chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 87.0
Sex: M
Vaccine: COVID19-2
Symptoms: Orthostatic hypotension, SARS-CoV-2 test positive, Wound haemorrhage
Clinical narrative: Patient is a 88 y.o. male with history of a fib on Eliquis, SSS with pacemaker HTN, T2DM admitted to the hospital on 10/24/2023 for recent falls at home & chronic weakness. Patient had overall negative trauma workup, however was found to have hazy opacifications on CXR with elevated BNP. Echo was done which showed stable HF not in exacerbation. Additionally was found to be COVID-19 positive with positive orthostatics. During his hospital course he remained normotensive while holding all of his home antihypertensives. Falls were likely related to hypotension secondary to COVID19 infection and antihypertensive medications. During the hospital stay he was seen by PT/OT who recommended SNF which patient declined and was made aware of risks associated. He was offered remdesivir for his COVID infection and patient declined.    Action Items to be Addressed After Discharge 1) COVID19 Infection - follow up symptoms, supportive 2) HTN/HF - Consider restarting home BP medications; BMP 3) Orthostatic Hypotension; follow up PT 4) Atrial Fibrillation - Adjusted eliquis 5mg BID to eliquis 2.5mg BID given age/renal function   Discharge Diagnosis and Associated Hospital Course   Generalized weakness Recurrent falls COVID-19 infection Orthostatic hypotension HTN Patient had  unwitnessed falls at home, one directly after standing. CXR (10/24) with mild hazy opacification L lung. Found to have orthostatic hypotension, likely culprit for falls. Seen by PT/OT recommending SNF, family declined, discussed risks and patient and family understood. Family declined COVID19 treatment with remdesivir. Considered outpatient PT while patient is only in area for roughly approximately 2 weeks before returning to home. Referral placed.  -Consider restarting and/or decreasing home antihypertensives, repeat BMP -Follow up PT   Chronic HFpEF BNP elevated 2,560. Increased from 734 in 2019. Likely related to infection vs less likely heart failure exacerbation. -Echo (10/26) with EF 59, LVH normal wall function. RSVP 46   CKD AKI, unable to rule in nor ruled out  Consistent with baseline. Unclear etiology as diabetes is well controlled.  - On admission Cr 1.82, 1.4 on discharge   Chronic Afib On home Eliquis 5 mg BID - held on admission due to bleeding from wounds on upper extremity - Restarted Eliquis dose reduced to 2.5mg BID given CKD and age   Anemia of Chronic Disease - Stable Appears consistent with baseline.   Chronic Thrombocytopenia - Stable Consistent with baseline   NIDT2DM  Diet-controlled - Continue SSI while admitted.
Age: 16.0
Sex: F
Vaccine: MNQ
Symptoms: Expired product administered, No adverse event
Clinical narrative: On 12/14/2023 patient was given a vaccine that had expired 11/30/2023.  Patients parent was notified of the event and the patient has been scheduled to be revaccinated. The patient has had no adverse reaction or symptoms to the vaccine.
Age: 46.0
Sex: M
Vaccine: HEP
Symptoms: Abscess, Incisional drainage, Injection site erythema, Injection site swelling, Pyrexia
Clinical narrative: Swelling and redness at injection site, in addition to fever. The patient initially reported that they symptoms had started the day of vaccine administration (12/01/23), but during office visit on 12/21/23 the patient reported that symptoms started more recently around 12/15/23.  The patient reported symptoms to the clinic on 12/20/23 and was encouraged to be seen by a provider. The patient was seen at the walk-in clinic on 12/21/23. During this appointment, an I&D procedure was performed as there was an abscess on the patient's left shoulder. The patient was also prescribed antibiotics and ibuprofen. It is unclear if the abscess was caused by the vaccine administration, or if it was caused by a different factor (the patient had also tolerated the first injection).
Age: 10.0
Sex: M
Vaccine: COVID19
Symptoms: Asthma
Clinical narrative: Asthma attack for 2 days requiring dexamethasone
Age: 92.0
Sex: F
Vaccine: RSV
Symptoms: Immune-mediated adverse reaction, Injection site induration, Injection site swelling, Injection site warmth, Peripheral swelling
Clinical narrative: patient called afternoon 12/22 saying the arm where she received the vaccine was 3 times the size. After asking her more questions, also gathered it was warm to the touch below injection site as well as hard as a rock. injection site itself seemed fine. arm also had many marks like one normally gets under skin when on warfarin ( which the patient is). She did not have these marks on any other part of her body. I advised her to seek medical care. She called about 8:00 pm 12/21 to tell me the medical professional she went to see said she had a severe immune mediated response to the vaccine, dr gave her a prescription to use if it got worse or started to streak, and to go home and rest take tylenol every 6-8 hours and to use a warm compress. that provider also told her she should have never received the vaccine  due to her medical history ( she did not tell her history to the pharmacy aside what she responded to on the vaccine consent form). She had been advised by one of her medical providers to receive the vaccine.
Age: 6.0
Sex: F
Vaccine: COVID19
Symptoms: Expired product administered, No adverse event
Clinical narrative: No adverse effects known, but patient was administered the vaccination past the "beyond use date" that goes into effect when changed from being stored frozen to refrigerated.
Age: 81.0
Sex: F
Vaccine: RSV
Symptoms: Chest pain
Clinical narrative: Patient had chest pain the day of the vaccination and through the night.  Chest pain resolved the following day.
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anaemia of chronic disease, COVID-19, COVID-19 pneumonia, Culture urine negative
Clinical narrative: Patient is a 71 y.o. male patient of No primary care provider on file. with no past medical history presented to Hospital from another Hospital where he had presented initially for acute respiratory failure.  Patient was found to have COVID, got intubated on October 3, patient failed extubation on 12th, 15th.  Patient found to have no cuff leak and was suspected to have some vocal cord/tracheal edema.  Family had initially refused trach and PEG but on October 16 family agreed on trach and PEG.  Patient's CODE STATUS remains DNR CCA per outside hospital record.  Patient was transferred to our hospital for pulmonology evaluation and to continue further discussion regarding trach/PEG.   COVID-19 pneumonia Acute hypoxic respiratory failure 2/2 above Suspected vocal cord/tracheal edema Failed extubation at outlying facility Status post trach and PEG Critical care following, continue vent support as needed Patient finished course of IV remdesivir at outlying facility Is out of window for isolation. Palliative care following Oxygen support as needed Per critical care team patient stable for discharge to LTAC with ongoing treatment   Patient had fever spike on night of 10/22, no further fever Order procalcitonin, pending Blood culture x2, 1 set is positive for staph might be contamination, repeat blood culture pending Urine culture negative Sputum culture yeast No further fevers, no need for further antibiotics   Hypertension Given borderline pressure this was held Will need to monitor blood pressure closely as outpatient and resume BP meds as needed   Severe protein calorie malnutrition Continue tube feeds discharge   Anemia likely anemia of chronic disease Hemoglobin 7.9 Hemoglobin was monitored   Diabetes type 2 blood sugar is okay Continue Lantus and sliding scale coverage ICU related myopathy PT OT     Patient stable for discharge to LTAC with ongoing medical treatment management.
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Endotracheal intubation, Endotracheal intubation complication, Gastrostomy, Haemoglobin normal, Hypertension
Clinical narrative: Patient is a 71 y.o. male patient of No primary care provider on file. with no past medical history presented to Hospital from another Hospital where he had presented initially for acute respiratory failure.  Patient was found to have COVID, got intubated on October 3, patient failed extubation on 12th, 15th.  Patient found to have no cuff leak and was suspected to have some vocal cord/tracheal edema.  Family had initially refused trach and PEG but on October 16 family agreed on trach and PEG.  Patient's CODE STATUS remains DNR CCA per outside hospital record.  Patient was transferred to our hospital for pulmonology evaluation and to continue further discussion regarding trach/PEG.   COVID-19 pneumonia Acute hypoxic respiratory failure 2/2 above Suspected vocal cord/tracheal edema Failed extubation at outlying facility Status post trach and PEG Critical care following, continue vent support as needed Patient finished course of IV remdesivir at outlying facility Is out of window for isolation. Palliative care following Oxygen support as needed Per critical care team patient stable for discharge to LTAC with ongoing treatment   Patient had fever spike on night of 10/22, no further fever Order procalcitonin, pending Blood culture x2, 1 set is positive for staph might be contamination, repeat blood culture pending Urine culture negative Sputum culture yeast No further fevers, no need for further antibiotics   Hypertension Given borderline pressure this was held Will need to monitor blood pressure closely as outpatient and resume BP meds as needed   Severe protein calorie malnutrition Continue tube feeds discharge   Anemia likely anemia of chronic disease Hemoglobin 7.9 Hemoglobin was monitored   Diabetes type 2 blood sugar is okay Continue Lantus and sliding scale coverage ICU related myopathy PT OT     Patient stable for discharge to LTAC with ongoing medical treatment management.
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Intensive care, Laryngeal oedema, Malnutrition, Myopathy, Pyrexia
Clinical narrative: Patient is a 71 y.o. male patient of No primary care provider on file. with no past medical history presented to Hospital from another Hospital where he had presented initially for acute respiratory failure.  Patient was found to have COVID, got intubated on October 3, patient failed extubation on 12th, 15th.  Patient found to have no cuff leak and was suspected to have some vocal cord/tracheal edema.  Family had initially refused trach and PEG but on October 16 family agreed on trach and PEG.  Patient's CODE STATUS remains DNR CCA per outside hospital record.  Patient was transferred to our hospital for pulmonology evaluation and to continue further discussion regarding trach/PEG.   COVID-19 pneumonia Acute hypoxic respiratory failure 2/2 above Suspected vocal cord/tracheal edema Failed extubation at outlying facility Status post trach and PEG Critical care following, continue vent support as needed Patient finished course of IV remdesivir at outlying facility Is out of window for isolation. Palliative care following Oxygen support as needed Per critical care team patient stable for discharge to LTAC with ongoing treatment   Patient had fever spike on night of 10/22, no further fever Order procalcitonin, pending Blood culture x2, 1 set is positive for staph might be contamination, repeat blood culture pending Urine culture negative Sputum culture yeast No further fevers, no need for further antibiotics   Hypertension Given borderline pressure this was held Will need to monitor blood pressure closely as outpatient and resume BP meds as needed   Severe protein calorie malnutrition Continue tube feeds discharge   Anemia likely anemia of chronic disease Hemoglobin 7.9 Hemoglobin was monitored   Diabetes type 2 blood sugar is okay Continue Lantus and sliding scale coverage ICU related myopathy PT OT     Patient stable for discharge to LTAC with ongoing medical treatment management.
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Sputum culture, Staphylococcus test positive, Tracheal oedema, Tracheostomy
Clinical narrative: Patient is a 71 y.o. male patient of No primary care provider on file. with no past medical history presented to Hospital from another Hospital where he had presented initially for acute respiratory failure.  Patient was found to have COVID, got intubated on October 3, patient failed extubation on 12th, 15th.  Patient found to have no cuff leak and was suspected to have some vocal cord/tracheal edema.  Family had initially refused trach and PEG but on October 16 family agreed on trach and PEG.  Patient's CODE STATUS remains DNR CCA per outside hospital record.  Patient was transferred to our hospital for pulmonology evaluation and to continue further discussion regarding trach/PEG.   COVID-19 pneumonia Acute hypoxic respiratory failure 2/2 above Suspected vocal cord/tracheal edema Failed extubation at outlying facility Status post trach and PEG Critical care following, continue vent support as needed Patient finished course of IV remdesivir at outlying facility Is out of window for isolation. Palliative care following Oxygen support as needed Per critical care team patient stable for discharge to LTAC with ongoing treatment   Patient had fever spike on night of 10/22, no further fever Order procalcitonin, pending Blood culture x2, 1 set is positive for staph might be contamination, repeat blood culture pending Urine culture negative Sputum culture yeast No further fevers, no need for further antibiotics   Hypertension Given borderline pressure this was held Will need to monitor blood pressure closely as outpatient and resume BP meds as needed   Severe protein calorie malnutrition Continue tube feeds discharge   Anemia likely anemia of chronic disease Hemoglobin 7.9 Hemoglobin was monitored   Diabetes type 2 blood sugar is okay Continue Lantus and sliding scale coverage ICU related myopathy PT OT     Patient stable for discharge to LTAC with ongoing medical treatment management.
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Weaning failure
Clinical narrative: Patient is a 71 y.o. male patient of No primary care provider on file. with no past medical history presented to Hospital from another Hospital where he had presented initially for acute respiratory failure.  Patient was found to have COVID, got intubated on October 3, patient failed extubation on 12th, 15th.  Patient found to have no cuff leak and was suspected to have some vocal cord/tracheal edema.  Family had initially refused trach and PEG but on October 16 family agreed on trach and PEG.  Patient's CODE STATUS remains DNR CCA per outside hospital record.  Patient was transferred to our hospital for pulmonology evaluation and to continue further discussion regarding trach/PEG.   COVID-19 pneumonia Acute hypoxic respiratory failure 2/2 above Suspected vocal cord/tracheal edema Failed extubation at outlying facility Status post trach and PEG Critical care following, continue vent support as needed Patient finished course of IV remdesivir at outlying facility Is out of window for isolation. Palliative care following Oxygen support as needed Per critical care team patient stable for discharge to LTAC with ongoing treatment   Patient had fever spike on night of 10/22, no further fever Order procalcitonin, pending Blood culture x2, 1 set is positive for staph might be contamination, repeat blood culture pending Urine culture negative Sputum culture yeast No further fevers, no need for further antibiotics   Hypertension Given borderline pressure this was held Will need to monitor blood pressure closely as outpatient and resume BP meds as needed   Severe protein calorie malnutrition Continue tube feeds discharge   Anemia likely anemia of chronic disease Hemoglobin 7.9 Hemoglobin was monitored   Diabetes type 2 blood sugar is okay Continue Lantus and sliding scale coverage ICU related myopathy PT OT     Patient stable for discharge to LTAC with ongoing medical treatment management.
Age: 8.0
Sex: F
Vaccine: COVID19, FLUC4
Symptoms: Decreased appetite, Incorrect dose administered
Clinical narrative: Upon scanning the VAR, we noticed the sticker for the adult dose.  Not sure if patient got Adult or Pediatric since there were multiple patients (1 adult and 2 pediatric).  Followed up with patient's mom and she  says  her child is not eating.
Age: 75.0
Sex: F
Vaccine: FLU4
Symptoms: Injected limb mobility decreased, Injection site pain, Injection site reaction, Myalgia
Clinical narrative: Patient reports that starting two days after her flu vaccine she began to have pain in the lateral posterior side of right upper arm. She continues to have this pain and it interferes with her arm mobility.  Exam was negative for muscle weakness, erythema, edema, positive for tenderness to palpation of triceps muscles(note that injection was done in the deltoid muscle).  Pain continues today. Patient is referred to physical therapy.
Age: 68.0
Sex: F
Vaccine: COVID19-2
Symptoms: Diarrhoea, Muscle spasms, Vomiting
Clinical narrative: Five hours after receiving this booster I started cramping. Then had diarrhea and at the same time started throwing up. After many vaccinations I have never has a reaction. This was a first. Felt a little better by the end of the night.
Age: 43.0
Sex: M
Vaccine: COVID19, RSV
Symptoms: Unevaluable event
Clinical narrative: None reported
Age: 80.0
Sex: F
Vaccine: COVID19-2
Symptoms: Asthenia, Blood magnesium normal, Blood potassium decreased, COVID-19, Chest X-ray normal
Clinical narrative: Patient is an 81 y.o. female who presented from home on 10/15/2023 with generalized weakness, altered mental status. Recently diagnosed with COVID-19 and started on Paxlovid on 10/11.She completed Paxlovid while inpatient and did well throughout her course, though remains generally weak so discharged to SNF for continued therapy.         Assessment and Plan   Generalized weakness  Acute encephalopathy Presents with increased generalized weakness and confusion over the last day or so prior to admit. Recently diagnosed with COVID-19, started on Paxlovid on 10/11/23. +Nausea and vomiting, decreased oral intake - CT head on admission negative for acute intracranial abnormality. - Urinalysis unremarkable - Symptoms likely due to COVID-19 infection and mild dehydration  - Slowly improving but remains generally weak. PT/OT/CM following- discharged to SNF   COVID-19 infection Diagnosed week prior to admit, prescribed Paxlovid on 10/11/23 - Presented with: Generalized weakness, confusion - Symptom onset: ~10/10/23 (cough, sore throat) - Positive COVID-19: 10/11/23; home test - Vaccination status: Vaccinated with Pfizer with last dose 11/28/22 - CXR on admission showed no acute cardiopulmonary abnormalities. Lungs are clear. - Oxygen status: > 92% on room air  - Continued Paxlovid for the last dose while inpatient, now complete.  - Isolation discontinued 10/20 after discussion with infection prevention.    Hypokalemia K 2.8 on admission. Likely due to poor oral intake - Replaced in the ED and has since been stable for the most part. Mg normal. Appetite improved.    Parkinsonism  Follows with neurology, Dr. - Continue Sinemet as per home regimen  Alzheimer's dementia - Continue home Aricept and Namenda Large granular lymphocytic leukemia Follows with hematology/oncology at facility. On weekly methotrexate - Hold methotrexate in the setting of acute infection- discussed with husband will hold this weeks's dose (usually takes Thursday) and resume 10/26 if continues to improve.  - Follow-up with hematology/oncology as outpatient   Hypothyroidism - Continue Synthroid at home dose   Overactive bladder - Resume Myrbetriq on discharge   Recurrent major depression - Continue sertraline 100 mg daily as per home regimen
Age: 80.0
Sex: F
Vaccine: COVID19-2
Symptoms: Computerised tomogram head normal, Confusional state, Cough, Dehydration, Encephalopathy
Clinical narrative: Patient is an 81 y.o. female who presented from home on 10/15/2023 with generalized weakness, altered mental status. Recently diagnosed with COVID-19 and started on Paxlovid on 10/11.She completed Paxlovid while inpatient and did well throughout her course, though remains generally weak so discharged to SNF for continued therapy.         Assessment and Plan   Generalized weakness  Acute encephalopathy Presents with increased generalized weakness and confusion over the last day or so prior to admit. Recently diagnosed with COVID-19, started on Paxlovid on 10/11/23. +Nausea and vomiting, decreased oral intake - CT head on admission negative for acute intracranial abnormality. - Urinalysis unremarkable - Symptoms likely due to COVID-19 infection and mild dehydration  - Slowly improving but remains generally weak. PT/OT/CM following- discharged to SNF   COVID-19 infection Diagnosed week prior to admit, prescribed Paxlovid on 10/11/23 - Presented with: Generalized weakness, confusion - Symptom onset: ~10/10/23 (cough, sore throat) - Positive COVID-19: 10/11/23; home test - Vaccination status: Vaccinated with Pfizer with last dose 11/28/22 - CXR on admission showed no acute cardiopulmonary abnormalities. Lungs are clear. - Oxygen status: > 92% on room air  - Continued Paxlovid for the last dose while inpatient, now complete.  - Isolation discontinued 10/20 after discussion with infection prevention.    Hypokalemia K 2.8 on admission. Likely due to poor oral intake - Replaced in the ED and has since been stable for the most part. Mg normal. Appetite improved.    Parkinsonism  Follows with neurology, Dr. - Continue Sinemet as per home regimen  Alzheimer's dementia - Continue home Aricept and Namenda Large granular lymphocytic leukemia Follows with hematology/oncology at facility. On weekly methotrexate - Hold methotrexate in the setting of acute infection- discussed with husband will hold this weeks's dose (usually takes Thursday) and resume 10/26 if continues to improve.  - Follow-up with hematology/oncology as outpatient   Hypothyroidism - Continue Synthroid at home dose   Overactive bladder - Resume Myrbetriq on discharge   Recurrent major depression - Continue sertraline 100 mg daily as per home regimen
Age: 80.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hypokalaemia, Hypophagia, Mental status changes, Nausea, Oropharyngeal pain
Clinical narrative: Patient is an 81 y.o. female who presented from home on 10/15/2023 with generalized weakness, altered mental status. Recently diagnosed with COVID-19 and started on Paxlovid on 10/11.She completed Paxlovid while inpatient and did well throughout her course, though remains generally weak so discharged to SNF for continued therapy.         Assessment and Plan   Generalized weakness  Acute encephalopathy Presents with increased generalized weakness and confusion over the last day or so prior to admit. Recently diagnosed with COVID-19, started on Paxlovid on 10/11/23. +Nausea and vomiting, decreased oral intake - CT head on admission negative for acute intracranial abnormality. - Urinalysis unremarkable - Symptoms likely due to COVID-19 infection and mild dehydration  - Slowly improving but remains generally weak. PT/OT/CM following- discharged to SNF   COVID-19 infection Diagnosed week prior to admit, prescribed Paxlovid on 10/11/23 - Presented with: Generalized weakness, confusion - Symptom onset: ~10/10/23 (cough, sore throat) - Positive COVID-19: 10/11/23; home test - Vaccination status: Vaccinated with Pfizer with last dose 11/28/22 - CXR on admission showed no acute cardiopulmonary abnormalities. Lungs are clear. - Oxygen status: > 92% on room air  - Continued Paxlovid for the last dose while inpatient, now complete.  - Isolation discontinued 10/20 after discussion with infection prevention.    Hypokalemia K 2.8 on admission. Likely due to poor oral intake - Replaced in the ED and has since been stable for the most part. Mg normal. Appetite improved.    Parkinsonism  Follows with neurology, Dr. - Continue Sinemet as per home regimen  Alzheimer's dementia - Continue home Aricept and Namenda Large granular lymphocytic leukemia Follows with hematology/oncology at facility. On weekly methotrexate - Hold methotrexate in the setting of acute infection- discussed with husband will hold this weeks's dose (usually takes Thursday) and resume 10/26 if continues to improve.  - Follow-up with hematology/oncology as outpatient   Hypothyroidism - Continue Synthroid at home dose   Overactive bladder - Resume Myrbetriq on discharge   Recurrent major depression - Continue sertraline 100 mg daily as per home regimen
Age: 80.0
Sex: F
Vaccine: COVID19-2
Symptoms: SARS-CoV-2 test positive, Urine analysis normal, Vomiting
Clinical narrative: Patient is an 81 y.o. female who presented from home on 10/15/2023 with generalized weakness, altered mental status. Recently diagnosed with COVID-19 and started on Paxlovid on 10/11.She completed Paxlovid while inpatient and did well throughout her course, though remains generally weak so discharged to SNF for continued therapy.         Assessment and Plan   Generalized weakness  Acute encephalopathy Presents with increased generalized weakness and confusion over the last day or so prior to admit. Recently diagnosed with COVID-19, started on Paxlovid on 10/11/23. +Nausea and vomiting, decreased oral intake - CT head on admission negative for acute intracranial abnormality. - Urinalysis unremarkable - Symptoms likely due to COVID-19 infection and mild dehydration  - Slowly improving but remains generally weak. PT/OT/CM following- discharged to SNF   COVID-19 infection Diagnosed week prior to admit, prescribed Paxlovid on 10/11/23 - Presented with: Generalized weakness, confusion - Symptom onset: ~10/10/23 (cough, sore throat) - Positive COVID-19: 10/11/23; home test - Vaccination status: Vaccinated with Pfizer with last dose 11/28/22 - CXR on admission showed no acute cardiopulmonary abnormalities. Lungs are clear. - Oxygen status: > 92% on room air  - Continued Paxlovid for the last dose while inpatient, now complete.  - Isolation discontinued 10/20 after discussion with infection prevention.    Hypokalemia K 2.8 on admission. Likely due to poor oral intake - Replaced in the ED and has since been stable for the most part. Mg normal. Appetite improved.    Parkinsonism  Follows with neurology, Dr. - Continue Sinemet as per home regimen  Alzheimer's dementia - Continue home Aricept and Namenda Large granular lymphocytic leukemia Follows with hematology/oncology at facility. On weekly methotrexate - Hold methotrexate in the setting of acute infection- discussed with husband will hold this weeks's dose (usually takes Thursday) and resume 10/26 if continues to improve.  - Follow-up with hematology/oncology as outpatient   Hypothyroidism - Continue Synthroid at home dose   Overactive bladder - Resume Myrbetriq on discharge   Recurrent major depression - Continue sertraline 100 mg daily as per home regimen
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Acidosis hyperchloraemic, Acute respiratory failure, Anaemia, Anxiety, Blood albumin
Clinical narrative: Patient is a 87 y.o. male patient of D.O. with history of HTN, prior CVA, HLD presented to Hospital with viral syndrome secondary to COVID-19.   COVID-19 infection Viral Pneumonia due to COVID-19 Acute respiratory failure with hypoxia, resolved Bacterial PNA Vaccinated with initial series of two shots but no subsequent boosters No respiratory sx other than sore throat; remains on RA CXR negative for pleural effusion or pneumothorax; no rib fracture seen. No active lung disease.  Rpt CXR 10/13 mild coarse linear/strandy and hazy/patchy perihilar and left basilar airspace disease.  The lungs otherwise remain clear. Oxygen: 3L 10/13-10/14, 1L 10/14-10/15, room air 10/16 AM ID consulted; Dexamethasone 10/11-10/20 OR discharge and Remdesivir initiated 10/11-10/15  Sputum culture resulted 10/20 with mssa and enterobacter, no leukocytosis, but is at risk for secondary bacterial pneumonia after covid pna, keflex x5 10/20-10/25 Urine antigens (-). Strep negative. COVID positive.  Vibratory pep, Guaifenasin, IS Monitor with supportive therapy   Non-Anion Gap Metabolic Acidosis Lactic Acidosis  Hyperchloremia  Due to hyperchloremia and lactate elevation Lactate elevation persisted despite fluids, albumin He is tolerating po, he has no abd pain, and an overall benign exam Given serum bicarb has improved and he is asymptomatic, stopped checked lactate    Anemia No evidence of acute blood loss Suspect due to dilutional effect  Daily cbc   HTN Chronic, stable BP 132/68 Continue home Metoprolol HLD Prior CVA Previously on statin in 4/2023 Discontinued in July 2023 Encouraged resumption  Continue ASA   Physical Deconditioning Secondary to COVID pna / symptoms PT/OT have been following SNF on discharge 10/20 AM   Delirium resolved Likely 2/2 acute infection requiring hospitalization Reportedly anxious on the evening of 10/11 with concern for visual hallucination. Anxiousness with re-occurrence 10/12 overnight.   Resolved on 10/12 exam with pt A&Ox3, answers questions appropriately.  10/13: A&Ox3 to person, place, and situation; correctly identifies the year; incorrect month.  10/14: A&O x3 Haldol prn  Cont to monitor; further delirium management as needed
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Blood bicarbonate abnormal, Blood lactic acid increased, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal
Clinical narrative: Patient is a 87 y.o. male patient of D.O. with history of HTN, prior CVA, HLD presented to Hospital with viral syndrome secondary to COVID-19.   COVID-19 infection Viral Pneumonia due to COVID-19 Acute respiratory failure with hypoxia, resolved Bacterial PNA Vaccinated with initial series of two shots but no subsequent boosters No respiratory sx other than sore throat; remains on RA CXR negative for pleural effusion or pneumothorax; no rib fracture seen. No active lung disease.  Rpt CXR 10/13 mild coarse linear/strandy and hazy/patchy perihilar and left basilar airspace disease.  The lungs otherwise remain clear. Oxygen: 3L 10/13-10/14, 1L 10/14-10/15, room air 10/16 AM ID consulted; Dexamethasone 10/11-10/20 OR discharge and Remdesivir initiated 10/11-10/15  Sputum culture resulted 10/20 with mssa and enterobacter, no leukocytosis, but is at risk for secondary bacterial pneumonia after covid pna, keflex x5 10/20-10/25 Urine antigens (-). Strep negative. COVID positive.  Vibratory pep, Guaifenasin, IS Monitor with supportive therapy   Non-Anion Gap Metabolic Acidosis Lactic Acidosis  Hyperchloremia  Due to hyperchloremia and lactate elevation Lactate elevation persisted despite fluids, albumin He is tolerating po, he has no abd pain, and an overall benign exam Given serum bicarb has improved and he is asymptomatic, stopped checked lactate    Anemia No evidence of acute blood loss Suspect due to dilutional effect  Daily cbc   HTN Chronic, stable BP 132/68 Continue home Metoprolol HLD Prior CVA Previously on statin in 4/2023 Discontinued in July 2023 Encouraged resumption  Continue ASA   Physical Deconditioning Secondary to COVID pna / symptoms PT/OT have been following SNF on discharge 10/20 AM   Delirium resolved Likely 2/2 acute infection requiring hospitalization Reportedly anxious on the evening of 10/11 with concern for visual hallucination. Anxiousness with re-occurrence 10/12 overnight.   Resolved on 10/12 exam with pt A&Ox3, answers questions appropriately.  10/13: A&Ox3 to person, place, and situation; correctly identifies the year; incorrect month.  10/14: A&O x3 Haldol prn  Cont to monitor; further delirium management as needed
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Delirium, Enterobacter test positive, Hyperchloraemia, Hypoxia, Lactic acidosis
Clinical narrative: Patient is a 87 y.o. male patient of D.O. with history of HTN, prior CVA, HLD presented to Hospital with viral syndrome secondary to COVID-19.   COVID-19 infection Viral Pneumonia due to COVID-19 Acute respiratory failure with hypoxia, resolved Bacterial PNA Vaccinated with initial series of two shots but no subsequent boosters No respiratory sx other than sore throat; remains on RA CXR negative for pleural effusion or pneumothorax; no rib fracture seen. No active lung disease.  Rpt CXR 10/13 mild coarse linear/strandy and hazy/patchy perihilar and left basilar airspace disease.  The lungs otherwise remain clear. Oxygen: 3L 10/13-10/14, 1L 10/14-10/15, room air 10/16 AM ID consulted; Dexamethasone 10/11-10/20 OR discharge and Remdesivir initiated 10/11-10/15  Sputum culture resulted 10/20 with mssa and enterobacter, no leukocytosis, but is at risk for secondary bacterial pneumonia after covid pna, keflex x5 10/20-10/25 Urine antigens (-). Strep negative. COVID positive.  Vibratory pep, Guaifenasin, IS Monitor with supportive therapy   Non-Anion Gap Metabolic Acidosis Lactic Acidosis  Hyperchloremia  Due to hyperchloremia and lactate elevation Lactate elevation persisted despite fluids, albumin He is tolerating po, he has no abd pain, and an overall benign exam Given serum bicarb has improved and he is asymptomatic, stopped checked lactate    Anemia No evidence of acute blood loss Suspect due to dilutional effect  Daily cbc   HTN Chronic, stable BP 132/68 Continue home Metoprolol HLD Prior CVA Previously on statin in 4/2023 Discontinued in July 2023 Encouraged resumption  Continue ASA   Physical Deconditioning Secondary to COVID pna / symptoms PT/OT have been following SNF on discharge 10/20 AM   Delirium resolved Likely 2/2 acute infection requiring hospitalization Reportedly anxious on the evening of 10/11 with concern for visual hallucination. Anxiousness with re-occurrence 10/12 overnight.   Resolved on 10/12 exam with pt A&Ox3, answers questions appropriately.  10/13: A&Ox3 to person, place, and situation; correctly identifies the year; incorrect month.  10/14: A&O x3 Haldol prn  Cont to monitor; further delirium management as needed
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Lung disorder, Oropharyngeal pain, Physical deconditioning, Pneumonia bacterial, Pneumonia viral
Clinical narrative: Patient is a 87 y.o. male patient of D.O. with history of HTN, prior CVA, HLD presented to Hospital with viral syndrome secondary to COVID-19.   COVID-19 infection Viral Pneumonia due to COVID-19 Acute respiratory failure with hypoxia, resolved Bacterial PNA Vaccinated with initial series of two shots but no subsequent boosters No respiratory sx other than sore throat; remains on RA CXR negative for pleural effusion or pneumothorax; no rib fracture seen. No active lung disease.  Rpt CXR 10/13 mild coarse linear/strandy and hazy/patchy perihilar and left basilar airspace disease.  The lungs otherwise remain clear. Oxygen: 3L 10/13-10/14, 1L 10/14-10/15, room air 10/16 AM ID consulted; Dexamethasone 10/11-10/20 OR discharge and Remdesivir initiated 10/11-10/15  Sputum culture resulted 10/20 with mssa and enterobacter, no leukocytosis, but is at risk for secondary bacterial pneumonia after covid pna, keflex x5 10/20-10/25 Urine antigens (-). Strep negative. COVID positive.  Vibratory pep, Guaifenasin, IS Monitor with supportive therapy   Non-Anion Gap Metabolic Acidosis Lactic Acidosis  Hyperchloremia  Due to hyperchloremia and lactate elevation Lactate elevation persisted despite fluids, albumin He is tolerating po, he has no abd pain, and an overall benign exam Given serum bicarb has improved and he is asymptomatic, stopped checked lactate    Anemia No evidence of acute blood loss Suspect due to dilutional effect  Daily cbc   HTN Chronic, stable BP 132/68 Continue home Metoprolol HLD Prior CVA Previously on statin in 4/2023 Discontinued in July 2023 Encouraged resumption  Continue ASA   Physical Deconditioning Secondary to COVID pna / symptoms PT/OT have been following SNF on discharge 10/20 AM   Delirium resolved Likely 2/2 acute infection requiring hospitalization Reportedly anxious on the evening of 10/11 with concern for visual hallucination. Anxiousness with re-occurrence 10/12 overnight.   Resolved on 10/12 exam with pt A&Ox3, answers questions appropriately.  10/13: A&Ox3 to person, place, and situation; correctly identifies the year; incorrect month.  10/14: A&O x3 Haldol prn  Cont to monitor; further delirium management as needed
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Sputum culture positive, Staphylococcus test positive, Streptococcus test negative, Urine antigen test
Clinical narrative: Patient is a 87 y.o. male patient of D.O. with history of HTN, prior CVA, HLD presented to Hospital with viral syndrome secondary to COVID-19.   COVID-19 infection Viral Pneumonia due to COVID-19 Acute respiratory failure with hypoxia, resolved Bacterial PNA Vaccinated with initial series of two shots but no subsequent boosters No respiratory sx other than sore throat; remains on RA CXR negative for pleural effusion or pneumothorax; no rib fracture seen. No active lung disease.  Rpt CXR 10/13 mild coarse linear/strandy and hazy/patchy perihilar and left basilar airspace disease.  The lungs otherwise remain clear. Oxygen: 3L 10/13-10/14, 1L 10/14-10/15, room air 10/16 AM ID consulted; Dexamethasone 10/11-10/20 OR discharge and Remdesivir initiated 10/11-10/15  Sputum culture resulted 10/20 with mssa and enterobacter, no leukocytosis, but is at risk for secondary bacterial pneumonia after covid pna, keflex x5 10/20-10/25 Urine antigens (-). Strep negative. COVID positive.  Vibratory pep, Guaifenasin, IS Monitor with supportive therapy   Non-Anion Gap Metabolic Acidosis Lactic Acidosis  Hyperchloremia  Due to hyperchloremia and lactate elevation Lactate elevation persisted despite fluids, albumin He is tolerating po, he has no abd pain, and an overall benign exam Given serum bicarb has improved and he is asymptomatic, stopped checked lactate    Anemia No evidence of acute blood loss Suspect due to dilutional effect  Daily cbc   HTN Chronic, stable BP 132/68 Continue home Metoprolol HLD Prior CVA Previously on statin in 4/2023 Discontinued in July 2023 Encouraged resumption  Continue ASA   Physical Deconditioning Secondary to COVID pna / symptoms PT/OT have been following SNF on discharge 10/20 AM   Delirium resolved Likely 2/2 acute infection requiring hospitalization Reportedly anxious on the evening of 10/11 with concern for visual hallucination. Anxiousness with re-occurrence 10/12 overnight.   Resolved on 10/12 exam with pt A&Ox3, answers questions appropriately.  10/13: A&Ox3 to person, place, and situation; correctly identifies the year; incorrect month.  10/14: A&O x3 Haldol prn  Cont to monitor; further delirium management as needed
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Viral infection
Clinical narrative: Patient is a 87 y.o. male patient of D.O. with history of HTN, prior CVA, HLD presented to Hospital with viral syndrome secondary to COVID-19.   COVID-19 infection Viral Pneumonia due to COVID-19 Acute respiratory failure with hypoxia, resolved Bacterial PNA Vaccinated with initial series of two shots but no subsequent boosters No respiratory sx other than sore throat; remains on RA CXR negative for pleural effusion or pneumothorax; no rib fracture seen. No active lung disease.  Rpt CXR 10/13 mild coarse linear/strandy and hazy/patchy perihilar and left basilar airspace disease.  The lungs otherwise remain clear. Oxygen: 3L 10/13-10/14, 1L 10/14-10/15, room air 10/16 AM ID consulted; Dexamethasone 10/11-10/20 OR discharge and Remdesivir initiated 10/11-10/15  Sputum culture resulted 10/20 with mssa and enterobacter, no leukocytosis, but is at risk for secondary bacterial pneumonia after covid pna, keflex x5 10/20-10/25 Urine antigens (-). Strep negative. COVID positive.  Vibratory pep, Guaifenasin, IS Monitor with supportive therapy   Non-Anion Gap Metabolic Acidosis Lactic Acidosis  Hyperchloremia  Due to hyperchloremia and lactate elevation Lactate elevation persisted despite fluids, albumin He is tolerating po, he has no abd pain, and an overall benign exam Given serum bicarb has improved and he is asymptomatic, stopped checked lactate    Anemia No evidence of acute blood loss Suspect due to dilutional effect  Daily cbc   HTN Chronic, stable BP 132/68 Continue home Metoprolol HLD Prior CVA Previously on statin in 4/2023 Discontinued in July 2023 Encouraged resumption  Continue ASA   Physical Deconditioning Secondary to COVID pna / symptoms PT/OT have been following SNF on discharge 10/20 AM   Delirium resolved Likely 2/2 acute infection requiring hospitalization Reportedly anxious on the evening of 10/11 with concern for visual hallucination. Anxiousness with re-occurrence 10/12 overnight.   Resolved on 10/12 exam with pt A&Ox3, answers questions appropriately.  10/13: A&Ox3 to person, place, and situation; correctly identifies the year; incorrect month.  10/14: A&O x3 Haldol prn  Cont to monitor; further delirium management as needed
Age: 65.0
Sex: F
Vaccine: TDAP
Symptoms: Gastrointestinal disorder, Muscle spasms
Clinical narrative: reported on 12/22/2023 that client had started back on 11/07/2023 with charley horses cramps in legs, she has had them for the past 6 weeks.  she has not been seen by a physician  she "doesn't have one and hasn't needed one" She also c/o Gi issues unknown how long symptoms have been going on.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Arthralgia, Asthenia, Blood creatinine increased, COVID-19
Clinical narrative: Patient is a 83 y.o. male with a history of CAD s/p CABG and stent and CKD IV who presented to Facility 10/25/2023 with generalized weakness. Found to have COVID-19.   1. COVID 19: positive test 10/25/23. Wife has had COVID since ~10/20/23. No hypoxia. Dr. (ID) recommended 3 days remedesivir which he completed 10/27/23. Isolation per protocol.  2. Generalized Weakness: in the setting of COVID 19 infection with reduced mobility. PT/OT followed. 3. Elevated Troponin: troponin 53 on admit with flat trend. No reported chest pain. Supportive care continued. 4. Right Shoulder Pain: history of chronic pain but limited mobility noted on admit exam. Possible fall prior to admit. Xray on admission nonacute.  Supportive care continued. 5. CAD: history of stent and CABG. Last stent was 3/2022. ASA continued. Off plavix due to GI bleed. 6. AKI on CKD IV: baseline Cr 2.0, Cr 2.19 on admission. Resolved with gentle fluids. 7. OSA: not on CPAP. 8. HTN: per history. Home meds continued. 9. Chronic Pain: neck shoulder pain; continued home controlled medications. 10. Code status: Full code
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Chronic kidney disease, Condition aggravated, Gastrointestinal haemorrhage, Mobility decreased, SARS-CoV-2 test positive
Clinical narrative: Patient is a 83 y.o. male with a history of CAD s/p CABG and stent and CKD IV who presented to Facility 10/25/2023 with generalized weakness. Found to have COVID-19.   1. COVID 19: positive test 10/25/23. Wife has had COVID since ~10/20/23. No hypoxia. Dr. (ID) recommended 3 days remedesivir which he completed 10/27/23. Isolation per protocol.  2. Generalized Weakness: in the setting of COVID 19 infection with reduced mobility. PT/OT followed. 3. Elevated Troponin: troponin 53 on admit with flat trend. No reported chest pain. Supportive care continued. 4. Right Shoulder Pain: history of chronic pain but limited mobility noted on admit exam. Possible fall prior to admit. Xray on admission nonacute.  Supportive care continued. 5. CAD: history of stent and CABG. Last stent was 3/2022. ASA continued. Off plavix due to GI bleed. 6. AKI on CKD IV: baseline Cr 2.0, Cr 2.19 on admission. Resolved with gentle fluids. 7. OSA: not on CPAP. 8. HTN: per history. Home meds continued. 9. Chronic Pain: neck shoulder pain; continued home controlled medications. 10. Code status: Full code
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Troponin increased, X-ray normal
Clinical narrative: Patient is a 83 y.o. male with a history of CAD s/p CABG and stent and CKD IV who presented to Facility 10/25/2023 with generalized weakness. Found to have COVID-19.   1. COVID 19: positive test 10/25/23. Wife has had COVID since ~10/20/23. No hypoxia. Dr. (ID) recommended 3 days remedesivir which he completed 10/27/23. Isolation per protocol.  2. Generalized Weakness: in the setting of COVID 19 infection with reduced mobility. PT/OT followed. 3. Elevated Troponin: troponin 53 on admit with flat trend. No reported chest pain. Supportive care continued. 4. Right Shoulder Pain: history of chronic pain but limited mobility noted on admit exam. Possible fall prior to admit. Xray on admission nonacute.  Supportive care continued. 5. CAD: history of stent and CABG. Last stent was 3/2022. ASA continued. Off plavix due to GI bleed. 6. AKI on CKD IV: baseline Cr 2.0, Cr 2.19 on admission. Resolved with gentle fluids. 7. OSA: not on CPAP. 8. HTN: per history. Home meds continued. 9. Chronic Pain: neck shoulder pain; continued home controlled medications. 10. Code status: Full code
Age: 76.0
Sex: M
Vaccine: COVID19-2
Symptoms: Abdominal pain, Acute respiratory failure, Asthenia, Blood urea increased, Bronchial wall thickening
Clinical narrative: Patient is a pleasant 77-year-old male presented to the emergency department a chief complaint of flulike symptoms including cough, fever, myalgias, chest tightness, abdominal pain, diarrhea that been ongoing since 10/15/2023.  Patient reports that his wife is at home and has been diagnosed with COVID-19, currently on Paxlovid.  Patient reports he has been increasingly short of breath, a productive cough of sputum that has been blood-tinged but is noted to be minimal.  He has taken Tessalon Perles and coughing has ceased.  Patient reports that he is normally very active, but is increasingly weak but denies any falls or trauma.  Sinus sitting at bedside and states that the whole family was camping last weekend, and he had felt ill a few days ago.  Patient also notes that his granddaughter was found to be positive for strep throat within the last week.  Denies any tobacco, alcohol illicit drug use.  Denies any chronic cardiovascular or pulmonary conditions.  He denies any lightheadedness, dizziness, nausea/vomiting, melena, or hematochezia.   Work-up in the ED: As above patient to be positive for COVID-19 pneumonia and exhibited hypoxia with ambulation down to 85%.  Currently on 2 L nasal cannula to maintain oxygen saturation above 90%.  Was given loading dose of Decadron, ceftriaxone, and azithromycin in the ED.  Patient is noted to have slight worsening of renal function with GFR 53, CRT 1.37, and BUN 23, but does not meet criteria for AKI.  CT findings as above.  At this current time patient is hemodynamically stable and will be admitted under the hospitalist service for further work-up continuation of care.   Clinical Summary   Patient was admitted to the medical surgical unit due to acute hypoxic respiratory failure secondary to COVID-19 infection with probable pneumonitis with evidence of tracheal wall thickening and thickening of the mainstem bronchi.  Patient had no reoccurrence of hemoptysis.  He was placed on remdesivir and dexamethasone.  The following morning patient was feeling significantly improved, no longer requiring oxygen and requesting discharge.  I personally ambulated the patient in the room and he had no SPO2 less than 90% with ambulation and conversation.  Discussed Paxlovid with patient who wished to proceed with therapy.  Medications were reviewed and patient was instructed to stop his statin until completion of Paxlovid.  He was also given steroid and short course antibiotic related to the tracheal inflammation.  I have asked that he follow-up with pulmonology in regards to the CT findings of tracheal wall and maintenance stem bronchi thickening which may warrant biopsy in the future.  He did have some mild to moderate thrombocytopenia likely related to COVID.  I have asked him to recheck lab works in 1 week.     Discharge diagnosis Acute hypoxic respiratory failure, secondary to COVID-19 pneumonitis without consolidating pneumonia Hemoptysis Hypertension Hyperlipidemia