chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 72.0
Sex: F
Vaccine: COVID19-2
Symptoms: Arthralgia, Joint range of motion decreased, Laboratory test normal, Magnetic resonance imaging abnormal, Musculoskeletal stiffness
Clinical narrative: I had pain in my right shoulder and then about a week or two after that I started having pain in my muscles and joints. It was pain and stiffness throughout my right shoulders the to my calf, heels, foot or both of my legs. I waited a couple of weeks to see if it would go away. I couldn't raise my arm and it was painful. I had a Xray, and it showed nothing wrong. Then after being sent to a orthopedic doctor. I was having more pain increasing throughout my body. My PCP did order a bunch of lab work and stuff. Nothing was found in significance she everything looked good. Then after I saw her, she had me stop my Atorvastatin. After the Ortho doctor I was given a MRI of my shoulder. It showed a partial tear in my rotator cup, I received a cortisone injection in my shoulder and the pain went away in my shoulder and the rest of my body. He has now been about two weeks. My aches and pain in my body is coming back, but the shoulder pain is not. I going to contact my doctor this week.
Age: 72.0
Sex: F
Vaccine: COVID19-2
Symptoms: Myalgia, Pain, Pain in extremity, Rotator cuff syndrome, X-ray limb normal
Clinical narrative: I had pain in my right shoulder and then about a week or two after that I started having pain in my muscles and joints. It was pain and stiffness throughout my right shoulders the to my calf, heels, foot or both of my legs. I waited a couple of weeks to see if it would go away. I couldn't raise my arm and it was painful. I had a Xray, and it showed nothing wrong. Then after being sent to a orthopedic doctor. I was having more pain increasing throughout my body. My PCP did order a bunch of lab work and stuff. Nothing was found in significance she everything looked good. Then after I saw her, she had me stop my Atorvastatin. After the Ortho doctor I was given a MRI of my shoulder. It showed a partial tear in my rotator cup, I received a cortisone injection in my shoulder and the pain went away in my shoulder and the rest of my body. He has now been about two weeks. My aches and pain in my body is coming back, but the shoulder pain is not. I going to contact my doctor this week.
Age: 69.0
Sex: F
Vaccine: COVID19-2
Symptoms: COVID-19, Cough, Diarrhoea, Fatigue, Malaise
Clinical narrative: On Sunday on 2/26/23, I started with a runny nose, sneezing and feeling fatigue and tired. I went to bed and woke up feeling worse. I was nauseated and had diarrhea .Took 2 tests and it was positive and called my doctor and he prescribed Paxlovid that Monday at 1 or 2PM in the afternoon. After that finished and on 3/5/23, I had a sinus infection and I was on steroids and antibiotics.  I now have a cough which started on 4/12/23. I  will be starting on a Zpack Azithromycin and Loratadine after another Telehealth this morning .
Age: 69.0
Sex: F
Vaccine: COVID19-2
Symptoms: Nausea, Rhinorrhoea, SARS-CoV-2 test positive, Sinusitis, Sneezing
Clinical narrative: On Sunday on 2/26/23, I started with a runny nose, sneezing and feeling fatigue and tired. I went to bed and woke up feeling worse. I was nauseated and had diarrhea .Took 2 tests and it was positive and called my doctor and he prescribed Paxlovid that Monday at 1 or 2PM in the afternoon. After that finished and on 3/5/23, I had a sinus infection and I was on steroids and antibiotics.  I now have a cough which started on 4/12/23. I  will be starting on a Zpack Azithromycin and Loratadine after another Telehealth this morning .
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Asthenia, Asymptomatic bacteriuria, Bacterial test positive, COVID-19
Clinical narrative: Patient is a 78 y.o. female who presented on 3/8/2023 with ongoing nausea, vomiting and weakness found to have COVID-19 viral illness and acute hypoxia. Also treating for CAP.  Patient clinically improved to room air and was discharged with antibiotics to complete a course for community-acquired pneumonia.  She was also found to have bacteria in her urine culture and will receive simultaneous treatment for that as well.   Acute Respiratory Failure with Hypoxia - suspect due to below - room air sat 88% in ER - placed on 3L NC (not on O2 at baseline), down to 2L - CT chest show "tree in bud nodules in bilat upper lobes, no evidence of PE", suspect should be able to wean off o2 in next 24-48 hrs -Patient was able to wean off of oxygen by the time of discharge.   Fever Sepsis due to CAP - Tmax 102.8 temp 3/8 but has remained afebrile since - suspect due to COVID-19 viral illness, pneumonia  - CT chest show "Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE."\ -Patient received Rocephin and azithromycin.  Was reduced down to Rocephin and then discharged on cefdinir.   Asymptomatic bacteriuria -Patient noted to have positive urine culture with greater than 100,000 E. Coli -Patient was receiving ceftriaxone in the inpatient setting -We will complete treatment course with cefdinir. -She does follow with urology in the outpatient setting, would recommend continue to follow-up with them.   COVID-19 viral illness - Presented with: Fevers, nausea vomiting, weakness - Positive COVID-19: 3/8 at Hospital - Vaccination status: Vaccinated with Moderna with last dose 2022 - CT Chest on admission showed Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE. - Oxygen status: 2L NC - Decadron: Yes. Expected end date 3/19 - Remdesivir: No. - Note: she tested positive for covid on 2/25/23 (had minimal sx - chest congestion at the time so did not receive any tx and symptoms resolved completely).  She tested "negative" for covid at ECF on 3/7. Dtr notes "GI bug" is going around at her ECF     Nausea and Vomiting--resolved Dehydration - Suspect due to Infectious process, n/v PTA - Denies nausea, but has poor appetite - PRN zofran available    Seizure Disorder - tonic-clonic seizures, last seizure was 6/2015 - On multiple agents (Onfi, Keppra, Lamictal), will continue home regimen - Follows with Neurology (Dr), saw her 2/23/23 - seizure precautions   Type 2 Diabetes with long term insulin use - Home regimen includes Lantus 16 units twice daily, Jardiance -Given known incidences of UTI, feel that Jardiance is contraindicated and recommend to the patient to discontinue this on discharge. -Would recommend trialing metformin XR, Januvia, or a GLP-1 like Trulicity.
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram thorax abnormal, Culture urine positive, Decreased appetite, Dehydration, Escherichia infection
Clinical narrative: Patient is a 78 y.o. female who presented on 3/8/2023 with ongoing nausea, vomiting and weakness found to have COVID-19 viral illness and acute hypoxia. Also treating for CAP.  Patient clinically improved to room air and was discharged with antibiotics to complete a course for community-acquired pneumonia.  She was also found to have bacteria in her urine culture and will receive simultaneous treatment for that as well.   Acute Respiratory Failure with Hypoxia - suspect due to below - room air sat 88% in ER - placed on 3L NC (not on O2 at baseline), down to 2L - CT chest show "tree in bud nodules in bilat upper lobes, no evidence of PE", suspect should be able to wean off o2 in next 24-48 hrs -Patient was able to wean off of oxygen by the time of discharge.   Fever Sepsis due to CAP - Tmax 102.8 temp 3/8 but has remained afebrile since - suspect due to COVID-19 viral illness, pneumonia  - CT chest show "Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE."\ -Patient received Rocephin and azithromycin.  Was reduced down to Rocephin and then discharged on cefdinir.   Asymptomatic bacteriuria -Patient noted to have positive urine culture with greater than 100,000 E. Coli -Patient was receiving ceftriaxone in the inpatient setting -We will complete treatment course with cefdinir. -She does follow with urology in the outpatient setting, would recommend continue to follow-up with them.   COVID-19 viral illness - Presented with: Fevers, nausea vomiting, weakness - Positive COVID-19: 3/8 at Hospital - Vaccination status: Vaccinated with Moderna with last dose 2022 - CT Chest on admission showed Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE. - Oxygen status: 2L NC - Decadron: Yes. Expected end date 3/19 - Remdesivir: No. - Note: she tested positive for covid on 2/25/23 (had minimal sx - chest congestion at the time so did not receive any tx and symptoms resolved completely).  She tested "negative" for covid at ECF on 3/7. Dtr notes "GI bug" is going around at her ECF     Nausea and Vomiting--resolved Dehydration - Suspect due to Infectious process, n/v PTA - Denies nausea, but has poor appetite - PRN zofran available    Seizure Disorder - tonic-clonic seizures, last seizure was 6/2015 - On multiple agents (Onfi, Keppra, Lamictal), will continue home regimen - Follows with Neurology (Dr), saw her 2/23/23 - seizure precautions   Type 2 Diabetes with long term insulin use - Home regimen includes Lantus 16 units twice daily, Jardiance -Given known incidences of UTI, feel that Jardiance is contraindicated and recommend to the patient to discontinue this on discharge. -Would recommend trialing metformin XR, Januvia, or a GLP-1 like Trulicity.
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Escherichia test positive, Hypoxia, Malaise, Nausea, Pneumonia
Clinical narrative: Patient is a 78 y.o. female who presented on 3/8/2023 with ongoing nausea, vomiting and weakness found to have COVID-19 viral illness and acute hypoxia. Also treating for CAP.  Patient clinically improved to room air and was discharged with antibiotics to complete a course for community-acquired pneumonia.  She was also found to have bacteria in her urine culture and will receive simultaneous treatment for that as well.   Acute Respiratory Failure with Hypoxia - suspect due to below - room air sat 88% in ER - placed on 3L NC (not on O2 at baseline), down to 2L - CT chest show "tree in bud nodules in bilat upper lobes, no evidence of PE", suspect should be able to wean off o2 in next 24-48 hrs -Patient was able to wean off of oxygen by the time of discharge.   Fever Sepsis due to CAP - Tmax 102.8 temp 3/8 but has remained afebrile since - suspect due to COVID-19 viral illness, pneumonia  - CT chest show "Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE."\ -Patient received Rocephin and azithromycin.  Was reduced down to Rocephin and then discharged on cefdinir.   Asymptomatic bacteriuria -Patient noted to have positive urine culture with greater than 100,000 E. Coli -Patient was receiving ceftriaxone in the inpatient setting -We will complete treatment course with cefdinir. -She does follow with urology in the outpatient setting, would recommend continue to follow-up with them.   COVID-19 viral illness - Presented with: Fevers, nausea vomiting, weakness - Positive COVID-19: 3/8 at Hospital - Vaccination status: Vaccinated with Moderna with last dose 2022 - CT Chest on admission showed Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE. - Oxygen status: 2L NC - Decadron: Yes. Expected end date 3/19 - Remdesivir: No. - Note: she tested positive for covid on 2/25/23 (had minimal sx - chest congestion at the time so did not receive any tx and symptoms resolved completely).  She tested "negative" for covid at ECF on 3/7. Dtr notes "GI bug" is going around at her ECF     Nausea and Vomiting--resolved Dehydration - Suspect due to Infectious process, n/v PTA - Denies nausea, but has poor appetite - PRN zofran available    Seizure Disorder - tonic-clonic seizures, last seizure was 6/2015 - On multiple agents (Onfi, Keppra, Lamictal), will continue home regimen - Follows with Neurology (Dr), saw her 2/23/23 - seizure precautions   Type 2 Diabetes with long term insulin use - Home regimen includes Lantus 16 units twice daily, Jardiance -Given known incidences of UTI, feel that Jardiance is contraindicated and recommend to the patient to discontinue this on discharge. -Would recommend trialing metformin XR, Januvia, or a GLP-1 like Trulicity.
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Pulmonary mass, Pyrexia, Respiratory tract congestion, SARS-CoV-2 test positive, Sepsis
Clinical narrative: Patient is a 78 y.o. female who presented on 3/8/2023 with ongoing nausea, vomiting and weakness found to have COVID-19 viral illness and acute hypoxia. Also treating for CAP.  Patient clinically improved to room air and was discharged with antibiotics to complete a course for community-acquired pneumonia.  She was also found to have bacteria in her urine culture and will receive simultaneous treatment for that as well.   Acute Respiratory Failure with Hypoxia - suspect due to below - room air sat 88% in ER - placed on 3L NC (not on O2 at baseline), down to 2L - CT chest show "tree in bud nodules in bilat upper lobes, no evidence of PE", suspect should be able to wean off o2 in next 24-48 hrs -Patient was able to wean off of oxygen by the time of discharge.   Fever Sepsis due to CAP - Tmax 102.8 temp 3/8 but has remained afebrile since - suspect due to COVID-19 viral illness, pneumonia  - CT chest show "Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE."\ -Patient received Rocephin and azithromycin.  Was reduced down to Rocephin and then discharged on cefdinir.   Asymptomatic bacteriuria -Patient noted to have positive urine culture with greater than 100,000 E. Coli -Patient was receiving ceftriaxone in the inpatient setting -We will complete treatment course with cefdinir. -She does follow with urology in the outpatient setting, would recommend continue to follow-up with them.   COVID-19 viral illness - Presented with: Fevers, nausea vomiting, weakness - Positive COVID-19: 3/8 at Hospital - Vaccination status: Vaccinated with Moderna with last dose 2022 - CT Chest on admission showed Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE. - Oxygen status: 2L NC - Decadron: Yes. Expected end date 3/19 - Remdesivir: No. - Note: she tested positive for covid on 2/25/23 (had minimal sx - chest congestion at the time so did not receive any tx and symptoms resolved completely).  She tested "negative" for covid at ECF on 3/7. Dtr notes "GI bug" is going around at her ECF     Nausea and Vomiting--resolved Dehydration - Suspect due to Infectious process, n/v PTA - Denies nausea, but has poor appetite - PRN zofran available    Seizure Disorder - tonic-clonic seizures, last seizure was 6/2015 - On multiple agents (Onfi, Keppra, Lamictal), will continue home regimen - Follows with Neurology (Dr), saw her 2/23/23 - seizure precautions   Type 2 Diabetes with long term insulin use - Home regimen includes Lantus 16 units twice daily, Jardiance -Given known incidences of UTI, feel that Jardiance is contraindicated and recommend to the patient to discontinue this on discharge. -Would recommend trialing metformin XR, Januvia, or a GLP-1 like Trulicity.
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Vomiting
Clinical narrative: Patient is a 78 y.o. female who presented on 3/8/2023 with ongoing nausea, vomiting and weakness found to have COVID-19 viral illness and acute hypoxia. Also treating for CAP.  Patient clinically improved to room air and was discharged with antibiotics to complete a course for community-acquired pneumonia.  She was also found to have bacteria in her urine culture and will receive simultaneous treatment for that as well.   Acute Respiratory Failure with Hypoxia - suspect due to below - room air sat 88% in ER - placed on 3L NC (not on O2 at baseline), down to 2L - CT chest show "tree in bud nodules in bilat upper lobes, no evidence of PE", suspect should be able to wean off o2 in next 24-48 hrs -Patient was able to wean off of oxygen by the time of discharge.   Fever Sepsis due to CAP - Tmax 102.8 temp 3/8 but has remained afebrile since - suspect due to COVID-19 viral illness, pneumonia  - CT chest show "Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE."\ -Patient received Rocephin and azithromycin.  Was reduced down to Rocephin and then discharged on cefdinir.   Asymptomatic bacteriuria -Patient noted to have positive urine culture with greater than 100,000 E. Coli -Patient was receiving ceftriaxone in the inpatient setting -We will complete treatment course with cefdinir. -She does follow with urology in the outpatient setting, would recommend continue to follow-up with them.   COVID-19 viral illness - Presented with: Fevers, nausea vomiting, weakness - Positive COVID-19: 3/8 at Hospital - Vaccination status: Vaccinated with Moderna with last dose 2022 - CT Chest on admission showed Tree-in-bud nodules in the bilateral upper lobes, which is nonspecific and may be infectious or inflammatory. No evidence of PE. - Oxygen status: 2L NC - Decadron: Yes. Expected end date 3/19 - Remdesivir: No. - Note: she tested positive for covid on 2/25/23 (had minimal sx - chest congestion at the time so did not receive any tx and symptoms resolved completely).  She tested "negative" for covid at ECF on 3/7. Dtr notes "GI bug" is going around at her ECF     Nausea and Vomiting--resolved Dehydration - Suspect due to Infectious process, n/v PTA - Denies nausea, but has poor appetite - PRN zofran available    Seizure Disorder - tonic-clonic seizures, last seizure was 6/2015 - On multiple agents (Onfi, Keppra, Lamictal), will continue home regimen - Follows with Neurology (Dr), saw her 2/23/23 - seizure precautions   Type 2 Diabetes with long term insulin use - Home regimen includes Lantus 16 units twice daily, Jardiance -Given known incidences of UTI, feel that Jardiance is contraindicated and recommend to the patient to discontinue this on discharge. -Would recommend trialing metformin XR, Januvia, or a GLP-1 like Trulicity.
Age: 39.0
Sex: F
Vaccine: TDAP
Symptoms: Erythema, Oedema peripheral, Tenderness
Clinical narrative: Axillary swelling, tenderness & redness
Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Agitation, Asthenia, Bladder catheterisation
Clinical narrative: Patient is a 93 y/o male who presented from assisted living on 3/10/2023 with hypoxia requiring nonrebreather per EMS in the setting of recently positive COVID-19 test 3/8. Hospital course complicated by acute delirium, AKI, lactic acidosis and worsening respiratory status resulting in goals of care discussion with family. Changed to DNRCC on evening of 3/12/23 and pt expired on am of 3/13/23.         Assessment and Plan   Acute hypoxic respiratory failure Prior history of chronic respiratory failure -Secondary to COVID PNA -Noted to be chronically on 4 L per discharge summary February 2023, however patient and his son report he has not been requiring oxygen at his assisted living facility -Required escalating O2 during hospitalization until decision made to change to comfort care and expired on 3/13/23   COVID-19 infection -Presented with: Hypoxia, coughing, tachypnea -Symptom onset: Unclear, possibly 3/6 to 3/8 -Positive COVID-19: 3/8 at outside facility -Vaccination status: Vaccinated with Pfizer with last dose 2021 -CXR on admission showed bilateral infiltrates  -Treated with decadron and remdesivr   Agitation, metabolic encephalopathy POA Hx of Delirium -Patient was started on Zyprexa by Behavioral Health for delirium symptoms Feb 2023 hospitalization -Worsened this admission in setting of hypoxia, infection   Dysphagia -Patient demonstrated mild dysarthria, which is chronic per family when not wearing his dentures -Also increased risk of aspiration from generalized weakness, infection -SLP evaluation recommending short-term alternative nutrition and NPO -Code status changed to comfort care   AKI on CKD 3 Lactic Acidosis -Multifactorial in setting of acute illness -Worsening Cr during hospitalization despite IVF and foley placement -Made CC   Atrial Fib -Maintained on Eliquis and Metoprolol prior to hospitalization
Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Blood creatinine abnormal, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Chronic kidney disease
Clinical narrative: Patient is a 93 y/o male who presented from assisted living on 3/10/2023 with hypoxia requiring nonrebreather per EMS in the setting of recently positive COVID-19 test 3/8. Hospital course complicated by acute delirium, AKI, lactic acidosis and worsening respiratory status resulting in goals of care discussion with family. Changed to DNRCC on evening of 3/12/23 and pt expired on am of 3/13/23.         Assessment and Plan   Acute hypoxic respiratory failure Prior history of chronic respiratory failure -Secondary to COVID PNA -Noted to be chronically on 4 L per discharge summary February 2023, however patient and his son report he has not been requiring oxygen at his assisted living facility -Required escalating O2 during hospitalization until decision made to change to comfort care and expired on 3/13/23   COVID-19 infection -Presented with: Hypoxia, coughing, tachypnea -Symptom onset: Unclear, possibly 3/6 to 3/8 -Positive COVID-19: 3/8 at outside facility -Vaccination status: Vaccinated with Pfizer with last dose 2021 -CXR on admission showed bilateral infiltrates  -Treated with decadron and remdesivr   Agitation, metabolic encephalopathy POA Hx of Delirium -Patient was started on Zyprexa by Behavioral Health for delirium symptoms Feb 2023 hospitalization -Worsened this admission in setting of hypoxia, infection   Dysphagia -Patient demonstrated mild dysarthria, which is chronic per family when not wearing his dentures -Also increased risk of aspiration from generalized weakness, infection -SLP evaluation recommending short-term alternative nutrition and NPO -Code status changed to comfort care   AKI on CKD 3 Lactic Acidosis -Multifactorial in setting of acute illness -Worsening Cr during hospitalization despite IVF and foley placement -Made CC   Atrial Fib -Maintained on Eliquis and Metoprolol prior to hospitalization
Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Cough, Death, Delirium, Dysarthria
Clinical narrative: Patient is a 93 y/o male who presented from assisted living on 3/10/2023 with hypoxia requiring nonrebreather per EMS in the setting of recently positive COVID-19 test 3/8. Hospital course complicated by acute delirium, AKI, lactic acidosis and worsening respiratory status resulting in goals of care discussion with family. Changed to DNRCC on evening of 3/12/23 and pt expired on am of 3/13/23.         Assessment and Plan   Acute hypoxic respiratory failure Prior history of chronic respiratory failure -Secondary to COVID PNA -Noted to be chronically on 4 L per discharge summary February 2023, however patient and his son report he has not been requiring oxygen at his assisted living facility -Required escalating O2 during hospitalization until decision made to change to comfort care and expired on 3/13/23   COVID-19 infection -Presented with: Hypoxia, coughing, tachypnea -Symptom onset: Unclear, possibly 3/6 to 3/8 -Positive COVID-19: 3/8 at outside facility -Vaccination status: Vaccinated with Pfizer with last dose 2021 -CXR on admission showed bilateral infiltrates  -Treated with decadron and remdesivr   Agitation, metabolic encephalopathy POA Hx of Delirium -Patient was started on Zyprexa by Behavioral Health for delirium symptoms Feb 2023 hospitalization -Worsened this admission in setting of hypoxia, infection   Dysphagia -Patient demonstrated mild dysarthria, which is chronic per family when not wearing his dentures -Also increased risk of aspiration from generalized weakness, infection -SLP evaluation recommending short-term alternative nutrition and NPO -Code status changed to comfort care   AKI on CKD 3 Lactic Acidosis -Multifactorial in setting of acute illness -Worsening Cr during hospitalization despite IVF and foley placement -Made CC   Atrial Fib -Maintained on Eliquis and Metoprolol prior to hospitalization
Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Dysphagia, Hypoxia, Infection, Lactic acidosis, Lung infiltration
Clinical narrative: Patient is a 93 y/o male who presented from assisted living on 3/10/2023 with hypoxia requiring nonrebreather per EMS in the setting of recently positive COVID-19 test 3/8. Hospital course complicated by acute delirium, AKI, lactic acidosis and worsening respiratory status resulting in goals of care discussion with family. Changed to DNRCC on evening of 3/12/23 and pt expired on am of 3/13/23.         Assessment and Plan   Acute hypoxic respiratory failure Prior history of chronic respiratory failure -Secondary to COVID PNA -Noted to be chronically on 4 L per discharge summary February 2023, however patient and his son report he has not been requiring oxygen at his assisted living facility -Required escalating O2 during hospitalization until decision made to change to comfort care and expired on 3/13/23   COVID-19 infection -Presented with: Hypoxia, coughing, tachypnea -Symptom onset: Unclear, possibly 3/6 to 3/8 -Positive COVID-19: 3/8 at outside facility -Vaccination status: Vaccinated with Pfizer with last dose 2021 -CXR on admission showed bilateral infiltrates  -Treated with decadron and remdesivr   Agitation, metabolic encephalopathy POA Hx of Delirium -Patient was started on Zyprexa by Behavioral Health for delirium symptoms Feb 2023 hospitalization -Worsened this admission in setting of hypoxia, infection   Dysphagia -Patient demonstrated mild dysarthria, which is chronic per family when not wearing his dentures -Also increased risk of aspiration from generalized weakness, infection -SLP evaluation recommending short-term alternative nutrition and NPO -Code status changed to comfort care   AKI on CKD 3 Lactic Acidosis -Multifactorial in setting of acute illness -Worsening Cr during hospitalization despite IVF and foley placement -Made CC   Atrial Fib -Maintained on Eliquis and Metoprolol prior to hospitalization
Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Metabolic encephalopathy, SARS-CoV-2 test positive, Tachypnoea
Clinical narrative: Patient is a 93 y/o male who presented from assisted living on 3/10/2023 with hypoxia requiring nonrebreather per EMS in the setting of recently positive COVID-19 test 3/8. Hospital course complicated by acute delirium, AKI, lactic acidosis and worsening respiratory status resulting in goals of care discussion with family. Changed to DNRCC on evening of 3/12/23 and pt expired on am of 3/13/23.         Assessment and Plan   Acute hypoxic respiratory failure Prior history of chronic respiratory failure -Secondary to COVID PNA -Noted to be chronically on 4 L per discharge summary February 2023, however patient and his son report he has not been requiring oxygen at his assisted living facility -Required escalating O2 during hospitalization until decision made to change to comfort care and expired on 3/13/23   COVID-19 infection -Presented with: Hypoxia, coughing, tachypnea -Symptom onset: Unclear, possibly 3/6 to 3/8 -Positive COVID-19: 3/8 at outside facility -Vaccination status: Vaccinated with Pfizer with last dose 2021 -CXR on admission showed bilateral infiltrates  -Treated with decadron and remdesivr   Agitation, metabolic encephalopathy POA Hx of Delirium -Patient was started on Zyprexa by Behavioral Health for delirium symptoms Feb 2023 hospitalization -Worsened this admission in setting of hypoxia, infection   Dysphagia -Patient demonstrated mild dysarthria, which is chronic per family when not wearing his dentures -Also increased risk of aspiration from generalized weakness, infection -SLP evaluation recommending short-term alternative nutrition and NPO -Code status changed to comfort care   AKI on CKD 3 Lactic Acidosis -Multifactorial in setting of acute illness -Worsening Cr during hospitalization despite IVF and foley placement -Made CC   Atrial Fib -Maintained on Eliquis and Metoprolol prior to hospitalization
Age: 4.0
Sex: M
Vaccine: DTAPIPV
Symptoms: Erythema, Induration, Injection site erythema, Injection site induration, Injection site swelling
Clinical narrative: Pain and local mild induration within 12 hours of injection. Worsening induration/redness/warmth AND swelling of entire left upper thigh and left knee by 24 hours (office visit at that time).
Age: 4.0
Sex: M
Vaccine: DTAPIPV
Symptoms: Injection site warmth, Joint swelling, Joint warmth, Pain
Clinical narrative: Pain and local mild induration within 12 hours of injection. Worsening induration/redness/warmth AND swelling of entire left upper thigh and left knee by 24 hours (office visit at that time).
Age: 66.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Death, Fatigue, Haemorrhage, Malaise, Thrombosis
Clinical narrative: Tiredness, general feeling of unwellness, over 4 months time weight loss, type-2 diabetes diagnosis, death.  Patient had blood clots and physicians could not determine the source of the bleeding.
Age: 66.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Type 2 diabetes mellitus, Weight decreased
Clinical narrative: Tiredness, general feeling of unwellness, over 4 months time weight loss, type-2 diabetes diagnosis, death.  Patient had blood clots and physicians could not determine the source of the bleeding.
Age: 75.0
Sex: M
Vaccine: COVID19-2
Symptoms: COVID-19, Cough, Hypersensitivity, Lethargy, Malaise
Clinical narrative: Thursday, January 12, 2023, I had allergy symptoms with sneezing and cough and itchy throat.  Friday it was about the same.  Saturday, I worked outside for about 10 hours and when I went in and showered, I just felt awful.  I took Tylenol and Mucinex.  Sunday I was unable to go to church.  I had same symptoms but now very lethargic.  I visited my doctor Monday.  My vitals were good, but I did test positive for COVID-19.  I was prescribed Paxlovid.  Tuesday I was better and did not take it due to kidney issues and by Wednesday I was fine.
Age: 75.0
Sex: M
Vaccine: COVID19-2
Symptoms: SARS-CoV-2 test positive, Sneezing, Throat irritation
Clinical narrative: Thursday, January 12, 2023, I had allergy symptoms with sneezing and cough and itchy throat.  Friday it was about the same.  Saturday, I worked outside for about 10 hours and when I went in and showered, I just felt awful.  I took Tylenol and Mucinex.  Sunday I was unable to go to church.  I had same symptoms but now very lethargic.  I visited my doctor Monday.  My vitals were good, but I did test positive for COVID-19.  I was prescribed Paxlovid.  Tuesday I was better and did not take it due to kidney issues and by Wednesday I was fine.
Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Injection site erythema, Injection site pain, Injection site swelling, Injection site warmth
Clinical narrative: Patient reported having COVID arm (swelling, redness, pain, and warmth at the injection site).  The vaccination was not given here.  But, I wanted to document the it happened anyway.
Age: 88.0
Sex: F
Vaccine: COVID19-2
Symptoms: Incorrect product formulation administered
Clinical narrative: Patient accidently received a bivalent booster dose instead of a monovalent dose for their 1st primary series dose.
Age: 65.0
Sex: F
Vaccine: PNC20, VARZOS
Symptoms: Burning sensation, Infection, Rash, Rash erythematous, Rash pruritic
Clinical narrative: Patient received Shingrix and Prevnar 20 in the same arm on 4/4/23. Patient called the pharmacy on 4/10/23 stating that her arm had a red rash that was itching and burning. Patient went to urgent care and was told it was an infection from vaccination and was given Keflex.
Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: Patient received a monovalent dose for their booster instead of the bivalent formulation.
Age: 78.0
Sex: M
Vaccine: COVID19-2
Symptoms: Acute kidney injury, Acute respiratory failure, Angiogram pulmonary abnormal, Blood creatinine increased, Blood culture negative
Clinical narrative: 78 y.o. male patient of MD with history of CAD w/stent, CHF, CVA, DM, HTN, neuropathy, who presented to Hospital with dyspnea    Acute hypoxic respiratory failure  Covid Pneumonia/CAP Sepsis  Symptoms present on admission: Cough, shortness of breath and malaise Afebrile, HR 120's, WBC 11k Date of covid positive test: 3/17/23 Vaccination status: vaccinated Imaging: CTPA 3/17 showing left lower lobe consolidation. Neg PE.  Oxygen requirements on admission: 4 L NC, 89% on RA Continue CAP coverage for any secondary infection, continue Decadron and Remdesivir  Blood cx -NGTD urinary antigens not sent  Able to wean off oxygen, on room air O2 sats remained stable even with exertion Completed 5-day course of remdesivir, continued Decadron for 5 more days at discharge Continue Omnicef for 5 more days at discharge, completed Zithromax course On the day of discharge denies shortness of breath, able to ambulate without difficulty     AKI on CKD (Resolved) Hyperkalemia (Resolved) Baseline Cr 1.0 - 1.1, creatinine trended up to 1.3,  held diuretics.  Hyperkalemia treated with Lokelma Creatinine back to baseline, resumed torsemide 10 mg every other day and spironolactone 25 mg daily Creatinine remained stable, recommended to resume lisinopril at 2.5 mg daily if blood pressure greater than 140 Follow-up BMP in 2 to 3 days after discharge     CAD  HFrEF Hx of PCI in 2008  Follows with Dr.  Echo 9/2021: EF~45% Trop and NT pro BNP neg on admission Cont ASA, statin, BB Resumed Aldactone and torsemide as mentioned above  HTN  Adjusted blood pressure medications as mentioned above   Asthma No wheezing No home O2 Cont home inhalers, prn albuterol    DM Home Rx; glimepiride and metformin Last A1c 8.4 (5/2022) Resume Amaryl, metformin Januvia and glipizide and empagliflozin at discharge     GERD No active symptoms  Continue antacids
Age: 78.0
Sex: M
Vaccine: COVID19-2
Symptoms: COVID-19, COVID-19 pneumonia, Chronic kidney disease, Cough, Diuretic therapy
Clinical narrative: 78 y.o. male patient of MD with history of CAD w/stent, CHF, CVA, DM, HTN, neuropathy, who presented to Hospital with dyspnea    Acute hypoxic respiratory failure  Covid Pneumonia/CAP Sepsis  Symptoms present on admission: Cough, shortness of breath and malaise Afebrile, HR 120's, WBC 11k Date of covid positive test: 3/17/23 Vaccination status: vaccinated Imaging: CTPA 3/17 showing left lower lobe consolidation. Neg PE.  Oxygen requirements on admission: 4 L NC, 89% on RA Continue CAP coverage for any secondary infection, continue Decadron and Remdesivir  Blood cx -NGTD urinary antigens not sent  Able to wean off oxygen, on room air O2 sats remained stable even with exertion Completed 5-day course of remdesivir, continued Decadron for 5 more days at discharge Continue Omnicef for 5 more days at discharge, completed Zithromax course On the day of discharge denies shortness of breath, able to ambulate without difficulty     AKI on CKD (Resolved) Hyperkalemia (Resolved) Baseline Cr 1.0 - 1.1, creatinine trended up to 1.3,  held diuretics.  Hyperkalemia treated with Lokelma Creatinine back to baseline, resumed torsemide 10 mg every other day and spironolactone 25 mg daily Creatinine remained stable, recommended to resume lisinopril at 2.5 mg daily if blood pressure greater than 140 Follow-up BMP in 2 to 3 days after discharge     CAD  HFrEF Hx of PCI in 2008  Follows with Dr.  Echo 9/2021: EF~45% Trop and NT pro BNP neg on admission Cont ASA, statin, BB Resumed Aldactone and torsemide as mentioned above  HTN  Adjusted blood pressure medications as mentioned above   Asthma No wheezing No home O2 Cont home inhalers, prn albuterol    DM Home Rx; glimepiride and metformin Last A1c 8.4 (5/2022) Resume Amaryl, metformin Januvia and glipizide and empagliflozin at discharge     GERD No active symptoms  Continue antacids
Age: 78.0
Sex: M
Vaccine: COVID19-2
Symptoms: Dyspnoea, Hyperkalaemia, Lung consolidation, Malaise, N-terminal prohormone brain natriuretic peptide normal
Clinical narrative: 78 y.o. male patient of MD with history of CAD w/stent, CHF, CVA, DM, HTN, neuropathy, who presented to Hospital with dyspnea    Acute hypoxic respiratory failure  Covid Pneumonia/CAP Sepsis  Symptoms present on admission: Cough, shortness of breath and malaise Afebrile, HR 120's, WBC 11k Date of covid positive test: 3/17/23 Vaccination status: vaccinated Imaging: CTPA 3/17 showing left lower lobe consolidation. Neg PE.  Oxygen requirements on admission: 4 L NC, 89% on RA Continue CAP coverage for any secondary infection, continue Decadron and Remdesivir  Blood cx -NGTD urinary antigens not sent  Able to wean off oxygen, on room air O2 sats remained stable even with exertion Completed 5-day course of remdesivir, continued Decadron for 5 more days at discharge Continue Omnicef for 5 more days at discharge, completed Zithromax course On the day of discharge denies shortness of breath, able to ambulate without difficulty     AKI on CKD (Resolved) Hyperkalemia (Resolved) Baseline Cr 1.0 - 1.1, creatinine trended up to 1.3,  held diuretics.  Hyperkalemia treated with Lokelma Creatinine back to baseline, resumed torsemide 10 mg every other day and spironolactone 25 mg daily Creatinine remained stable, recommended to resume lisinopril at 2.5 mg daily if blood pressure greater than 140 Follow-up BMP in 2 to 3 days after discharge     CAD  HFrEF Hx of PCI in 2008  Follows with Dr.  Echo 9/2021: EF~45% Trop and NT pro BNP neg on admission Cont ASA, statin, BB Resumed Aldactone and torsemide as mentioned above  HTN  Adjusted blood pressure medications as mentioned above   Asthma No wheezing No home O2 Cont home inhalers, prn albuterol    DM Home Rx; glimepiride and metformin Last A1c 8.4 (5/2022) Resume Amaryl, metformin Januvia and glipizide and empagliflozin at discharge     GERD No active symptoms  Continue antacids
Age: 78.0
Sex: M
Vaccine: COVID19-2
Symptoms: Pneumonia, SARS-CoV-2 test positive, Sepsis, Troponin normal, White blood cell count increased
Clinical narrative: 78 y.o. male patient of MD with history of CAD w/stent, CHF, CVA, DM, HTN, neuropathy, who presented to Hospital with dyspnea    Acute hypoxic respiratory failure  Covid Pneumonia/CAP Sepsis  Symptoms present on admission: Cough, shortness of breath and malaise Afebrile, HR 120's, WBC 11k Date of covid positive test: 3/17/23 Vaccination status: vaccinated Imaging: CTPA 3/17 showing left lower lobe consolidation. Neg PE.  Oxygen requirements on admission: 4 L NC, 89% on RA Continue CAP coverage for any secondary infection, continue Decadron and Remdesivir  Blood cx -NGTD urinary antigens not sent  Able to wean off oxygen, on room air O2 sats remained stable even with exertion Completed 5-day course of remdesivir, continued Decadron for 5 more days at discharge Continue Omnicef for 5 more days at discharge, completed Zithromax course On the day of discharge denies shortness of breath, able to ambulate without difficulty     AKI on CKD (Resolved) Hyperkalemia (Resolved) Baseline Cr 1.0 - 1.1, creatinine trended up to 1.3,  held diuretics.  Hyperkalemia treated with Lokelma Creatinine back to baseline, resumed torsemide 10 mg every other day and spironolactone 25 mg daily Creatinine remained stable, recommended to resume lisinopril at 2.5 mg daily if blood pressure greater than 140 Follow-up BMP in 2 to 3 days after discharge     CAD  HFrEF Hx of PCI in 2008  Follows with Dr.  Echo 9/2021: EF~45% Trop and NT pro BNP neg on admission Cont ASA, statin, BB Resumed Aldactone and torsemide as mentioned above  HTN  Adjusted blood pressure medications as mentioned above   Asthma No wheezing No home O2 Cont home inhalers, prn albuterol    DM Home Rx; glimepiride and metformin Last A1c 8.4 (5/2022) Resume Amaryl, metformin Januvia and glipizide and empagliflozin at discharge     GERD No active symptoms  Continue antacids
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: Patient received a monovalent dose for their booster dose instead of the bivalent formulation.
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea
Clinical narrative: Dyspnea
Age: 0.75
Sex: M
Vaccine: COVID19
Symptoms: Irritability, Pyrexia, Rash
Clinical narrative: rash on body, fever, fussiness
Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: Patient received a monovalent dose for their booster dose instead of the bivalent formulation.
Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anxiety, Muscular weakness, Pain in extremity, Periarthritis
Clinical narrative: J96.00 ACUTE RESPIRATORY FAILURE 12/10/2021 ADHESIVE CAPSULITIS OF LEFT SHOULDER J96.00 ACUTE RESPIRATORY FAILURE 12/10/2021 LEFT ARM PAIN J96.00 ACUTE RESPIRATORY FAILURE 12/10/2021 ADHESIVE CAPSULITIS OF LEFT SHOULDER J96.00 ACUTE RESPIRATORY FAILURE 12/10/2021 UNSPECIFIED ANXIETY J96.00 ACUTE RESPIRATORY FAILURE 12/10/2021 WEAKNESS OF LEFT ARM
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Anaemia, Aspartate aminotransferase increased, Asthenia, Atelectasis, Bladder catheterisation
Clinical narrative: Patient is a 81 y.o. male patient of MD with history of Late stage dementia, CAD, HLD  presented to a local Hospital with fever, weakness, SOB, covid positive test .   Covid Virus infection  Weakness P/w fever, SOB, weakness, tested + for covid on 3/27/23 Initial VS 99.5-69-18-117/64 93-95% on room air  CXR trace atelectasis otherwise negative  LA normal AST mildly elevated to 56, other hepatic panel normal Troponin 27 UA negative for infection VBG 7.37/49  IV fluids given Foley placed Monitor for Hypoxia  PT/SS/OT Placement secured and transportation set up for this afternoon   Late stage Dementia with Behavior Disturbance  Follows with neurology Continue Aricept, Namenda and trazadone  Delirium precautions    CAD s/p CABG x 3 Cardiomyopathy HLD HTN Unable to assess for CP  Troponin normal EKG no ischemia  Resume Coreg, Asa,  Lisinopril  Allergies to all statins, do not carry crestor   Cardiac monitoring  Anemia Thrombocytopenia  Hgb 11.4, Plt 115 Both have chronicity but plts lower likely reactive
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Blood gases, COVID-19, Cardiac monitoring, Chest X-ray abnormal, Dyspnoea
Clinical narrative: Patient is a 81 y.o. male patient of MD with history of Late stage dementia, CAD, HLD  presented to a local Hospital with fever, weakness, SOB, covid positive test .   Covid Virus infection  Weakness P/w fever, SOB, weakness, tested + for covid on 3/27/23 Initial VS 99.5-69-18-117/64 93-95% on room air  CXR trace atelectasis otherwise negative  LA normal AST mildly elevated to 56, other hepatic panel normal Troponin 27 UA negative for infection VBG 7.37/49  IV fluids given Foley placed Monitor for Hypoxia  PT/SS/OT Placement secured and transportation set up for this afternoon   Late stage Dementia with Behavior Disturbance  Follows with neurology Continue Aricept, Namenda and trazadone  Delirium precautions    CAD s/p CABG x 3 Cardiomyopathy HLD HTN Unable to assess for CP  Troponin normal EKG no ischemia  Resume Coreg, Asa,  Lisinopril  Allergies to all statins, do not carry crestor   Cardiac monitoring  Anemia Thrombocytopenia  Hgb 11.4, Plt 115 Both have chronicity but plts lower likely reactive
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Electrocardiogram normal, Haemoglobin decreased, Laboratory test normal, Liver function test normal, Platelet count decreased
Clinical narrative: Patient is a 81 y.o. male patient of MD with history of Late stage dementia, CAD, HLD  presented to a local Hospital with fever, weakness, SOB, covid positive test .   Covid Virus infection  Weakness P/w fever, SOB, weakness, tested + for covid on 3/27/23 Initial VS 99.5-69-18-117/64 93-95% on room air  CXR trace atelectasis otherwise negative  LA normal AST mildly elevated to 56, other hepatic panel normal Troponin 27 UA negative for infection VBG 7.37/49  IV fluids given Foley placed Monitor for Hypoxia  PT/SS/OT Placement secured and transportation set up for this afternoon   Late stage Dementia with Behavior Disturbance  Follows with neurology Continue Aricept, Namenda and trazadone  Delirium precautions    CAD s/p CABG x 3 Cardiomyopathy HLD HTN Unable to assess for CP  Troponin normal EKG no ischemia  Resume Coreg, Asa,  Lisinopril  Allergies to all statins, do not carry crestor   Cardiac monitoring  Anemia Thrombocytopenia  Hgb 11.4, Plt 115 Both have chronicity but plts lower likely reactive
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Pyrexia, SARS-CoV-2 test positive, Thrombocytopenia, Troponin normal, Urine analysis normal
Clinical narrative: Patient is a 81 y.o. male patient of MD with history of Late stage dementia, CAD, HLD  presented to a local Hospital with fever, weakness, SOB, covid positive test .   Covid Virus infection  Weakness P/w fever, SOB, weakness, tested + for covid on 3/27/23 Initial VS 99.5-69-18-117/64 93-95% on room air  CXR trace atelectasis otherwise negative  LA normal AST mildly elevated to 56, other hepatic panel normal Troponin 27 UA negative for infection VBG 7.37/49  IV fluids given Foley placed Monitor for Hypoxia  PT/SS/OT Placement secured and transportation set up for this afternoon   Late stage Dementia with Behavior Disturbance  Follows with neurology Continue Aricept, Namenda and trazadone  Delirium precautions    CAD s/p CABG x 3 Cardiomyopathy HLD HTN Unable to assess for CP  Troponin normal EKG no ischemia  Resume Coreg, Asa,  Lisinopril  Allergies to all statins, do not carry crestor   Cardiac monitoring  Anemia Thrombocytopenia  Hgb 11.4, Plt 115 Both have chronicity but plts lower likely reactive
Age: 70.0
Sex: F
Vaccine: COVID19, FLU4
Symptoms: Chills, Feeling hot, Muscular weakness
Clinical narrative: I had very mild fever 100.0 and I had chills. I have muscle weakness.
Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoxia, Mental status changes
Clinical narrative: R09.02 HYPOXIA 7/2/2022 ALTERED MENTAL STATUS, UNSPECIFIED
Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: Patient received a monovalent dose for their booster dose instead of the bivalent formulation.
Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Respiratory failure
Clinical narrative: J96.21 ACUTE ON CHRONIC HYPOXEMIC RESPIRATORY FAILURE 9/16/2022 ACUTE RENAL FAILURE, UNSPECIFIED
Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Cough, No adverse event, Respiratory tract congestion, SARS-CoV-2 test positive
Clinical narrative: I did not have an adverse reaction to the vaccine. I tested positive for COVID-19 on 04/04/2023. I contacted my doctor and got a prescription for Paxlovid. I stopped taking it as the taste was terrible and the diarrhea. I was just coming off knee surgery and could not take it. As of today, I have chest congestion and a cough.
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Seizure
Clinical narrative: Moderna vaccine was administered - reported by patient  J96.01 ACUTE HYPOXEMIC RESPIRATORY FAILURE 9/21/2022 SEIZURE, UNSPECIFIED
Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Idiopathic pulmonary fibrosis
Clinical narrative: J96.00 ACUTE RESPIRATORY FAILURE 8/3/2022 IDIOPATHIC PULMONARY FIBROSIS
Age: 70.0
Sex: F
Vaccine: COVID19-2
Symptoms: Anticoagulant therapy, Joint swelling, Limb discomfort, Pain in extremity, Peripheral swelling
Clinical narrative: In December of 2022 my legs felt heavy to me when I would walk.  On January 29, 2023, I had severe pain in my right calf and my ankle and calf were noticeably swollen.  I recognized this as a possible DVT.  I went to visit the doctor on January 31, 2023.  I went to the emergency department and had an ultrasound and started me on Eliquis.  I saw a vascular surgeon on March 13th and was advised to stay on this medication for one year.