chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram thorax, Echocardiogram, Ejection fraction, Essential hypertension, Heart rate irregular
Clinical narrative: Physician Discharge Summary   Patient ID:  79 y.o.    Admit Date:  8/8/2022   Discharge Date:   8/11/2022   Discharge Diagnosis:  Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Essential hypertension   Paroxysmal atrial fibrillation     Hospital Course:  79 year old female was admitted for Covid-19 pneumonia and treated with Remdesivir and steroids. Cardiology was involved for a fib with RVR. Rate became controlled later and she was started on anticoagulation. TTE showed normal LVEF. She is stable now and will be discharged home with NOAC and to resume Quinidine to keep the HR under control. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.9 °F (36.6 °C) Heart Rate (Monitor): 103 Pulse: 78 BP: (!) 129/94 Respirations: 18 SpO2: 99 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: irregular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO DIETARY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY   Significant Diagnostic Studies:   TTE, CT thorax   Operations: none   Disposition:  Home
Age: 80.0
Sex: F
Vaccine: COVID19-2
Symptoms: Asthenia, Chills, Fall, Feeling cold, Insomnia
Clinical narrative: Moderna booster yesterday, felt ok afterwards. Could not sleep well last night, tossing and turning, Fever and cold chills all night long. Extreme weakness this morning, fell, and could not get up.
Age: 80.0
Sex: F
Vaccine: COVID19-2
Symptoms: Mobility decreased, Pyrexia
Clinical narrative: Moderna booster yesterday, felt ok afterwards. Could not sleep well last night, tossing and turning, Fever and cold chills all night long. Extreme weakness this morning, fell, and could not get up.
Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Chest X-ray, Computerised tomogram, Electrocardiogram, Headache, Oxygen saturation decreased
Clinical narrative: headache, vomiting, drop in oxygen to 55
Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Ultrasound scan, Vomiting
Clinical narrative: headache, vomiting, drop in oxygen to 55
Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Culture urine positive, Fungal infection, Nervous system disorder, Neurogenic bladder
Clinical narrative: When I received the vaccine, I have a reaction with my nerves. My entire body starts itching. I also developed a Neurogenic Bladder. They prescribed Fluconazole for the yeast infection they found on 09/02/2022.
Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Pruritus
Clinical narrative: When I received the vaccine, I have a reaction with my nerves. My entire body starts itching. I also developed a Neurogenic Bladder. They prescribed Fluconazole for the yeast infection they found on 09/02/2022.
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Chest X-ray normal, Cough, Dyspnoea, Fatigue
Clinical narrative: Admission Date: 8/25/2022 Discharge Date: Aug 26, 2022  PRESENTING PROBLEM: Hypoxia [R09.02] COVID-19 [U07.1]   HOSPITAL COURSE:   59-year-old female with past medical history significant for atrial fibrillation, hypothyroidism, hypertension.  She presents emergency department 8/25 with several days of cough, shortness of breath and fatigue.  She tested positive for COVID.  She is hemodynamically stable initially however placed on 2 L of oxygen for support.  Chest x-ray was unremarkable.  She was started on Decadron.  By the following morning patient is feeling much better and is on room air.  Her symptoms were improved.  Discharged home in improved primary care condition to complete a course of Decadron and follow-up with primary care as needed.
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoxia, SARS-CoV-2 test positive
Clinical narrative: Admission Date: 8/25/2022 Discharge Date: Aug 26, 2022  PRESENTING PROBLEM: Hypoxia [R09.02] COVID-19 [U07.1]   HOSPITAL COURSE:   59-year-old female with past medical history significant for atrial fibrillation, hypothyroidism, hypertension.  She presents emergency department 8/25 with several days of cough, shortness of breath and fatigue.  She tested positive for COVID.  She is hemodynamically stable initially however placed on 2 L of oxygen for support.  Chest x-ray was unremarkable.  She was started on Decadron.  By the following morning patient is feeling much better and is on room air.  Her symptoms were improved.  Discharged home in improved primary care condition to complete a course of Decadron and follow-up with primary care as needed.
Age: 29.0
Sex: F
Vaccine: COVID19-2
Symptoms: Syringe issue
Clinical narrative: Vaccine Leak: I felt liquid run down my arm. I?m unsure how much leaked out because I wasn?t looking due to my fear of needles but I did feel the liquid run down my arm. I asked the pharmacist if it was blood she told me no that it was the vaccine liquid. I am worried because I do work with people although I?m not in healthcare and I?ve been waiting for the 3rd shot vigilantly. But now I don?t feel as safe and would like to ask for an extra booster or even 1/2 the dose if possible?
Age: 44.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: ADMINISTERED EXPIRED VACCINE
Age: 80.0
Sex: F
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: 07/17/1941
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: ADMINISTERED EXPIRED VACCINE
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain, Biliary catheter insertion, COVID-19, Carbohydrate antigen 19-9 increased, Chest X-ray normal
Clinical narrative: Admission Date: 8/24/2022 Discharge Date:  8/28/2022  PRESENTING PROBLEM: Primary sclerosing cholangitis [K83.01] Abdominal pain [R10.9] Elevated LFTs [R79.89] Intractable abdominal pain [R10.9] COVID-19 virus infection [U07.1] Cholangitis [K83.09]   HOSPITAL COURSE: The patient is a 59-year-old female with a history of PSC, chronic back pain, essential hypertension, remote history of Roux-en-Y gastric bypass, herpes simplex, and chronic pruritus due to PSC who presented with increasing abdominal pain, febrile illness and elevated LFTs..  Patient does have a history of PTC with biliary drain placed on 03/16/2022 at  which was removed on 04/05/2022.  At the time of admission she was found to have elevated LFTs.  CT scan of the abdomen pelvis showed no acute changes.  Patient was also found to have COVID infection, but chest x-ray was negative, and the patient's O2 saturations were stable on room air.   Patient was admitted to the hospital service and started on Zosyn.  GI was consulted.  Was also consulted, as it was initially felt the patient likely would need repeat PTC drainage.  MRCP was consistent with PSC with active cholangitis, with several areas of narrowing.  The case was discussed with attending, who felt that there was no need for intervention.  Hepatology initially felt that the patient would require PTC with brushings of the bile ducts, as CA 19 9 is elevated.  With antibiotics the patient's abdominal pain significantly improved and LFTs also returned to near normal levels.  With clinical improvement and improved LFTs, it was felt the patient did not require PTC drainage at this time.  Patient's case is to be discussed by GI with the soft tissue tumor board on 09/13.  Patient also has an appoint with on 09/13 and was encouraged to keep this appointment.   The patient did have positive COVID test, with fever on admission however was otherwise asymptomatic with regards to her COVID infection, and was not treated with Paxlovid, remdesivir or dexamethasone.   As patient was clinically stable, she was transition from Zosyn to Augmentin, to be continued to complete a 14 day course of treatment, and discharged to home on 08/28.
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Cholangitis, Cholangitis sclerosing, Computerised tomogram abdomen normal, Condition aggravated, Liver function test increased
Clinical narrative: Admission Date: 8/24/2022 Discharge Date:  8/28/2022  PRESENTING PROBLEM: Primary sclerosing cholangitis [K83.01] Abdominal pain [R10.9] Elevated LFTs [R79.89] Intractable abdominal pain [R10.9] COVID-19 virus infection [U07.1] Cholangitis [K83.09]   HOSPITAL COURSE: The patient is a 59-year-old female with a history of PSC, chronic back pain, essential hypertension, remote history of Roux-en-Y gastric bypass, herpes simplex, and chronic pruritus due to PSC who presented with increasing abdominal pain, febrile illness and elevated LFTs..  Patient does have a history of PTC with biliary drain placed on 03/16/2022 at  which was removed on 04/05/2022.  At the time of admission she was found to have elevated LFTs.  CT scan of the abdomen pelvis showed no acute changes.  Patient was also found to have COVID infection, but chest x-ray was negative, and the patient's O2 saturations were stable on room air.   Patient was admitted to the hospital service and started on Zosyn.  GI was consulted.  Was also consulted, as it was initially felt the patient likely would need repeat PTC drainage.  MRCP was consistent with PSC with active cholangitis, with several areas of narrowing.  The case was discussed with attending, who felt that there was no need for intervention.  Hepatology initially felt that the patient would require PTC with brushings of the bile ducts, as CA 19 9 is elevated.  With antibiotics the patient's abdominal pain significantly improved and LFTs also returned to near normal levels.  With clinical improvement and improved LFTs, it was felt the patient did not require PTC drainage at this time.  Patient's case is to be discussed by GI with the soft tissue tumor board on 09/13.  Patient also has an appoint with on 09/13 and was encouraged to keep this appointment.   The patient did have positive COVID test, with fever on admission however was otherwise asymptomatic with regards to her COVID infection, and was not treated with Paxlovid, remdesivir or dexamethasone.   As patient was clinically stable, she was transition from Zosyn to Augmentin, to be continued to complete a 14 day course of treatment, and discharged to home on 08/28.
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Pyrexia, SARS-CoV-2 test positive
Clinical narrative: Admission Date: 8/24/2022 Discharge Date:  8/28/2022  PRESENTING PROBLEM: Primary sclerosing cholangitis [K83.01] Abdominal pain [R10.9] Elevated LFTs [R79.89] Intractable abdominal pain [R10.9] COVID-19 virus infection [U07.1] Cholangitis [K83.09]   HOSPITAL COURSE: The patient is a 59-year-old female with a history of PSC, chronic back pain, essential hypertension, remote history of Roux-en-Y gastric bypass, herpes simplex, and chronic pruritus due to PSC who presented with increasing abdominal pain, febrile illness and elevated LFTs..  Patient does have a history of PTC with biliary drain placed on 03/16/2022 at  which was removed on 04/05/2022.  At the time of admission she was found to have elevated LFTs.  CT scan of the abdomen pelvis showed no acute changes.  Patient was also found to have COVID infection, but chest x-ray was negative, and the patient's O2 saturations were stable on room air.   Patient was admitted to the hospital service and started on Zosyn.  GI was consulted.  Was also consulted, as it was initially felt the patient likely would need repeat PTC drainage.  MRCP was consistent with PSC with active cholangitis, with several areas of narrowing.  The case was discussed with attending, who felt that there was no need for intervention.  Hepatology initially felt that the patient would require PTC with brushings of the bile ducts, as CA 19 9 is elevated.  With antibiotics the patient's abdominal pain significantly improved and LFTs also returned to near normal levels.  With clinical improvement and improved LFTs, it was felt the patient did not require PTC drainage at this time.  Patient's case is to be discussed by GI with the soft tissue tumor board on 09/13.  Patient also has an appoint with on 09/13 and was encouraged to keep this appointment.   The patient did have positive COVID test, with fever on admission however was otherwise asymptomatic with regards to her COVID infection, and was not treated with Paxlovid, remdesivir or dexamethasone.   As patient was clinically stable, she was transition from Zosyn to Augmentin, to be continued to complete a 14 day course of treatment, and discharged to home on 08/28.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Auscultation, COVID-19, Cardiac failure acute, Cardiac failure congestive, Echocardiogram
Clinical narrative: Patient ID: 75 y.o.   Admit Date:  8/8/2022   Discharge Date:   8/12/2022   Discharge Diagnosis:  Principal Problem:   Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure Active Problems:   Pneumonia due to COVID-19 virus   Elevated troponin   COPD (chronic obstructive pulmonary disease)   HTN (hypertension)   Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin     Hospital Course:  75 year old female was admitted for CHF exacerbation and Covid-19 infection. She has been treated with Remdesivir, steroids and empiric antibiotics. TTE show 50-55% LVEF. Cardiology recommend continuing BB. She will be discharged home today with hospice services per family request. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.3 °F (36.3 °C) Heart Rate (Monitor): 64 Pulse: 58 BP: 132/69 Respirations: 16 SpO2: 97 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: no edema Neuro: alert   Consults:  IP CONSULT TO PULMONOLOGY IP CONSULT TO CARDIOLOGY IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   TTE   Operations: none   Disposition:  Home with hospice   Discharge Condition:  Fair
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Ejection fraction, Left ventricular failure, Troponin increased
Clinical narrative: Patient ID: 75 y.o.   Admit Date:  8/8/2022   Discharge Date:   8/12/2022   Discharge Diagnosis:  Principal Problem:   Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure Active Problems:   Pneumonia due to COVID-19 virus   Elevated troponin   COPD (chronic obstructive pulmonary disease)   HTN (hypertension)   Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin     Hospital Course:  75 year old female was admitted for CHF exacerbation and Covid-19 infection. She has been treated with Remdesivir, steroids and empiric antibiotics. TTE show 50-55% LVEF. Cardiology recommend continuing BB. She will be discharged home today with hospice services per family request. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.3 °F (36.3 °C) Heart Rate (Monitor): 64 Pulse: 58 BP: 132/69 Respirations: 16 SpO2: 97 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: no edema Neuro: alert   Consults:  IP CONSULT TO PULMONOLOGY IP CONSULT TO CARDIOLOGY IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   TTE   Operations: none   Disposition:  Home with hospice   Discharge Condition:  Fair
Age: 47.0
Sex: M
Vaccine: COVID19-2
Symptoms: Facial pain, Headache
Clinical narrative: Terrible pain in my head all the way down my face.
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Auscultation, Bacterial sepsis, COVID-19, Computerised tomogram abdomen, Condition aggravated
Clinical narrative: Admit Date:  8/8/2022   Discharge Date:   8/12/2022   Discharge Diagnosis:  Principal Problem:   Other gram-negative sepsis Active Problems:   Acute renal failure with tubular necrosis   HTN (hypertension)   Renal stone   Kidney infection   COVID-19 virus infection     Hospital Course:  72 year old female was admitted for sepsis developing from the obstructing 6 mm calculus at the ureteropelvic junction in the right side. Cultures grew gram (-) bacilli and urine culture confirmed Klebsiella. She also tested (+) for Covid-19 infection on admission but did not need treatment for that. Renal failure improved with IV fluids. She had cystoscopy with placement of right ureteral stent. She was initially in the ICU for requiring pressor agent and later transferred to the floor. She has been on IV antibiotic. Procalcitonin was severely elevated as high as 65.59. It is 5.91 today. She will be discharged home today in stable condition on oral antibiotic. She will follow up with urology for laser lithotripsy and stone extraction in 2-3 weeks. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 98.7 °F (37.1 °C) Heart Rate (Monitor): 61 Pulse: 72 BP: 130/71 Respirations: 16 SpO2: 96 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO UROLOGY IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   Ct abdomen and pelvis   Operations: Cystoscopy, Right Retrograde Pyelogram, Right JJ Ureteral Stent Placement   Disposition:  Home    Discharge Condition:  Fair
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Culture positive, Culture urine positive, Cystoscopy abnormal, Intensive care, Klebsiella test positive
Clinical narrative: Admit Date:  8/8/2022   Discharge Date:   8/12/2022   Discharge Diagnosis:  Principal Problem:   Other gram-negative sepsis Active Problems:   Acute renal failure with tubular necrosis   HTN (hypertension)   Renal stone   Kidney infection   COVID-19 virus infection     Hospital Course:  72 year old female was admitted for sepsis developing from the obstructing 6 mm calculus at the ureteropelvic junction in the right side. Cultures grew gram (-) bacilli and urine culture confirmed Klebsiella. She also tested (+) for Covid-19 infection on admission but did not need treatment for that. Renal failure improved with IV fluids. She had cystoscopy with placement of right ureteral stent. She was initially in the ICU for requiring pressor agent and later transferred to the floor. She has been on IV antibiotic. Procalcitonin was severely elevated as high as 65.59. It is 5.91 today. She will be discharged home today in stable condition on oral antibiotic. She will follow up with urology for laser lithotripsy and stone extraction in 2-3 weeks. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 98.7 °F (37.1 °C) Heart Rate (Monitor): 61 Pulse: 72 BP: 130/71 Respirations: 16 SpO2: 96 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO UROLOGY IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   Ct abdomen and pelvis   Operations: Cystoscopy, Right Retrograde Pyelogram, Right JJ Ureteral Stent Placement   Disposition:  Home    Discharge Condition:  Fair
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Lithotripsy, Nephrolithiasis, Procalcitonin increased, Renal failure, Renal stone removal
Clinical narrative: Admit Date:  8/8/2022   Discharge Date:   8/12/2022   Discharge Diagnosis:  Principal Problem:   Other gram-negative sepsis Active Problems:   Acute renal failure with tubular necrosis   HTN (hypertension)   Renal stone   Kidney infection   COVID-19 virus infection     Hospital Course:  72 year old female was admitted for sepsis developing from the obstructing 6 mm calculus at the ureteropelvic junction in the right side. Cultures grew gram (-) bacilli and urine culture confirmed Klebsiella. She also tested (+) for Covid-19 infection on admission but did not need treatment for that. Renal failure improved with IV fluids. She had cystoscopy with placement of right ureteral stent. She was initially in the ICU for requiring pressor agent and later transferred to the floor. She has been on IV antibiotic. Procalcitonin was severely elevated as high as 65.59. It is 5.91 today. She will be discharged home today in stable condition on oral antibiotic. She will follow up with urology for laser lithotripsy and stone extraction in 2-3 weeks. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 98.7 °F (37.1 °C) Heart Rate (Monitor): 61 Pulse: 72 BP: 130/71 Respirations: 16 SpO2: 96 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO UROLOGY IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   Ct abdomen and pelvis   Operations: Cystoscopy, Right Retrograde Pyelogram, Right JJ Ureteral Stent Placement   Disposition:  Home    Discharge Condition:  Fair
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Ureteral stent insertion, Urogram abnormal
Clinical narrative: Admit Date:  8/8/2022   Discharge Date:   8/12/2022   Discharge Diagnosis:  Principal Problem:   Other gram-negative sepsis Active Problems:   Acute renal failure with tubular necrosis   HTN (hypertension)   Renal stone   Kidney infection   COVID-19 virus infection     Hospital Course:  72 year old female was admitted for sepsis developing from the obstructing 6 mm calculus at the ureteropelvic junction in the right side. Cultures grew gram (-) bacilli and urine culture confirmed Klebsiella. She also tested (+) for Covid-19 infection on admission but did not need treatment for that. Renal failure improved with IV fluids. She had cystoscopy with placement of right ureteral stent. She was initially in the ICU for requiring pressor agent and later transferred to the floor. She has been on IV antibiotic. Procalcitonin was severely elevated as high as 65.59. It is 5.91 today. She will be discharged home today in stable condition on oral antibiotic. She will follow up with urology for laser lithotripsy and stone extraction in 2-3 weeks. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 98.7 °F (37.1 °C) Heart Rate (Monitor): 61 Pulse: 72 BP: 130/71 Respirations: 16 SpO2: 96 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO UROLOGY IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   Ct abdomen and pelvis   Operations: Cystoscopy, Right Retrograde Pyelogram, Right JJ Ureteral Stent Placement   Disposition:  Home    Discharge Condition:  Fair
Age: 37.0
Sex: M
Vaccine: COVID19, COVID19-2
Symptoms: Arthralgia, Heart rate increased, Heart rate irregular, Hyperthyroidism, Tremor
Clinical narrative: Hyperthyroidism. Irregular heart beat, trembling, fast pulse, joint pain,
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain, Angiogram cerebral abnormal, Arteriogram carotid abnormal, Blood sodium decreased, COVID-19
Clinical narrative: Discharge Provider: MD Primary Care Provider: DO Admission Date: 8/28/2022 Discharge Date: Sep 4, 2022  PRESENTING PROBLEM: Acute hyponatremia [E87.1] Colitis [K52.9] Hyponatremia [E87.1] Vertebral artery dissection (HCC) [I77.74] COVID-19 [U07.1]   HOSPITAL COURSE: 83 year old female with history of hypertension and hyperlipidemia.  She was seen by her PCP 8/23 with complains of abdominal pain dysuria and was started on Bactrim.  She thought she was allergic to bactrim and stopped taking it.  She presented to the ED 8/27 and was discharged on Macrobid.  She presented to the ED 8/28 with 2 days of chills, rigors and malaise which worsened 24 hours prior to admission and worsening mental status.  On arrival to the ED a stroke code was called, CT head negative, CT angio head and neck showed concern for right cervical vertebral V2 segment dissection.  CT perfusion brain negative.  CT abdomen and pelvis showed left sided colitis.  Labs significant for sodium of 103.   She was given 100ml of 3% saline and admitted to the ICU for treatment of hyponatremia.  She remained on room air and asymptomatic from COVID standpoint.   Sodium continued to improve, but leveled off on 09/01/2022.  Salt tablets were added 3 times a day with noted improvement. Sodium was 134 on day of discharge and sodium tabs were decreased to BID and she was recommended to follow-up with her PCP in 1 week for repeat sodium check and determine at that time if sodium tablets could be discontinued.    Neurology was consulted in regards to her right cervical V2  segment dissection on CT and recommended ASA (81 mg daily) with outpatient follow-up with neurovascular clinic for repeat imaging in 3 months.    PT/OT evaluated patient and recommended home on discharge. Patient was discharged in stable condition and discharge instructions provided.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Chills, Colitis, Computerised tomogram abdomen abnormal, Computerised tomogram head normal, Condition aggravated
Clinical narrative: Discharge Provider: MD Primary Care Provider: DO Admission Date: 8/28/2022 Discharge Date: Sep 4, 2022  PRESENTING PROBLEM: Acute hyponatremia [E87.1] Colitis [K52.9] Hyponatremia [E87.1] Vertebral artery dissection (HCC) [I77.74] COVID-19 [U07.1]   HOSPITAL COURSE: 83 year old female with history of hypertension and hyperlipidemia.  She was seen by her PCP 8/23 with complains of abdominal pain dysuria and was started on Bactrim.  She thought she was allergic to bactrim and stopped taking it.  She presented to the ED 8/27 and was discharged on Macrobid.  She presented to the ED 8/28 with 2 days of chills, rigors and malaise which worsened 24 hours prior to admission and worsening mental status.  On arrival to the ED a stroke code was called, CT head negative, CT angio head and neck showed concern for right cervical vertebral V2 segment dissection.  CT perfusion brain negative.  CT abdomen and pelvis showed left sided colitis.  Labs significant for sodium of 103.   She was given 100ml of 3% saline and admitted to the ICU for treatment of hyponatremia.  She remained on room air and asymptomatic from COVID standpoint.   Sodium continued to improve, but leveled off on 09/01/2022.  Salt tablets were added 3 times a day with noted improvement. Sodium was 134 on day of discharge and sodium tabs were decreased to BID and she was recommended to follow-up with her PCP in 1 week for repeat sodium check and determine at that time if sodium tablets could be discontinued.    Neurology was consulted in regards to her right cervical V2  segment dissection on CT and recommended ASA (81 mg daily) with outpatient follow-up with neurovascular clinic for repeat imaging in 3 months.    PT/OT evaluated patient and recommended home on discharge. Patient was discharged in stable condition and discharge instructions provided.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Dysuria, Hyponatraemia, Intensive care, Malaise, Mental status changes
Clinical narrative: Discharge Provider: MD Primary Care Provider: DO Admission Date: 8/28/2022 Discharge Date: Sep 4, 2022  PRESENTING PROBLEM: Acute hyponatremia [E87.1] Colitis [K52.9] Hyponatremia [E87.1] Vertebral artery dissection (HCC) [I77.74] COVID-19 [U07.1]   HOSPITAL COURSE: 83 year old female with history of hypertension and hyperlipidemia.  She was seen by her PCP 8/23 with complains of abdominal pain dysuria and was started on Bactrim.  She thought she was allergic to bactrim and stopped taking it.  She presented to the ED 8/27 and was discharged on Macrobid.  She presented to the ED 8/28 with 2 days of chills, rigors and malaise which worsened 24 hours prior to admission and worsening mental status.  On arrival to the ED a stroke code was called, CT head negative, CT angio head and neck showed concern for right cervical vertebral V2 segment dissection.  CT perfusion brain negative.  CT abdomen and pelvis showed left sided colitis.  Labs significant for sodium of 103.   She was given 100ml of 3% saline and admitted to the ICU for treatment of hyponatremia.  She remained on room air and asymptomatic from COVID standpoint.   Sodium continued to improve, but leveled off on 09/01/2022.  Salt tablets were added 3 times a day with noted improvement. Sodium was 134 on day of discharge and sodium tabs were decreased to BID and she was recommended to follow-up with her PCP in 1 week for repeat sodium check and determine at that time if sodium tablets could be discontinued.    Neurology was consulted in regards to her right cervical V2  segment dissection on CT and recommended ASA (81 mg daily) with outpatient follow-up with neurovascular clinic for repeat imaging in 3 months.    PT/OT evaluated patient and recommended home on discharge. Patient was discharged in stable condition and discharge instructions provided.
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Perfusion brain scan normal, Vertebrobasilar artery dissection
Clinical narrative: Discharge Provider: MD Primary Care Provider: DO Admission Date: 8/28/2022 Discharge Date: Sep 4, 2022  PRESENTING PROBLEM: Acute hyponatremia [E87.1] Colitis [K52.9] Hyponatremia [E87.1] Vertebral artery dissection (HCC) [I77.74] COVID-19 [U07.1]   HOSPITAL COURSE: 83 year old female with history of hypertension and hyperlipidemia.  She was seen by her PCP 8/23 with complains of abdominal pain dysuria and was started on Bactrim.  She thought she was allergic to bactrim and stopped taking it.  She presented to the ED 8/27 and was discharged on Macrobid.  She presented to the ED 8/28 with 2 days of chills, rigors and malaise which worsened 24 hours prior to admission and worsening mental status.  On arrival to the ED a stroke code was called, CT head negative, CT angio head and neck showed concern for right cervical vertebral V2 segment dissection.  CT perfusion brain negative.  CT abdomen and pelvis showed left sided colitis.  Labs significant for sodium of 103.   She was given 100ml of 3% saline and admitted to the ICU for treatment of hyponatremia.  She remained on room air and asymptomatic from COVID standpoint.   Sodium continued to improve, but leveled off on 09/01/2022.  Salt tablets were added 3 times a day with noted improvement. Sodium was 134 on day of discharge and sodium tabs were decreased to BID and she was recommended to follow-up with her PCP in 1 week for repeat sodium check and determine at that time if sodium tablets could be discontinued.    Neurology was consulted in regards to her right cervical V2  segment dissection on CT and recommended ASA (81 mg daily) with outpatient follow-up with neurovascular clinic for repeat imaging in 3 months.    PT/OT evaluated patient and recommended home on discharge. Patient was discharged in stable condition and discharge instructions provided.
Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Blood test normal, Cardiac stress test normal, Fatigue, Headache, Nervousness
Clinical narrative: Starting the day after receiving the vaccine, I had a mild headache for about 2 months. Also, I had severe fatigue. After 2 months, the headache went away, but the fatigue persisted. I got nervous because it was not resolving and I'm normally not that fatigued. I knew something was off. I saw the doctor who said that he had seen similar reactions to mine but they never lasted as long as mine have so far. Its just now getting better where I will have a few days of feeling normal and then a day of feeling badly again. So, I am concerned on whether or not to get another vaccine/booster yet or to wait.
Age: 5.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect dose administered, No adverse event
Clinical narrative: Patient was administered the incorrect dose required to complete the series. Patient received Pfizer 6 month to 4 years old vaccine instead of 5-11yr vaccine. Patient had no adverse reaction to the vaccine administered after waiting in office for 15 minutes.
Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, COVID-19 pneumonia, Dyspnoea
Clinical narrative: Patient came to the ED complaining of worsening shortness of breath for 3-4 days.  Patient states they were diagnosed with Covid the prior week and treated with oral steroid and Z-Pak.  Patient admitted to hospital with bilateral Covid pneumonia.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Fatigue, Nasopharyngitis, Oropharyngeal pain, Pyrexia
Clinical narrative: I started off with a sore throat that turned into what was like a bad cold. I was blowing my nose a lot and had a fever with fatigue. It lasted about a week. I was given Paxlovid.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Rhinorrhoea, SARS-CoV-2 test positive
Clinical narrative: I started off with a sore throat that turned into what was like a bad cold. I was blowing my nose a lot and had a fever with fatigue. It lasted about a week. I was given Paxlovid.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Barium swallow, COVID-19, COVID-19 pneumonia, Dysphagia, Dyspnoea
Clinical narrative: Discharge Provider:  MD Primary Care Provider : None Physician, DO None   Admission Date: 8/28/2022 Admitting Diagnoses:  Pneumonia due to COVID 19 virus   Discharge Date: 9/2/2022  PRESENTING PROBLEM: Pneumonia due to COVID-19 virus   HOSPITAL COURSE: Patient is a 74-year-old female with past medical history significant for cerebral palsy, dysphagia, hyperlipidemia, depression and anxiety.  Patient had tested positive for COVID as an outpatient on 08/25 and due to worsening shortness of breath and hypoxia presented to the emergency department.  She was admitted on 2 L of supplemental oxygen.  She was started on remdesivir and given a dose of Lasix at admission.   Patient had been on a dysphagia diet at the facility.  She was re-evaluated by SLP during admission who recommended video swallow study which showed no concerns and diet was upgraded to general solids and thin liquids.   She completed Remdezivir. Dexamethasone was added when O2 on pulse ox dropped below 90%. She was evaluated by pulm rehab and O2 was arranged for use at her discharge facility. She was stable for discharge back to fountain view AL facility.  She will be discharged with a prescription for dexamethasone to complete a 10 day course.  She will be out of isolation after 10 days from her positive test on 08/25.  The patient can continue supportive care measurements after discharge including over-the-counter antitussive medications, and she was also prescribed an albuterol inhaler.   At time of discharge the patient was hemodynamically stable and all questions were answered at bedside.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoxia, SARS-CoV-2 test positive
Clinical narrative: Discharge Provider:  MD Primary Care Provider : None Physician, DO None   Admission Date: 8/28/2022 Admitting Diagnoses:  Pneumonia due to COVID 19 virus   Discharge Date: 9/2/2022  PRESENTING PROBLEM: Pneumonia due to COVID-19 virus   HOSPITAL COURSE: Patient is a 74-year-old female with past medical history significant for cerebral palsy, dysphagia, hyperlipidemia, depression and anxiety.  Patient had tested positive for COVID as an outpatient on 08/25 and due to worsening shortness of breath and hypoxia presented to the emergency department.  She was admitted on 2 L of supplemental oxygen.  She was started on remdesivir and given a dose of Lasix at admission.   Patient had been on a dysphagia diet at the facility.  She was re-evaluated by SLP during admission who recommended video swallow study which showed no concerns and diet was upgraded to general solids and thin liquids.   She completed Remdezivir. Dexamethasone was added when O2 on pulse ox dropped below 90%. She was evaluated by pulm rehab and O2 was arranged for use at her discharge facility. She was stable for discharge back to fountain view AL facility.  She will be discharged with a prescription for dexamethasone to complete a 10 day course.  She will be out of isolation after 10 days from her positive test on 08/25.  The patient can continue supportive care measurements after discharge including over-the-counter antitussive medications, and she was also prescribed an albuterol inhaler.   At time of discharge the patient was hemodynamically stable and all questions were answered at bedside.
Age: 5.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered, No adverse event
Clinical narrative: Patient was administered the incorrect dose required to complete the series. Pt received Pfizer 6 month to 4 years old vaccine instead of 5-11yr vaccine. Pt had no adverse reaction to the vaccine administered after waiting in office for 15 minutes.
Age: 40.0
Sex: M
Vaccine: COVID19-2
Symptoms: Dizziness, Feeling abnormal, Feeling drunk, Headache, Paranasal sinus discomfort
Clinical narrative: Light headedness, movement felt weird, like I was drunk without the intoxication, like when you move you kind of feel the rest of yourself trying to catch up to you.  Headache, sinus pressure.  I took a really hot shower (what I normally do for headaches or hangovers) and took a nap for about 2 hours. I felt a bit better upon waking up, but a slight headache remains.
Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, COVID-19, Chronic kidney disease, Dehydration, Essential hypertension
Clinical narrative: Hospital Course:  79 year old female was admitted for Covid-19 infection and worsening renal function from dehydration. She was treated with IV fluids and Remdesivir. Renal function improved. She will be given the thrid dose of Remdesivir today and discharged afterwards. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 98 °F (36.7 °C) Pulse: 77 BP: 152/61 Respirations: 18 SpO2: 96 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone     Significant Diagnostic Studies:   VQ scan, BLE venous US   Operations: none   Disposition:  Home    Discharge Condition:  Fair
Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Renal impairment, Troponin increased, Ultrasound Doppler, Ventilation/perfusion scan
Clinical narrative: Hospital Course:  79 year old female was admitted for Covid-19 infection and worsening renal function from dehydration. She was treated with IV fluids and Remdesivir. Renal function improved. She will be given the thrid dose of Remdesivir today and discharged afterwards. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 98 °F (36.7 °C) Pulse: 77 BP: 152/61 Respirations: 18 SpO2: 96 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone     Significant Diagnostic Studies:   VQ scan, BLE venous US   Operations: none   Disposition:  Home    Discharge Condition:  Fair
Age: 50.0
Sex: F
Vaccine: COVID19
Symptoms: Extra dose administered, Herpes zoster, Rash
Clinical narrative: Pt reports receiving her 4th Moderna dose of the COVID vaccine last week and the next day got an odd looking rash.  She was seen by a dermatologist and was diagnosed with Shingles.
Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive, Vaccine breakthrough infection
Clinical narrative: Breakthrough case admission after three vaccines  Moderna 3/2/21 Lot# 030A21A;  Moderna 4/1/21 Lot# 006B21A;  Moderna 12/2/21 Lot# 034F21A
Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Product storage error
Clinical narrative: administration error/vaccine given beyond use date.
Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, COVID-19, Chronic kidney disease, Renal tubular necrosis, Superinfection
Clinical narrative: Discharge Diagnosis:  Principal Problem:   Acute renal failure with acute tubular necrosis superimposed on stage 2 chronic kidney disease Active Problems:   Diabetes mellitus type 2, controlled   Hypokalemia   COVID-19 virus infection   Essential hypertension     Hospital Course:  91 year old male with DM was admitted with AKI and Covid-19 infection. He had previously received vaccine booster. He was treated with Remdesivir. Renal function improved with IV fluids. He was discharged home today in stable condition. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.5 °F (36.4 °C) Heart Rate (Monitor): 67 Pulse: 76 BP: 152/68 Respirations: 18 SpO2: 100 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   CXRF   Operations: none   Disposition:  Home    Discharge Condition:  Fair
Age: 87.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive, Vaccine breakthrough infection
Clinical narrative: Breakthrough case admission after 4 vaccines;  Moderna 2/4/21 Lot# 013M20A;  Moderna 3/4/21 Lot# 030A21A;  Moderna 11/9/21 Lot# 939905;  Moderna 5/13/22 Lot# 056M21A
Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Expired product administered, Product administration error
Clinical narrative: administration error/vaccine given beyond use date.
Age: 43.0
Sex: F
Vaccine: COVID19
Symptoms: Pruritus, Throat irritation, Urticaria
Clinical narrative: 2 weeks after the shot I started experiencing hives, but not on the vaccine spot but on the whole body, showlders inside knees back of neck and back of hips. ichy hives daily but it did not escalate to anaphilactic level, I took Allegra anti histamine 3 times on first days when it felt a bit itchy on my throath.  I decided to stop taking allegra as it effects were not immediate and the hives go down on their own. But symptoms persist for 16 days now.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered, Product administration error
Clinical narrative: administration error/vaccine given beyond use date.
Age: 29.0
Sex: M
Vaccine: HEPA
Symptoms: Extra dose administered
Clinical narrative: pt was given an extra dose of Hepatitis A. Did not need the third dose.
Age: 44.0
Sex: M
Vaccine: COVID19-2
Symptoms: Incorrect dose administered
Clinical narrative: Patient was given correct shot (Moderna bivalent booster), however 0.25 mls was administered instead of 0.5 mls. Patient agreed to come back to the store 2 hour and 15 minutes later to have the second half of the shot administered in the same arm.
Age: 79.0
Sex: U
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: administration error/vaccine given beyond use date.
Age: 90.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Death, SARS-CoV-2 test positive, Vaccine breakthrough infection
Clinical narrative: Breakthrough case after three vaccines; patient expired  Pfizer 1/16/21 Lot# EL0142;  Pfizer 2/6/21 Lot# EL9261;  Pfizer 10/11/21 Lot# EW0183;
Age: 59.0
Sex: M
Vaccine: COVID19
Symptoms: Anticoagulant therapy, COVID-19, Computerised tomogram abdomen abnormal, Infusion, International normalised ratio decreased
Clinical narrative: Patient is a 60 y.o. male who presents today with RLE swelling and pain. Pt. has a PMH of factor V Leiden mutation with recurrent DVTs, chronic back pain, essential HTN. Pt. was recently admitted from 7/10/22 to 7/16/22 with recurrent RLE DVT despite compliance with pradaxa. He was started on a heparin qtt and hematology and IR were consulted. He underwent a thrombectomy with right common iliac stneting. Hematology recommended changing oral anticoagulant to coumadin with 30 days of plavix. Since discharge patient was doing well until about one to two weeks ago he started to have RLE swelling and now worsening pain. Found to be COVID positive. CT abdomen and pelvis with thrombotic occlusion of the right iliofemoral stent. He underwent Right lower extremity venography with catheter directed mechanical thrombectomy8/25.Hematology following since patient has multiple anticoagulation regimen failure, recommend warfarin with INR goal 2.5 to 3.5 and Plavix.  In the meantime, patient was anticoagulated on IV heparin drip. Pharmacy dosed patient's Coumadin while in the hospital.  Eventually over an extended period, patient's INR began to climb and on the day of discharge was at 2.1.  Patient was comfortable with Lovenox bridging at home and following up with his PCP at discharge.  An appointment was made for him prior to discharge.  Patient already had prescriptions for Lovenox at home and was trained on its use.  Patient was medically stable for discharge.
Age: 59.0
Sex: M
Vaccine: COVID19
Symptoms: Pain in extremity, Peripheral swelling, SARS-CoV-2 test positive, Thrombectomy, Vascular stent occlusion
Clinical narrative: Patient is a 60 y.o. male who presents today with RLE swelling and pain. Pt. has a PMH of factor V Leiden mutation with recurrent DVTs, chronic back pain, essential HTN. Pt. was recently admitted from 7/10/22 to 7/16/22 with recurrent RLE DVT despite compliance with pradaxa. He was started on a heparin qtt and hematology and IR were consulted. He underwent a thrombectomy with right common iliac stneting. Hematology recommended changing oral anticoagulant to coumadin with 30 days of plavix. Since discharge patient was doing well until about one to two weeks ago he started to have RLE swelling and now worsening pain. Found to be COVID positive. CT abdomen and pelvis with thrombotic occlusion of the right iliofemoral stent. He underwent Right lower extremity venography with catheter directed mechanical thrombectomy8/25.Hematology following since patient has multiple anticoagulation regimen failure, recommend warfarin with INR goal 2.5 to 3.5 and Plavix.  In the meantime, patient was anticoagulated on IV heparin drip. Pharmacy dosed patient's Coumadin while in the hospital.  Eventually over an extended period, patient's INR began to climb and on the day of discharge was at 2.1.  Patient was comfortable with Lovenox bridging at home and following up with his PCP at discharge.  An appointment was made for him prior to discharge.  Patient already had prescriptions for Lovenox at home and was trained on its use.  Patient was medically stable for discharge.