerbation  Patient with weakness in setting of COVID-19 Per caregiver history, patient usually ambulates with walker however in the ER required 2 person assist just to get up Date of onset of symptoms: 11/10/2023 Symptoms present on admission: Weakness, shortness of breath Date of covid positive test: 11/10/2023 Vaccination status: vaccinated Imaging: CXR?bronchial wall cuffing, consistent with bronchitis or reactive airway disease.  No consolidative pneumonia or other acute pulmonary findings. Oxygen requirements on admission: None Current oxygen requirements: None ID consulted and giving patient paxlovid   Continue inhalers, incentive spirometry, Tessalon for cough, Mucinex for congestion PT/OT consulted, appears to have 24/7 care per nursing. Will likely just go home and continue his health aide   Elevated troponin In setting of COVID-19 Initial troponin 34 then repeat 36 EKG showed NSR with RBBB present on previous  No prior troponin on file Currently denying any chest pain Continue telemetry   Hypothyroidism Continue home levothyroxine TSH WNL Type 2 diabetes On metformin, glipizide at home Recommend likely stopping glipizide at home given risk of hypoglycemia, especially in elderly  Sliding scale insulin while inpatient    GERD Continue home PPI   Anxiety/depression Continue Lexapro   Hyperlipidemia Hold home statin and fenofibrate
Age: 86.0
Sex: M
Vaccine: COVID19-2
Symptoms: Blood culture negative, COVID-19, Chest X-ray normal, Computerised tomogram head normal, Condition aggravated
Clinical narrative: Patient is a 87 y.o. male patient of DO with history of dementia, hypertension, hyperlipidemia, and BPH.  He is admitted on 10/30/2023 with fatigue, decreased intake and increased confusion and found to be COVID-19 positive in ED.   Covid-19 Virus Infection Date of onset of symptoms: 10/29/2023 Symptoms present on admission: Cough, runny nose, decrease in day, loose stools Date of covid positive test: 10/30/2023 Vaccination status: vaccinated Imaging: Chest x-ray negative Oxygen requirements on admission: None Current oxygen requirements: None Medical therapy: Paxlovid Consultants following: ID consulted Anticipated special isolation end date: 11/3/2023 Maintenance IV fluids   Acute encephalopathy, secondary to COVID infection dehydration,  Metabolic Encephalopathy superimposed on dementia , improved Dementia Increasing confusion likely secondary to acute COVID-19 infection.  CT and head negative Continue home donepezil   Fever, 101.4 Likely secondary to COVID, normal white blood cells Blood cultures negative, UA negative, urine antigens negative Monitor off antibiotics   Hyperlipidemia: Continue home statin after finishing the Paxlovid course    Hypertension: Continue home metoprolol   BPH: Continue Flomax after finishing the Paxlovid course
Age: 86.0
Sex: M
Vaccine: COVID19-2
Symptoms: Confusional state, Cough, Dehydration, Dementia, Diarrhoea
Clinical narrative: Patient is a 87 y.o. male patient of DO with history of dementia, hypertension, hyperlipidemia, and BPH.  He is admitted on 10/30/2023 with fatigue, decreased intake and increased confusion and found to be COVID-19 positive in ED.   Covid-19 Virus Infection Date of onset of symptoms: 10/29/2023 Symptoms present on admission: Cough, runny nose, decrease in day, loose stools Date of covid positive test: 10/30/2023 Vaccination status: vaccinated Imaging: Chest x-ray negative Oxygen requirements on admission: None Current oxygen requirements: None Medical therapy: Paxlovid Consultants following: ID consulted Anticipated special isolation end date: 11/3/2023 Maintenance IV fluids   Acute encephalopathy, secondary to COVID infection dehydration,  Metabolic Encephalopathy superimposed on dementia , improved Dementia Increasing confusion likely secondary to acute COVID-19 infection.  CT and head negative Continue home donepezil   Fever, 101.4 Likely secondary to COVID, normal white blood cells Blood cultures negative, UA negative, urine antigens negative Monitor off antibiotics   Hyperlipidemia: Continue home statin after finishing the Paxlovid course    Hypertension: Continue home metoprolol   BPH: Continue Flomax after finishing the Paxlovid course
Age: 86.0
Sex: M
Vaccine: COVID19-2
Symptoms: Encephalopathy, Fatigue, Hypophagia, Metabolic encephalopathy, Pyrexia
Clinical narrative: Patient is a 87 y.o. male patient of DO with history of dementia, hypertension, hyperlipidemia, and BPH.  He is admitted on 10/30/2023 with fatigue, decreased intake and increased confusion and found to be COVID-19 positive in ED.   Covid-19 Virus Infection Date of onset of symptoms: 10/29/2023 Symptoms present on admission: Cough, runny nose, decrease in day, loose stools Date of covid positive test: 10/30/2023 Vaccination status: vaccinated Imaging: Chest x-ray negative Oxygen requirements on admission: None Current oxygen requirements: None Medical therapy: Paxlovid Consultants following: ID consulted Anticipated special isolation end date: 11/3/2023 Maintenance IV fluids   Acute encephalopathy, secondary to COVID infection dehydration,  Metabolic Encephalopathy superimposed on dementia , improved Dementia Increasing confusion likely secondary to acute COVID-19 infection.  CT and head negative Continue home donepezil   Fever, 101.4 Likely secondary to COVID, normal white blood cells Blood cultures negative, UA negative, urine antigens negative Monitor off antibiotics   Hyperlipidemia: Continue home statin after finishing the Paxlovid course    Hypertension: Continue home metoprolol   BPH: Continue Flomax after finishing the Paxlovid course
Age: 86.0
Sex: M
Vaccine: COVID19-2
Symptoms: Rhinorrhoea, SARS-CoV-2 test positive, Superinfection, Urine analysis normal, Urine antigen test
Clinical narrative: Patient is a 87 y.o. male patient of DO with history of dementia, hypertension, hyperlipidemia, and BPH.  He is admitted on 10/30/2023 with fatigue, decreased intake and increased confusion and found to be COVID-19 positive in ED.   Covid-19 Virus Infection Date of onset of symptoms: 10/29/2023 Symptoms present on admission: Cough, runny nose, decrease in day, loose stools Date of covid positive test: 10/30/2023 Vaccination status: vaccinated Imaging: Chest x-ray negative Oxygen requirements on admission: None Current oxygen requirements: None Medical therapy: Paxlovid Consultants following: ID consulted Anticipated special isolation end date: 11/3/2023 Maintenance IV fluids   Acute encephalopathy, secondary to COVID infection dehydration,  Metabolic Encephalopathy superimposed on dementia , improved Dementia Increasing confusion likely secondary to acute COVID-19 infection.  CT and head negative Continue home donepezil   Fever, 101.4 Likely secondary to COVID, normal white blood cells Blood cultures negative, UA negative, urine antigens negative Monitor off antibiotics   Hyperlipidemia: Continue home statin after finishing the Paxlovid course    Hypertension: Continue home metoprolol   BPH: Continue Flomax after finishing the Paxlovid course
Age: 86.0
Sex: M
Vaccine: COVID19-2
Symptoms: White blood cell count normal
Clinical narrative: Patient is a 87 y.o. male patient of DO with history of dementia, hypertension, hyperlipidemia, and BPH.  He is admitted on 10/30/2023 with fatigue, decreased intake and increased confusion and found to be COVID-19 positive in ED.   Covid-19 Virus Infection Date of onset of symptoms: 10/29/2023 Symptoms present on admission: Cough, runny nose, decrease in day, loose stools Date of covid positive test: 10/30/2023 Vaccination status: vaccinated Imaging: Chest x-ray negative Oxygen requirements on admission: None Current oxygen requirements: None Medical therapy: Paxlovid Consultants following: ID consulted Anticipated special isolation end date: 11/3/2023 Maintenance IV fluids   Acute encephalopathy, secondary to COVID infection dehydration,  Metabolic Encephalopathy superimposed on dementia , improved Dementia Increasing confusion likely secondary to acute COVID-19 infection.  CT and head negative Continue home donepezil   Fever, 101.4 Likely secondary to COVID, normal white blood cells Blood cultures negative, UA negative, urine antigens negative Monitor off antibiotics   Hyperlipidemia: Continue home statin after finishing the Paxlovid course    Hypertension: Continue home metoprolol   BPH: Continue Flomax after finishing the Paxlovid course
Age: 77.0
Sex: M
Vaccine: HEPA
Symptoms: Underdose
Clinical narrative: Patient came in on 12/06/2023 to receive 1st Hep A Vaccine but Pediatric/Adolescent Hep A dose was administered instead. Patient only received 0.5-mL does and not the 1-mL dose.
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, COVID-19, COVID-19 pneumonia, Computerised tomogram thorax abnormal, Cough
Clinical narrative: Patient is a 92 y.o. female patient of MD with history of  brain and carotid aneurysms, valvular heart disease, CAD, and HTN  presented to Hospital with Cough, congestion, and hypoxia and a positive COVID test.   Viral Sepsis due to COVID 19 Pneumonia with acute hypoxic respiratory failure, POA  Date of onset of symptoms: 11/5 Symptoms present on admission: Hypoxia, cough, congestion Date of covid positive test: 11/6 Vaccination status: vaccinated Imaging: CT PE showed no PE, but showed multifocal patchy airspace disease in the left upper and lower lobes. Oxygen requirements on admission: 2 L.  Not on oxygen at baseline.  Weaned off  Medical therapy: steroids Anticipated special isolation end date: 11/16    Hyponatremia Patient seems to have had chronic hyponatremia for over 6 months Continue home sodium tablets   CAD Per history patient had a stent placed in 1995 Continue ASA     Dementia Debility Patient is bed bound at baseline Patient baseline mentation around AAO x2   Cerebral aneurysms Mitral stenosis Aortic stenosis Continue ASA   Hypothyroidism Continue Synthroid   Depression Continue Zoloft   Chronic urinary retention? Patient has chronic indwelling Foley   Thrombocytopenia, POA Seems chronic. Monitor.   Goals of care discussion Discussed goals of care with patient's daughter who is also her POA.  Daughter endorses patient is to be DNR CCA, DNI.
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Hyponatraemia, Hypoxia, Lung disorder, Respiratory tract congestion, SARS-CoV-2 test positive
Clinical narrative: Patient is a 92 y.o. female patient of MD with history of  brain and carotid aneurysms, valvular heart disease, CAD, and HTN  presented to Hospital with Cough, congestion, and hypoxia and a positive COVID test.   Viral Sepsis due to COVID 19 Pneumonia with acute hypoxic respiratory failure, POA  Date of onset of symptoms: 11/5 Symptoms present on admission: Hypoxia, cough, congestion Date of covid positive test: 11/6 Vaccination status: vaccinated Imaging: CT PE showed no PE, but showed multifocal patchy airspace disease in the left upper and lower lobes. Oxygen requirements on admission: 2 L.  Not on oxygen at baseline.  Weaned off  Medical therapy: steroids Anticipated special isolation end date: 11/16    Hyponatremia Patient seems to have had chronic hyponatremia for over 6 months Continue home sodium tablets   CAD Per history patient had a stent placed in 1995 Continue ASA     Dementia Debility Patient is bed bound at baseline Patient baseline mentation around AAO x2   Cerebral aneurysms Mitral stenosis Aortic stenosis Continue ASA   Hypothyroidism Continue Synthroid   Depression Continue Zoloft   Chronic urinary retention? Patient has chronic indwelling Foley   Thrombocytopenia, POA Seems chronic. Monitor.   Goals of care discussion Discussed goals of care with patient's daughter who is also her POA.  Daughter endorses patient is to be DNR CCA, DNI.
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Thrombocytopenia, Viral sepsis
Clinical narrative: Patient is a 92 y.o. female patient of MD with history of  brain and carotid aneurysms, valvular heart disease, CAD, and HTN  presented to Hospital with Cough, congestion, and hypoxia and a positive COVID test.   Viral Sepsis due to COVID 19 Pneumonia with acute hypoxic respiratory failure, POA  Date of onset of symptoms: 11/5 Symptoms present on admission: Hypoxia, cough, congestion Date of covid positive test: 11/6 Vaccination status: vaccinated Imaging: CT PE showed no PE, but showed multifocal patchy airspace disease in the left upper and lower lobes. Oxygen requirements on admission: 2 L.  Not on oxygen at baseline.  Weaned off  Medical therapy: steroids Anticipated special isolation end date: 11/16    Hyponatremia Patient seems to have had chronic hyponatremia for over 6 months Continue home sodium tablets   CAD Per history patient had a stent placed in 1995 Continue ASA     Dementia Debility Patient is bed bound at baseline Patient baseline mentation around AAO x2   Cerebral aneurysms Mitral stenosis Aortic stenosis Continue ASA   Hypothyroidism Continue Synthroid   Depression Continue Zoloft   Chronic urinary retention? Patient has chronic indwelling Foley   Thrombocytopenia, POA Seems chronic. Monitor.   Goals of care discussion Discussed goals of care with patient's daughter who is also her POA.  Daughter endorses patient is to be DNR CCA, DNI.
Age: 4.0
Sex: M
Vaccine: COVID19
Symptoms: No adverse event, Tethered oral tissue
Clinical narrative: Spikevax given, wrong age group - No reaction
Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Blood glucose normal, Dizziness, Feeling hot, Nausea
Clinical narrative: NAUSEA  AND DIZZY / FEELING HOT.
Age: 60.0
Sex: F
Vaccine: HEPA
Symptoms: Underdose
Clinical narrative: Patient came in on 12/12/2023 to receive 1st Hep A Vaccine but Pediatric/Adolescent Hep A dose was administered instead. Patient only received 0.5-mL does and not the 1-mL dose.
Age: 40.0
Sex: M
Vaccine: HEPA
Symptoms: Underdose
Clinical narrative: Patient came in on 11/13/2023 to receive 1st Hep A Vaccine but Pediatric/Adolescent Hep A dose was administered instead. Patient only received 0.5-mL does and not the 1-mL dose.
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Aspiration, COVID-19, Death
Clinical narrative: Patient is a 90 y.o. male with a PMH of IPF, HFpEF, AFib (Eliquis), Metastatic Prostate Cancer who presented to Hospital 10/28/2023 following an unwitnessed fall at his assisted living. He was found to have an AKI, pericardial effusion, hypoxia, AMS, and COVID-19. His hospital course was complicated by delirium and aspiration, leading to acute hypoxic respiratory failure requiring BiPAP and transfer to the ICU. Palliative Care had been following, and after goals of care conversations on 11/10/2023 the patient was transitioned to DNR-CC. Patient expired at 0107 11/12/23.
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Delirium, Fall, Hypoxia, Intensive care, Mental status changes
Clinical narrative: Patient is a 90 y.o. male with a PMH of IPF, HFpEF, AFib (Eliquis), Metastatic Prostate Cancer who presented to Hospital 10/28/2023 following an unwitnessed fall at his assisted living. He was found to have an AKI, pericardial effusion, hypoxia, AMS, and COVID-19. His hospital course was complicated by delirium and aspiration, leading to acute hypoxic respiratory failure requiring BiPAP and transfer to the ICU. Palliative Care had been following, and after goals of care conversations on 11/10/2023 the patient was transitioned to DNR-CC. Patient expired at 0107 11/12/23.
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Pericardial effusion, Positive airway pressure therapy
Clinical narrative: Patient is a 90 y.o. male with a PMH of IPF, HFpEF, AFib (Eliquis), Metastatic Prostate Cancer who presented to Hospital 10/28/2023 following an unwitnessed fall at his assisted living. He was found to have an AKI, pericardial effusion, hypoxia, AMS, and COVID-19. His hospital course was complicated by delirium and aspiration, leading to acute hypoxic respiratory failure requiring BiPAP and transfer to the ICU. Palliative Care had been following, and after goals of care conversations on 11/10/2023 the patient was transitioned to DNR-CC. Patient expired at 0107 11/12/23.
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Acute respiratory failure, Angiogram pulmonary abnormal, Atelectasis, Atrial pressure increased, Blood creatine phosphokinase increased
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: COVID-19, Computerised tomogram abdomen normal, Computerised tomogram head normal, Computerised tomogram thorax normal, Confusional state
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Craniocerebral injury, Dehydration, Echocardiogram abnormal, Ejection fraction normal, Encephalopathy
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Erythema, Fall, Gait disturbance, Glycosylated haemoglobin normal, Hypoxia
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Imaging procedure, Leukocytosis, Lung infiltration, Metabolic encephalopathy, Pain in extremity
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Peripheral venous disease, Pneumonia, Pyuria, Rhabdomyolysis, SARS-CoV-2 test positive
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Tachycardia, Troponin increased, Ultrasound Doppler normal, Urinary tract infection, White blood cell count increased
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: X-ray limb
Clinical narrative: Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom.            Assessment and Plan   Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI  - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg   UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx   Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if  Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive   Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob   Fall  - unclear etiology, pt unable to give history, suspect mechanical in nature  - imaging negative for acute fracture or injury  - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration  Mild rhabdomyolysis  CPK 495 on admission and tachycardic -Improved with IVF   Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg   Diabetes mellitus type 2 with neuropathy  Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn  - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid   Essential HTN BP reviewed,fairly well controlled  - cont losartan and metoprolol w hold parameters   History of CVA - cont plavix    Major depression - cont bupropion with prn atarax    Morbid Obesity Body mass index is 42.81 kg/m². -Needs aggressive lifestyle modifications as outpatien
Age: 75.0
Sex: F
Vaccine: COVID19-2
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory failure, Anxiety, Asthenia
Clinical narrative: Patient is a 76 y.o. female patient of MD with history of CAD s/p CABG, HFpEF, MR s/p mitral clip, mechanical AVR, chronic hypoxic respiratory failure, uncontrolled type 2 diabetes mellitus, hypothyroidism, RLS, chronic pain, and depression/anxiety who presented to Hospital with fatigue and shortness of breath.   Acute on Chronic Hypoxic Respiratory Failure - Resolved COVID 19 Pneumonia Fatigue, decreased appetite, SOB. Initially saturating ok on chronic home 2L NC but worsened in ED and required 10L HFNC COVID positive, vaccinated x3 Tested positive 11/8, symptoms since 11/5  CXR non acute  Dexamethasone x10d Given AKI as below, remdesivir not ordered. May consider baricitinib if worsen.  CRP improving and weaned to RA Pulmonary followed   Generalized Weakness PT/OT rec 5-7d/week Patient not interested in SNF SW following, appreciate assistance    AKI - Resolved CKD Stage 3 Initial creatinine 1.96, baseline appears to be about 1.3 Admits to poor PO intake and continued Bumex daily Likely pre-renal in the setting of covid and above IVF given in ED, will hold on additional fluid given COVID  Initially held bumex, now resumed Continue to monitor with daily RFP's Cr stable at 1.2 Recommend repeat BMP in 1 week    NSTEMI, likely type 2 CAD s/p CABG Chronic HFpEF MR s/p Mitral Clip AVS s/p mechanical AVR Pulmonary Hypertension Tropinin elevated with flat trend  Patient denies chest pain EKG with paced rhythm, no clear ST changes Echo 11/2 with LVEF 56%, RVSP of 100, mild MVR, severe TVR Held bumex on admit due to AKI, now resumed Continue home aspirin and pravastatin Pharmacy consulted to dose coumadin, goal INR 2.5-3.5   Uncontrolled Type 2 Diabetes Mellitus Last A1C 8.0% on 10/10/23 Continue home long acting insulin, 20 units nightly Holding home sitagliptin while inpatient  Increased SSI; accuchecks Diabetic diet   Chronic Normocytic Anemia Leukopenia Hemoglobin 9.4 on admission, which appears to be about baseline WBC 4.44, likely due to COVID Continue home iron supplementation   Hypothyroidism Continue home levothyroxine   RLS Continue home requip   Chronic Pain Continue home Oxycodone    Depression/Anxiety Continue home zoloft PRN ativan Recommend close follow up with psychiatry for uncontrolled anxiety
Age: 75.0
Sex: F
Vaccine: COVID19-2
Symptoms: Blood creatinine increased, C-reactive protein abnormal, COVID-19, COVID-19 pneumonia, Chest X-ray normal
Clinical narrative: Patient is a 76 y.o. female patient of MD with history of CAD s/p CABG, HFpEF, MR s/p mitral clip, mechanical AVR, chronic hypoxic respiratory failure, uncontrolled type 2 diabetes mellitus, hypothyroidism, RLS, chronic pain, and depression/anxiety who presented to Hospital with fatigue and shortness of breath.   Acute on Chronic Hypoxic Respiratory Failure - Resolved COVID 19 Pneumonia Fatigue, decreased appetite, SOB. Initially saturating ok on chronic home 2L NC but worsened in ED and required 10L HFNC COVID positive, vaccinated x3 Tested positive 11/8, symptoms since 11/5  CXR non acute  Dexamethasone x10d Given AKI as below, remdesivir not ordered. May consider baricitinib if worsen.  CRP improving and weaned to RA Pulmonary followed   Generalized Weakness PT/OT rec 5-7d/week Patient not interested in SNF SW following, appreciate assistance    AKI - Resolved CKD Stage 3 Initial creatinine 1.96, baseline appears to be about 1.3 Admits to poor PO intake and continued Bumex daily Likely pre-renal in the setting of covid and above IVF given in ED, will hold on additional fluid given COVID  Initially held bumex, now resumed Continue to monitor with daily RFP's Cr stable at 1.2 Recommend repeat BMP in 1 week    NSTEMI, likely type 2 CAD s/p CABG Chronic HFpEF MR s/p Mitral Clip AVS s/p mechanical AVR Pulmonary Hypertension Tropinin elevated with flat trend  Patient denies chest pain EKG with paced rhythm, no clear ST changes Echo 11/2 with LVEF 56%, RVSP of 100, mild MVR, severe TVR Held bumex on admit due to AKI, now resumed Continue home aspirin and pravastatin Pharmacy consulted to dose coumadin, goal INR 2.5-3.5   Uncontrolled Type 2 Diabetes Mellitus Last A1C 8.0% on 10/10/23 Continue home long acting insulin, 20 units nightly Holding home sitagliptin while inpatient  Increased SSI; accuchecks Diabetic diet   Chronic Normocytic Anemia Leukopenia Hemoglobin 9.4 on admission, which appears to be about baseline WBC 4.44, likely due to COVID Continue home iron supplementation   Hypothyroidism Continue home levothyroxine   RLS Continue home requip   Chronic Pain Continue home Oxycodone    Depression/Anxiety Continue home zoloft PRN ativan Recommend close follow up with psychiatry for uncontrolled anxiety
Age: 75.0
Sex: F
Vaccine: COVID19-2
Symptoms: Condition aggravated, Decreased appetite, Dyspnoea, Echocardiogram abnormal, Ejection fraction
Clinical narrative: Patient is a 76 y.o. female patient of MD with history of CAD s/p CABG, HFpEF, MR s/p mitral clip, mechanical AVR, chronic hypoxic respiratory failure, uncontrolled type 2 diabetes mellitus, hypothyroidism, RLS, chronic pain, and depression/anxiety who presented to Hospital with fatigue and shortness of breath.   Acute on Chronic Hypoxic Respiratory Failure - Resolved COVID 19 Pneumonia Fatigue, decreased appetite, SOB. Initially saturating ok on chronic home 2L NC but worsened in ED and required 10L HFNC COVID positive, vaccinated x3 Tested positive 11/8, symptoms since 11/5  CXR non acute  Dexamethasone x10d Given AKI as below, remdesivir not ordered. May consider baricitinib if worsen.  CRP improving and weaned to RA Pulmonary followed   Generalized Weakness PT/OT rec 5-7d/week Patient not interested in SNF SW following, appreciate assistance    AKI - Resolved CKD Stage 3 Initial creatinine 1.96, baseline appears to be about 1.3 Admits to poor PO intake and continued Bumex daily Likely pre-renal in the setting of covid and above IVF given in ED, will hold on additional fluid given COVID  Initially held bumex, now resumed Continue to monitor with daily RFP's Cr stable at 1.2 Recommend repeat BMP in 1 week    NSTEMI, likely type 2 CAD s/p CABG Chronic HFpEF MR s/p Mitral Clip AVS s/p mechanical AVR Pulmonary Hypertension Tropinin elevated with flat trend  Patient denies chest pain EKG with paced rhythm, no clear ST changes Echo 11/2 with LVEF 56%, RVSP of 100, mild MVR, severe TVR Held bumex on admit due to AKI, now resumed Continue home aspirin and pravastatin Pharmacy consulted to dose coumadin, goal INR 2.5-3.5   Uncontrolled Type 2 Diabetes Mellitus Last A1C 8.0% on 10/10/23 Continue home long acting insulin, 20 units nightly Holding home sitagliptin while inpatient  Increased SSI; accuchecks Diabetic diet   Chronic Normocytic Anemia Leukopenia Hemoglobin 9.4 on admission, which appears to be about baseline WBC 4.44, likely due to COVID Continue home iron supplementation   Hypothyroidism Continue home levothyroxine   RLS Continue home requip   Chronic Pain Continue home Oxycodone    Depression/Anxiety Continue home zoloft PRN ativan Recommend close follow up with psychiatry for uncontrolled anxiety