chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 58.0
Sex: F
Vaccine: COVID19-2
Symptoms: Respiratory failure, Tachycardia, Tachypnoea, White blood cell count increased
Clinical narrative: Admit date: 1/26/2024  Discharge date: 01/28/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD Reason for Admission: hypoxia, dyspnea 2/2 COVID and multifocal pneumonia  Brief Summary of Hospital Stay: 59 YO female with h/o chronic pain, chronic obstructive pulmonary disease, bipolar 2 disorder, borderline personality disorder, depression with anxiety, GERD, OSA, and glaucoma who presents with dry rattly cough and shortness of breath for over 2 weeks. In the ED she was febrile, mildly tachycardic, and mildly tachypneic.  Upon arrival, SpO2 was 83% on room air which improved with oxygen via 4 L nasal cannula. Initial labs were notable for leukocytosis (16.2), elevated D-dimer (1010), potassium 3.4, and CT pulmonary CTA showed no PE but multifocal bilateral pneumonia. She received one bolus of NS and was started on Rocephin  and  Doxycycline there, which was continued by hospitalist team, who admitted for acute hypoxic respiratory insufficiency related to multifocal pneumonia and COVID. She also received antitussives, DuoNEb inhalations and was started on Remdesivir once admitted. The patient's clinical condition improved rapidly and she was discharged without the need of oxygen on the second day of admission. She was evaluated by PT who recommended disposition to be home with home therapy or with assist. Discharged to Home.
Age: 64.0
Sex: F
Vaccine: PNC20, TDAP
Symptoms: Erythema, Headache, Injected limb mobility decreased, Injection site erythema, Injection site pain
Clinical narrative: c/o worsening R upper arm pain, redness, swelling, warmth and headache since Monday (02/05/24) evening after receiving Prevnar 20 and Tdap, both on the R Deltoid. Since then, she reports symptoms have worsened. She has had cellulitis before, on the R eye. She states that a doctor she works with has told her it looks like cellulitis.   Pt states she has difficulty moving her R arm and the redness and swelling is spreading down to her forearm. Pt is afebrile but states she has been taking Tylenol round the clock.
Age: 64.0
Sex: F
Vaccine: PNC20, TDAP
Symptoms: Injection site swelling, Injection site warmth, Peripheral swelling
Clinical narrative: c/o worsening R upper arm pain, redness, swelling, warmth and headache since Monday (02/05/24) evening after receiving Prevnar 20 and Tdap, both on the R Deltoid. Since then, she reports symptoms have worsened. She has had cellulitis before, on the R eye. She states that a doctor she works with has told her it looks like cellulitis.   Pt states she has difficulty moving her R arm and the redness and swelling is spreading down to her forearm. Pt is afebrile but states she has been taking Tylenol round the clock.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Acute left ventricular failure, COVID-19, Cardiac stress test normal, Diastolic dysfunction, Diuretic therapy
Clinical narrative: Admit date: 1/25/2024  Discharge date:  1/29/2024  Admitting Physician:  MD   Attending Physician at the Time of Discharge:  MD  Primary Care Physician:  MD,   Reason for Admission:  Shortness of breaths  Brief Summary of Hospital Stay: Patient is a 76 YO female with h/o former smoker (quit 5/2022), HLD, hypertension, GERD admitted 1/25 for shortness of breath and found to have acute systolic heart failure and COVID infection with hypoxia.  Patient was aggressively diuresed with quick resolution of hypoxia.  Patient was also treated briefly with remdesivir and steroids although these were able to be discontinued once patient was no longer hypoxic.  Cardiology consulted for acute systolic failure with EF showing EF of 30-35% with grade 2 diastolic dysfunction.  Stress test performed did not reveal any reversible ischemia.  EKG noted Q-waves per Dr. for which patient started on aspirin.  Patient advised that she can come out of isolation (currently requiring a mask when in public per CDC guidelines) on 2/1 from COVID as long as she does not have a fever in the out 24 hours previous.  Patient discharged on carvedilol 3.125 and lisinopril 2.5 and Lasix 20 mg daily as well as baby aspirin with plan for outpatient follow-up with primary care doctor and clinic.  Patient to get a blood pressure cuff to monitor blood pressures which have been fairly soft which will limit further medications consistent with goal-directed medical therapy.  BMP ordered for 1 week from now to monitor renal function given the initiation of ACE inhibitor and Lasix.  Patient at time of discharge denying shortness of breath at rest although with mild dyspnea with exertion and felt confident about discharge home and looking forward to wanting to restart work soon. Discharged to Home.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Dyspnoea exertional, Ejection fraction decreased, Electrocardiogram Q waves, Ex-tobacco user
Clinical narrative: Admit date: 1/25/2024  Discharge date:  1/29/2024  Admitting Physician:  MD   Attending Physician at the Time of Discharge:  MD  Primary Care Physician:  MD,   Reason for Admission:  Shortness of breaths  Brief Summary of Hospital Stay: Patient is a 76 YO female with h/o former smoker (quit 5/2022), HLD, hypertension, GERD admitted 1/25 for shortness of breath and found to have acute systolic heart failure and COVID infection with hypoxia.  Patient was aggressively diuresed with quick resolution of hypoxia.  Patient was also treated briefly with remdesivir and steroids although these were able to be discontinued once patient was no longer hypoxic.  Cardiology consulted for acute systolic failure with EF showing EF of 30-35% with grade 2 diastolic dysfunction.  Stress test performed did not reveal any reversible ischemia.  EKG noted Q-waves per Dr. for which patient started on aspirin.  Patient advised that she can come out of isolation (currently requiring a mask when in public per CDC guidelines) on 2/1 from COVID as long as she does not have a fever in the out 24 hours previous.  Patient discharged on carvedilol 3.125 and lisinopril 2.5 and Lasix 20 mg daily as well as baby aspirin with plan for outpatient follow-up with primary care doctor and clinic.  Patient to get a blood pressure cuff to monitor blood pressures which have been fairly soft which will limit further medications consistent with goal-directed medical therapy.  BMP ordered for 1 week from now to monitor renal function given the initiation of ACE inhibitor and Lasix.  Patient at time of discharge denying shortness of breath at rest although with mild dyspnea with exertion and felt confident about discharge home and looking forward to wanting to restart work soon. Discharged to Home.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoxia, Impaired work ability
Clinical narrative: Admit date: 1/25/2024  Discharge date:  1/29/2024  Admitting Physician:  MD   Attending Physician at the Time of Discharge:  MD  Primary Care Physician:  MD,   Reason for Admission:  Shortness of breaths  Brief Summary of Hospital Stay: Patient is a 76 YO female with h/o former smoker (quit 5/2022), HLD, hypertension, GERD admitted 1/25 for shortness of breath and found to have acute systolic heart failure and COVID infection with hypoxia.  Patient was aggressively diuresed with quick resolution of hypoxia.  Patient was also treated briefly with remdesivir and steroids although these were able to be discontinued once patient was no longer hypoxic.  Cardiology consulted for acute systolic failure with EF showing EF of 30-35% with grade 2 diastolic dysfunction.  Stress test performed did not reveal any reversible ischemia.  EKG noted Q-waves per Dr. for which patient started on aspirin.  Patient advised that she can come out of isolation (currently requiring a mask when in public per CDC guidelines) on 2/1 from COVID as long as she does not have a fever in the out 24 hours previous.  Patient discharged on carvedilol 3.125 and lisinopril 2.5 and Lasix 20 mg daily as well as baby aspirin with plan for outpatient follow-up with primary care doctor and clinic.  Patient to get a blood pressure cuff to monitor blood pressures which have been fairly soft which will limit further medications consistent with goal-directed medical therapy.  BMP ordered for 1 week from now to monitor renal function given the initiation of ACE inhibitor and Lasix.  Patient at time of discharge denying shortness of breath at rest although with mild dyspnea with exertion and felt confident about discharge home and looking forward to wanting to restart work soon. Discharged to Home.
Age: 52.0
Sex: F
Vaccine: COVID19-2
Symptoms: Acute kidney injury, Blood creatinine increased, Blood potassium increased, COVID-19, Carbon dioxide decreased
Clinical narrative: Patient Name:   DOB:   Admission Date and Time: 1/25/2024  2:21 PM Discharge Date: 1/30/2024 Attending Physicians:  DO, MD, DO, MD Discharge Physician:  PA Admission Diagnosis: AKI (acute kidney injury)   Discharge Diagnosis: AKI (acute kidney injury)                                         PREMORBID FUNCTIONAL STATUS Premorbid Functional Status:  Level of Independence: Independent with transfers; Independent with ambulation  IADL:  IADL Comments: Pt reports beig IND w/ all IADLs at baseline, drives  BADL:  BADL Comments: Pt reports being IND w/ all BADLs at baseline  REHABILITATION COURSE  This is a 53 YO female with past medical history of Eagle-Barrett syndrome (prune belly syndrome) with colostomy and urostomy.  She was recently hospitalized 12/31/23 through 1/8/24 for SBO and intertrigo and discharged in stable condition.  On 1/19/24 the patient returned to Hospital emergency department at the request of her nephrologist after routine labs revealed a K of 6.6 and an AKI (creatinine of 4.6 on admission).    The patient reported a history of diarrhea for about 2 weeks prior and AKI was felt to be secondary to decreased intravascular volume.  RRT was not recommended by nephrology and creatinine has steadily decreased, today down to 2.7.   The patient was seen at the bedside where she reports primarily left-sided weakness.  She states that a few years ago she underwent a bowel resection and required rehabilitation postoperatively due to similar left-sided weakness.  She reports using leg braces at baseline, since she was a child.    When medically stable, the patient was discharged to facility for  acute inpatient rehabilitation of functional and cognitive deficits.  On 1/28/24 the patient developed a cough and sore throat.  She was found to test positive for covid on 1/29/24.  IV was unable to be placed after multiple attempts however the patient was stable and only mildly symptomatic.  Today the patient developed rigors and a fever, as well as tachycardia.  She reports feeling shortness of breath however is not hypoxic.  RR is 22.  BMP revealed a CO2 of 14 and K of 6.2.  Lokelma ordered for 3 doses.  Transfer was requested of hospitalist team at facility.   Transferred to Acute Care Hospital
Age: 52.0
Sex: F
Vaccine: COVID19-2
Symptoms: Chills, Cognitive disorder, Cough, Diarrhoea, Dyspnoea
Clinical narrative: Patient Name:   DOB:   Admission Date and Time: 1/25/2024  2:21 PM Discharge Date: 1/30/2024 Attending Physicians:  DO, MD, DO, MD Discharge Physician:  PA Admission Diagnosis: AKI (acute kidney injury)   Discharge Diagnosis: AKI (acute kidney injury)                                         PREMORBID FUNCTIONAL STATUS Premorbid Functional Status:  Level of Independence: Independent with transfers; Independent with ambulation  IADL:  IADL Comments: Pt reports beig IND w/ all IADLs at baseline, drives  BADL:  BADL Comments: Pt reports being IND w/ all BADLs at baseline  REHABILITATION COURSE  This is a 53 YO female with past medical history of Eagle-Barrett syndrome (prune belly syndrome) with colostomy and urostomy.  She was recently hospitalized 12/31/23 through 1/8/24 for SBO and intertrigo and discharged in stable condition.  On 1/19/24 the patient returned to Hospital emergency department at the request of her nephrologist after routine labs revealed a K of 6.6 and an AKI (creatinine of 4.6 on admission).    The patient reported a history of diarrhea for about 2 weeks prior and AKI was felt to be secondary to decreased intravascular volume.  RRT was not recommended by nephrology and creatinine has steadily decreased, today down to 2.7.   The patient was seen at the bedside where she reports primarily left-sided weakness.  She states that a few years ago she underwent a bowel resection and required rehabilitation postoperatively due to similar left-sided weakness.  She reports using leg braces at baseline, since she was a child.    When medically stable, the patient was discharged to facility for  acute inpatient rehabilitation of functional and cognitive deficits.  On 1/28/24 the patient developed a cough and sore throat.  She was found to test positive for covid on 1/29/24.  IV was unable to be placed after multiple attempts however the patient was stable and only mildly symptomatic.  Today the patient developed rigors and a fever, as well as tachycardia.  She reports feeling shortness of breath however is not hypoxic.  RR is 22.  BMP revealed a CO2 of 14 and K of 6.2.  Lokelma ordered for 3 doses.  Transfer was requested of hospitalist team at facility.   Transferred to Acute Care Hospital
Age: 52.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hemiparesis, Intertrigo, Loss of personal independence in daily activities, Oropharyngeal pain, Pyrexia
Clinical narrative: Patient Name:   DOB:   Admission Date and Time: 1/25/2024  2:21 PM Discharge Date: 1/30/2024 Attending Physicians:  DO, MD, DO, MD Discharge Physician:  PA Admission Diagnosis: AKI (acute kidney injury)   Discharge Diagnosis: AKI (acute kidney injury)                                         PREMORBID FUNCTIONAL STATUS Premorbid Functional Status:  Level of Independence: Independent with transfers; Independent with ambulation  IADL:  IADL Comments: Pt reports beig IND w/ all IADLs at baseline, drives  BADL:  BADL Comments: Pt reports being IND w/ all BADLs at baseline  REHABILITATION COURSE  This is a 53 YO female with past medical history of Eagle-Barrett syndrome (prune belly syndrome) with colostomy and urostomy.  She was recently hospitalized 12/31/23 through 1/8/24 for SBO and intertrigo and discharged in stable condition.  On 1/19/24 the patient returned to Hospital emergency department at the request of her nephrologist after routine labs revealed a K of 6.6 and an AKI (creatinine of 4.6 on admission).    The patient reported a history of diarrhea for about 2 weeks prior and AKI was felt to be secondary to decreased intravascular volume.  RRT was not recommended by nephrology and creatinine has steadily decreased, today down to 2.7.   The patient was seen at the bedside where she reports primarily left-sided weakness.  She states that a few years ago she underwent a bowel resection and required rehabilitation postoperatively due to similar left-sided weakness.  She reports using leg braces at baseline, since she was a child.    When medically stable, the patient was discharged to facility for  acute inpatient rehabilitation of functional and cognitive deficits.  On 1/28/24 the patient developed a cough and sore throat.  She was found to test positive for covid on 1/29/24.  IV was unable to be placed after multiple attempts however the patient was stable and only mildly symptomatic.  Today the patient developed rigors and a fever, as well as tachycardia.  She reports feeling shortness of breath however is not hypoxic.  RR is 22.  BMP revealed a CO2 of 14 and K of 6.2.  Lokelma ordered for 3 doses.  Transfer was requested of hospitalist team at facility.   Transferred to Acute Care Hospital
Age: 52.0
Sex: F
Vaccine: COVID19-2
Symptoms: SARS-CoV-2 test positive, Small intestinal obstruction, Tachycardia
Clinical narrative: Patient Name:   DOB:   Admission Date and Time: 1/25/2024  2:21 PM Discharge Date: 1/30/2024 Attending Physicians:  DO, MD, DO, MD Discharge Physician:  PA Admission Diagnosis: AKI (acute kidney injury)   Discharge Diagnosis: AKI (acute kidney injury)                                         PREMORBID FUNCTIONAL STATUS Premorbid Functional Status:  Level of Independence: Independent with transfers; Independent with ambulation  IADL:  IADL Comments: Pt reports beig IND w/ all IADLs at baseline, drives  BADL:  BADL Comments: Pt reports being IND w/ all BADLs at baseline  REHABILITATION COURSE  This is a 53 YO female with past medical history of Eagle-Barrett syndrome (prune belly syndrome) with colostomy and urostomy.  She was recently hospitalized 12/31/23 through 1/8/24 for SBO and intertrigo and discharged in stable condition.  On 1/19/24 the patient returned to Hospital emergency department at the request of her nephrologist after routine labs revealed a K of 6.6 and an AKI (creatinine of 4.6 on admission).    The patient reported a history of diarrhea for about 2 weeks prior and AKI was felt to be secondary to decreased intravascular volume.  RRT was not recommended by nephrology and creatinine has steadily decreased, today down to 2.7.   The patient was seen at the bedside where she reports primarily left-sided weakness.  She states that a few years ago she underwent a bowel resection and required rehabilitation postoperatively due to similar left-sided weakness.  She reports using leg braces at baseline, since she was a child.    When medically stable, the patient was discharged to facility for  acute inpatient rehabilitation of functional and cognitive deficits.  On 1/28/24 the patient developed a cough and sore throat.  She was found to test positive for covid on 1/29/24.  IV was unable to be placed after multiple attempts however the patient was stable and only mildly symptomatic.  Today the patient developed rigors and a fever, as well as tachycardia.  She reports feeling shortness of breath however is not hypoxic.  RR is 22.  BMP revealed a CO2 of 14 and K of 6.2.  Lokelma ordered for 3 doses.  Transfer was requested of hospitalist team at facility.   Transferred to Acute Care Hospital
Age: 1.5
Sex: F
Vaccine: HEPA
Symptoms: Culture urine negative, Lymphadenopathy, Pyrexia
Clinical narrative: 3 day fever followed by cervical lymphadenopathy
Age: 0.58
Sex: M
Vaccine: DTAPIPVHIB
Symptoms: No adverse event
Clinical narrative: Patient had no adverse reactions to the vaccine
Age: 81.0
Sex: M
Vaccine: COVID19-2
Symptoms: Abdominal pain upper, Angiogram pulmonary abnormal, Asthenia, Atelectasis, Chest X-ray abnormal
Clinical narrative: Date of Birth: (Age: 82 YO)    Date of Admission: 1/26/2024 Date of Discharge: 1/31/2024 Brief Admission History and hospital course: Patient is a 82 YO male with a PMHx of coronary artery disease, GERD, hypothyroidism, anxiety, CVA, left popliteal DVT 2017 who presents with chest pain and abdominal pain for the past 3 weeks that come and go.  He reports they both usually occur at rest due to him being weak and not very active.  The chest pain is located on the left side, rated 10/10, last about an hour before it spontaneously subsides, described as stabbing.  The abdominal pain is located in the epigastric area, rated a 10/10, is not provoked or helped by anything, and described as stabbing.  He also endorses sinus congestion, runny nose, sore throat, productive cough, fever, and chills for the past 2 weeks.  He denies tobacco use, alcohol use, and illicit drug use. In the emergency department, he was initially tachycardic and hypotensive.  Hypotension resolved after 1.5 L of IVF.  Notable labs include D-dimer 23,140, hemoglobin 10.9, and platelets 120.  Chest x-ray with bibasilar subsegmental atelectasis; CT pulmonary CTA with acute segmental and subsegmental pulmonary emboli within the right lower lobe and left lower lobe with findings concerning for right heart strain, small left pleural effusion; and ultrasound venous bilateral with acute appearing DVT in the right lower extremity with reflected cardiac pulsations in the common femoral vein waveforms.  IR consulted and did not feel as if intervention would be beneficial.  Plan of care discussed with the patient who verbalized understanding was agreeable was good candidate for discharge as he was stable during the stay without any tachycardia, tachypnea or hypoxemia.  The patient to continue follow up with his PCP in 1 week and other specialist as scheduled.  Prescription sent to his pharmacy.  We were waiting for insurance approval to go back to Facility that he approved as of 01/31/2024 and discharged to the same facility.  Plan of care discussed with the patient nurse at bedside.  Code status at the day of discharge continue to be do not resuscitate/DNI with aggressive care. Discharged to SNF.
Age: 81.0
Sex: M
Vaccine: COVID19-2
Symptoms: Chest pain, Chills, Decreased activity, Deep vein thrombosis, Fibrin D dimer
Clinical narrative: Date of Birth: (Age: 82 YO)    Date of Admission: 1/26/2024 Date of Discharge: 1/31/2024 Brief Admission History and hospital course: Patient is a 82 YO male with a PMHx of coronary artery disease, GERD, hypothyroidism, anxiety, CVA, left popliteal DVT 2017 who presents with chest pain and abdominal pain for the past 3 weeks that come and go.  He reports they both usually occur at rest due to him being weak and not very active.  The chest pain is located on the left side, rated 10/10, last about an hour before it spontaneously subsides, described as stabbing.  The abdominal pain is located in the epigastric area, rated a 10/10, is not provoked or helped by anything, and described as stabbing.  He also endorses sinus congestion, runny nose, sore throat, productive cough, fever, and chills for the past 2 weeks.  He denies tobacco use, alcohol use, and illicit drug use. In the emergency department, he was initially tachycardic and hypotensive.  Hypotension resolved after 1.5 L of IVF.  Notable labs include D-dimer 23,140, hemoglobin 10.9, and platelets 120.  Chest x-ray with bibasilar subsegmental atelectasis; CT pulmonary CTA with acute segmental and subsegmental pulmonary emboli within the right lower lobe and left lower lobe with findings concerning for right heart strain, small left pleural effusion; and ultrasound venous bilateral with acute appearing DVT in the right lower extremity with reflected cardiac pulsations in the common femoral vein waveforms.  IR consulted and did not feel as if intervention would be beneficial.  Plan of care discussed with the patient who verbalized understanding was agreeable was good candidate for discharge as he was stable during the stay without any tachycardia, tachypnea or hypoxemia.  The patient to continue follow up with his PCP in 1 week and other specialist as scheduled.  Prescription sent to his pharmacy.  We were waiting for insurance approval to go back to Facility that he approved as of 01/31/2024 and discharged to the same facility.  Plan of care discussed with the patient nurse at bedside.  Code status at the day of discharge continue to be do not resuscitate/DNI with aggressive care. Discharged to SNF.
Age: 81.0
Sex: M
Vaccine: COVID19-2
Symptoms: Haemoglobin, Hypotension, Oropharyngeal pain, Pain, Platelet count decreased
Clinical narrative: Date of Birth: (Age: 82 YO)    Date of Admission: 1/26/2024 Date of Discharge: 1/31/2024 Brief Admission History and hospital course: Patient is a 82 YO male with a PMHx of coronary artery disease, GERD, hypothyroidism, anxiety, CVA, left popliteal DVT 2017 who presents with chest pain and abdominal pain for the past 3 weeks that come and go.  He reports they both usually occur at rest due to him being weak and not very active.  The chest pain is located on the left side, rated 10/10, last about an hour before it spontaneously subsides, described as stabbing.  The abdominal pain is located in the epigastric area, rated a 10/10, is not provoked or helped by anything, and described as stabbing.  He also endorses sinus congestion, runny nose, sore throat, productive cough, fever, and chills for the past 2 weeks.  He denies tobacco use, alcohol use, and illicit drug use. In the emergency department, he was initially tachycardic and hypotensive.  Hypotension resolved after 1.5 L of IVF.  Notable labs include D-dimer 23,140, hemoglobin 10.9, and platelets 120.  Chest x-ray with bibasilar subsegmental atelectasis; CT pulmonary CTA with acute segmental and subsegmental pulmonary emboli within the right lower lobe and left lower lobe with findings concerning for right heart strain, small left pleural effusion; and ultrasound venous bilateral with acute appearing DVT in the right lower extremity with reflected cardiac pulsations in the common femoral vein waveforms.  IR consulted and did not feel as if intervention would be beneficial.  Plan of care discussed with the patient who verbalized understanding was agreeable was good candidate for discharge as he was stable during the stay without any tachycardia, tachypnea or hypoxemia.  The patient to continue follow up with his PCP in 1 week and other specialist as scheduled.  Prescription sent to his pharmacy.  We were waiting for insurance approval to go back to Facility that he approved as of 01/31/2024 and discharged to the same facility.  Plan of care discussed with the patient nurse at bedside.  Code status at the day of discharge continue to be do not resuscitate/DNI with aggressive care. Discharged to SNF.
Age: 81.0
Sex: M
Vaccine: COVID19-2
Symptoms: Pleural effusion, Productive cough, Pulmonary embolism, Pyrexia, Rhinorrhoea
Clinical narrative: Date of Birth: (Age: 82 YO)    Date of Admission: 1/26/2024 Date of Discharge: 1/31/2024 Brief Admission History and hospital course: Patient is a 82 YO male with a PMHx of coronary artery disease, GERD, hypothyroidism, anxiety, CVA, left popliteal DVT 2017 who presents with chest pain and abdominal pain for the past 3 weeks that come and go.  He reports they both usually occur at rest due to him being weak and not very active.  The chest pain is located on the left side, rated 10/10, last about an hour before it spontaneously subsides, described as stabbing.  The abdominal pain is located in the epigastric area, rated a 10/10, is not provoked or helped by anything, and described as stabbing.  He also endorses sinus congestion, runny nose, sore throat, productive cough, fever, and chills for the past 2 weeks.  He denies tobacco use, alcohol use, and illicit drug use. In the emergency department, he was initially tachycardic and hypotensive.  Hypotension resolved after 1.5 L of IVF.  Notable labs include D-dimer 23,140, hemoglobin 10.9, and platelets 120.  Chest x-ray with bibasilar subsegmental atelectasis; CT pulmonary CTA with acute segmental and subsegmental pulmonary emboli within the right lower lobe and left lower lobe with findings concerning for right heart strain, small left pleural effusion; and ultrasound venous bilateral with acute appearing DVT in the right lower extremity with reflected cardiac pulsations in the common femoral vein waveforms.  IR consulted and did not feel as if intervention would be beneficial.  Plan of care discussed with the patient who verbalized understanding was agreeable was good candidate for discharge as he was stable during the stay without any tachycardia, tachypnea or hypoxemia.  The patient to continue follow up with his PCP in 1 week and other specialist as scheduled.  Prescription sent to his pharmacy.  We were waiting for insurance approval to go back to Facility that he approved as of 01/31/2024 and discharged to the same facility.  Plan of care discussed with the patient nurse at bedside.  Code status at the day of discharge continue to be do not resuscitate/DNI with aggressive care. Discharged to SNF.
Age: 81.0
Sex: M
Vaccine: COVID19-2
Symptoms: Sinus congestion, Tachycardia, Ultrasound Doppler abnormal
Clinical narrative: Date of Birth: (Age: 82 YO)    Date of Admission: 1/26/2024 Date of Discharge: 1/31/2024 Brief Admission History and hospital course: Patient is a 82 YO male with a PMHx of coronary artery disease, GERD, hypothyroidism, anxiety, CVA, left popliteal DVT 2017 who presents with chest pain and abdominal pain for the past 3 weeks that come and go.  He reports they both usually occur at rest due to him being weak and not very active.  The chest pain is located on the left side, rated 10/10, last about an hour before it spontaneously subsides, described as stabbing.  The abdominal pain is located in the epigastric area, rated a 10/10, is not provoked or helped by anything, and described as stabbing.  He also endorses sinus congestion, runny nose, sore throat, productive cough, fever, and chills for the past 2 weeks.  He denies tobacco use, alcohol use, and illicit drug use. In the emergency department, he was initially tachycardic and hypotensive.  Hypotension resolved after 1.5 L of IVF.  Notable labs include D-dimer 23,140, hemoglobin 10.9, and platelets 120.  Chest x-ray with bibasilar subsegmental atelectasis; CT pulmonary CTA with acute segmental and subsegmental pulmonary emboli within the right lower lobe and left lower lobe with findings concerning for right heart strain, small left pleural effusion; and ultrasound venous bilateral with acute appearing DVT in the right lower extremity with reflected cardiac pulsations in the common femoral vein waveforms.  IR consulted and did not feel as if intervention would be beneficial.  Plan of care discussed with the patient who verbalized understanding was agreeable was good candidate for discharge as he was stable during the stay without any tachycardia, tachypnea or hypoxemia.  The patient to continue follow up with his PCP in 1 week and other specialist as scheduled.  Prescription sent to his pharmacy.  We were waiting for insurance approval to go back to Facility that he approved as of 01/31/2024 and discharged to the same facility.  Plan of care discussed with the patient nurse at bedside.  Code status at the day of discharge continue to be do not resuscitate/DNI with aggressive care. Discharged to SNF.
Age: 2.0
Sex: F
Vaccine: COVID19
Symptoms: Incorrect dose administered, No adverse event, Product preparation error
Clinical narrative: Diluted 0.3 ml for the 5-11yr vaccine with 1.1 ml and gave 0.3ml. No reaction at this time but advised with Dr and advised no further vaccine needed.
Age: 62.0
Sex: F
Vaccine: COVID19-2
Symptoms: Anaemia, COVID-19, Diuretic therapy, End stage renal disease, Hypervolaemia
Clinical narrative: Admit date: 1/23/2024  Discharge date: 1/31/24  Admitting Physician:  MD   Attending Physician at the Time of Discharge: DO  Primary Care Physician:  MD,   Reason for Admission: hypoglycemia, volume overload, progression to ESRD  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) presented with abnormal labs found to have anemia, hypoglycemia and hypervolemia. Started on PD and outpatient follow up for this to continue at home arranged.  Insulin dose reduced in setting of illness, esrd and starting PD - stop SGLT2 with esrd status  Diuretic increased to help with volume removal  Covid without hypoxia - no directed therapy.  The patient was discharged in stable condition with improvement of symptoms and appropriate follow up planned. Discharged to Home Health Care.
Age: 62.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hypoglycaemia, Insulin therapy, Laboratory test abnormal
Clinical narrative: Admit date: 1/23/2024  Discharge date: 1/31/24  Admitting Physician:  MD   Attending Physician at the Time of Discharge: DO  Primary Care Physician:  MD,   Reason for Admission: hypoglycemia, volume overload, progression to ESRD  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) presented with abnormal labs found to have anemia, hypoglycemia and hypervolemia. Started on PD and outpatient follow up for this to continue at home arranged.  Insulin dose reduced in setting of illness, esrd and starting PD - stop SGLT2 with esrd status  Diuretic increased to help with volume removal  Covid without hypoxia - no directed therapy.  The patient was discharged in stable condition with improvement of symptoms and appropriate follow up planned. Discharged to Home Health Care.
Age: 61.0
Sex: F
Vaccine: UNK
Symptoms: Cardiac monitoring, Loss of consciousness
Clinical narrative: Daughter found me unconcious, called 911, hospitalized from 2/2/24 to 2/7/24left with meds, heart monitor, and follow ups.
Age: 101.0
Sex: F
Vaccine: COVID19
Symptoms: Atrial fibrillation, Blood magnesium, Blood potassium, Bradycardia, COVID-19
Clinical narrative: Admit date: 1/24/2024  Discharge date: 2/4/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: No att. providers found  Primary Care Physician: MD,    Reason for Admission:  Patient is a 103 YO female with past medical history of permanent Atrial fibrillation and arthritis who presented to the ED after a ground level fall earlier this morning. Patient reports she hit her head and denies loss of consciousness.   Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  See below note for details re: this hospitalization.  Hospital Course: No notes on file  These were her acute medical issues addressed:  Principal Problem:   COVID-19 infection    Atrial fibrillation on Eliquis   Ground-level fall   Other constipation   Sacral fracture, closed  COVID-19 with hypoxia (on admission) -Desaturation to 88%, placed on nasal cannula initially. -Has received 3 covid vaccines.  -patient completed a course of Remdesivir  and Decadron -recovered completely and was completely weaned off any supplemental O2 at discharge.  GLF -Imaging negative as above, no acute fracture on x-rays -B/L sacral fracture seen on CT. Unclear if these sacral fractures were post traumatic, or related to osteopenia/ insufficiency fractures. -PT/OT as tolerated, full weight-bearing  Sacral fractures, orthopedic surgery consult appreciated, patient needs pain control and weight-bearing as tolerated.  Will use Tylenol, half a dose of Ultram, lidocaine patch for pain control.  PT OT  Permanent Atrial fibrillation -Continued Home Eliquis, not on Beta blocker due to symptomatic bradycardia.  -Telemetry. K>4, Mag>2  Macular Degeneration -Continue teardrops and start tobramycin eyedrops for purulent drainage, improved  Constipation, MiraLax and senna and Dulcolax suppository if needed --now with loose stools.  Leg swelling -- no recent ECHO, Resumed daily Lasix.  Very stable throughout. No other acute issues. DC to NH in very stable condition after satisfying the 10 day quarantine period for COVID-19 patients being transferred to this facility. Discharged to SNF
Age: 101.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram abnormal, Condition aggravated, Constipation, Diarrhoea, Eye discharge
Clinical narrative: Admit date: 1/24/2024  Discharge date: 2/4/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: No att. providers found  Primary Care Physician: MD,    Reason for Admission:  Patient is a 103 YO female with past medical history of permanent Atrial fibrillation and arthritis who presented to the ED after a ground level fall earlier this morning. Patient reports she hit her head and denies loss of consciousness.   Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  See below note for details re: this hospitalization.  Hospital Course: No notes on file  These were her acute medical issues addressed:  Principal Problem:   COVID-19 infection    Atrial fibrillation on Eliquis   Ground-level fall   Other constipation   Sacral fracture, closed  COVID-19 with hypoxia (on admission) -Desaturation to 88%, placed on nasal cannula initially. -Has received 3 covid vaccines.  -patient completed a course of Remdesivir  and Decadron -recovered completely and was completely weaned off any supplemental O2 at discharge.  GLF -Imaging negative as above, no acute fracture on x-rays -B/L sacral fracture seen on CT. Unclear if these sacral fractures were post traumatic, or related to osteopenia/ insufficiency fractures. -PT/OT as tolerated, full weight-bearing  Sacral fractures, orthopedic surgery consult appreciated, patient needs pain control and weight-bearing as tolerated.  Will use Tylenol, half a dose of Ultram, lidocaine patch for pain control.  PT OT  Permanent Atrial fibrillation -Continued Home Eliquis, not on Beta blocker due to symptomatic bradycardia.  -Telemetry. K>4, Mag>2  Macular Degeneration -Continue teardrops and start tobramycin eyedrops for purulent drainage, improved  Constipation, MiraLax and senna and Dulcolax suppository if needed --now with loose stools.  Leg swelling -- no recent ECHO, Resumed daily Lasix.  Very stable throughout. No other acute issues. DC to NH in very stable condition after satisfying the 10 day quarantine period for COVID-19 patients being transferred to this facility. Discharged to SNF
Age: 101.0
Sex: F
Vaccine: COVID19
Symptoms: Fall, Fractured sacrum, Head injury, Hypoxia, Oxygen saturation decreased
Clinical narrative: Admit date: 1/24/2024  Discharge date: 2/4/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: No att. providers found  Primary Care Physician: MD,    Reason for Admission:  Patient is a 103 YO female with past medical history of permanent Atrial fibrillation and arthritis who presented to the ED after a ground level fall earlier this morning. Patient reports she hit her head and denies loss of consciousness.   Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  See below note for details re: this hospitalization.  Hospital Course: No notes on file  These were her acute medical issues addressed:  Principal Problem:   COVID-19 infection    Atrial fibrillation on Eliquis   Ground-level fall   Other constipation   Sacral fracture, closed  COVID-19 with hypoxia (on admission) -Desaturation to 88%, placed on nasal cannula initially. -Has received 3 covid vaccines.  -patient completed a course of Remdesivir  and Decadron -recovered completely and was completely weaned off any supplemental O2 at discharge.  GLF -Imaging negative as above, no acute fracture on x-rays -B/L sacral fracture seen on CT. Unclear if these sacral fractures were post traumatic, or related to osteopenia/ insufficiency fractures. -PT/OT as tolerated, full weight-bearing  Sacral fractures, orthopedic surgery consult appreciated, patient needs pain control and weight-bearing as tolerated.  Will use Tylenol, half a dose of Ultram, lidocaine patch for pain control.  PT OT  Permanent Atrial fibrillation -Continued Home Eliquis, not on Beta blocker due to symptomatic bradycardia.  -Telemetry. K>4, Mag>2  Macular Degeneration -Continue teardrops and start tobramycin eyedrops for purulent drainage, improved  Constipation, MiraLax and senna and Dulcolax suppository if needed --now with loose stools.  Leg swelling -- no recent ECHO, Resumed daily Lasix.  Very stable throughout. No other acute issues. DC to NH in very stable condition after satisfying the 10 day quarantine period for COVID-19 patients being transferred to this facility. Discharged to SNF
Age: 101.0
Sex: F
Vaccine: COVID19
Symptoms: Peripheral swelling, Purulent discharge, X-ray normal
Clinical narrative: Admit date: 1/24/2024  Discharge date: 2/4/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: No att. providers found  Primary Care Physician: MD,    Reason for Admission:  Patient is a 103 YO female with past medical history of permanent Atrial fibrillation and arthritis who presented to the ED after a ground level fall earlier this morning. Patient reports she hit her head and denies loss of consciousness.   Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  See below note for details re: this hospitalization.  Hospital Course: No notes on file  These were her acute medical issues addressed:  Principal Problem:   COVID-19 infection    Atrial fibrillation on Eliquis   Ground-level fall   Other constipation   Sacral fracture, closed  COVID-19 with hypoxia (on admission) -Desaturation to 88%, placed on nasal cannula initially. -Has received 3 covid vaccines.  -patient completed a course of Remdesivir  and Decadron -recovered completely and was completely weaned off any supplemental O2 at discharge.  GLF -Imaging negative as above, no acute fracture on x-rays -B/L sacral fracture seen on CT. Unclear if these sacral fractures were post traumatic, or related to osteopenia/ insufficiency fractures. -PT/OT as tolerated, full weight-bearing  Sacral fractures, orthopedic surgery consult appreciated, patient needs pain control and weight-bearing as tolerated.  Will use Tylenol, half a dose of Ultram, lidocaine patch for pain control.  PT OT  Permanent Atrial fibrillation -Continued Home Eliquis, not on Beta blocker due to symptomatic bradycardia.  -Telemetry. K>4, Mag>2  Macular Degeneration -Continue teardrops and start tobramycin eyedrops for purulent drainage, improved  Constipation, MiraLax and senna and Dulcolax suppository if needed --now with loose stools.  Leg swelling -- no recent ECHO, Resumed daily Lasix.  Very stable throughout. No other acute issues. DC to NH in very stable condition after satisfying the 10 day quarantine period for COVID-19 patients being transferred to this facility. Discharged to SNF
Age: 104.0
Sex: F
Vaccine: COVID19-2
Symptoms: COVID-19, Chronic respiratory failure, Cough, Fall, Hip fracture
Clinical narrative: Admit date: 1/31/2024  Discharge date: 2/5/2024  Admitting Physician: MD   Discharge Physician: DO  Reason for Admission: Hip fracture   Discharge Problem List     Hypothyroidism   Chronic kidney disease (CKD), stage III-IV (moderate)     Dyslipidemia   Left upper lobe consolidation     Pulmonary infection due to Mycobacterium chimaera  intracellulare     Chronic respiratory failure with hypoxia     Chronic cough   History of COVID-19   Glaucoma   Intertrochanteric fracture of right hip     Ground-level fall  Procedures: right intramedullary nail fixation 2/1  Consultations: Orthopedic Surgery   Hospital Course: Patient is a 105-year-old female with a past medical history significant for chronic respiratory insufficiency on 2 L nasal cannula, ulcerative colitis, hypothyroidism, CKD and hypertension.  She presented to the emergency department on 01/31/2024 due to a ground level fall at home which resulted in right hip fracture.  She was seen by Orthopedic surgery on 02/01/2024 who performed right femur intramedullary nail fixation.  Patient tolerated this procedure well.  She did well postop.  She was seen by PT OT who recommended IPR placement, she was accepted at IPR.  Of note patient did have a COVID test which was positive prior to discharge, however, patient states she was positive back on January 15th so this is likely related to an old infection.  IPR was notified of her recent positivity.  She will be going to IPR for further recommendations.  She will follow up with Orthopedic surgery as well as her primary care provider after discharge. Discharged to Rehab Facility.
Age: 104.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hypoxia, Intramedullary rod insertion, Lung consolidation, Mycobacterium avium complex infection, SARS-CoV-2 test positive
Clinical narrative: Admit date: 1/31/2024  Discharge date: 2/5/2024  Admitting Physician: MD   Discharge Physician: DO  Reason for Admission: Hip fracture   Discharge Problem List     Hypothyroidism   Chronic kidney disease (CKD), stage III-IV (moderate)     Dyslipidemia   Left upper lobe consolidation     Pulmonary infection due to Mycobacterium chimaera  intracellulare     Chronic respiratory failure with hypoxia     Chronic cough   History of COVID-19   Glaucoma   Intertrochanteric fracture of right hip     Ground-level fall  Procedures: right intramedullary nail fixation 2/1  Consultations: Orthopedic Surgery   Hospital Course: Patient is a 105-year-old female with a past medical history significant for chronic respiratory insufficiency on 2 L nasal cannula, ulcerative colitis, hypothyroidism, CKD and hypertension.  She presented to the emergency department on 01/31/2024 due to a ground level fall at home which resulted in right hip fracture.  She was seen by Orthopedic surgery on 02/01/2024 who performed right femur intramedullary nail fixation.  Patient tolerated this procedure well.  She did well postop.  She was seen by PT OT who recommended IPR placement, she was accepted at IPR.  Of note patient did have a COVID test which was positive prior to discharge, however, patient states she was positive back on January 15th so this is likely related to an old infection.  IPR was notified of her recent positivity.  She will be going to IPR for further recommendations.  She will follow up with Orthopedic surgery as well as her primary care provider after discharge. Discharged to Rehab Facility.
Age: 42.0
Sex: F
Vaccine: HEPAB
Symptoms: Antibody test negative
Clinical narrative: Patient completed full Twinrix accelerated series (Lot # 9RT94 administered on 1/9/20, 1/16/20, 2/8/20, and lot # DK23D administered on 2/22/21. Clinic informed by patient on 2/2/24 that patient had titers drawn showing no immunity to Hepatitis A. Recommended by clinic and PCP to repeat/booster.
Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Blood bicarbonate decreased, Blood creatinine, Blood lactic acid normal, COVID-19 pneumonia
Clinical narrative: Admit date: 2/2/2024  Discharge date: 2/6/24  Admitting Physician: DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD Reason for Admission: Patient is a 86 YO year old female with past medical history of interstitial lung disease with bronchiectasis, metastatic breast cancer on Faslodex and Ibrance, Atrial fibrillation not on anticoagulation, T2DM insulin dependent with diabetic retinopathy,  CKD4, alzheimer's dementia (reportedly nonverbal at baseline), HTN, HLD presenting to Hospital with fever, cough, difficulty breathing.  Patient unable to give significant history.  Most history gleaned from chart review.  Patient arrived via EMS from facility for complaint of fever, cough, difficulty breathing.  Facility noted that her symptoms started earlier today, presenting as a productive cough with a fever of 100.2.  She was reportedly hypoxic with 70% on room air which improved with 4 L nasal cannula.  On speaking to the patient, she can give yes or no answers, but otherwise simply mumbles.  This is apparently her baseline according to her facility, in report from ER resident.   ED Course:  In the emergency room, she presented with a heart rate of 102, respiratory rate 30, she was febrile at 102° F, blood pressure was stable, she was satting 93% on 2 L nasal cannula.  Lab work was significant for hemoglobin 9.1, white blood cell count was normal but she demonstrated a lymphopenia.  Creatinine is 2.5, baseline possibly 1.7.  Bicarb is 20.  ProBNP 2938, lactate was normal.  ABG was obtained demonstrated a well compensated metabolic acidosis with compensatory respiratory alkalosis.  UA demonstrated large leukocytes with greater than 100 WBCs and many casts.  Viral respiratory panel is pending, chest x-ray demonstrated a right upper lobe infiltrate concerning for pneumonia.  She will be admitted to inpatient status for sepsis secondary to community-acquired versus aspiration pneumonia  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  She was admitted for COVID 19 pneumonia with hypoxia. CXR showed consolidation suggestive of pneumonia and given this was possibly bacterial she was given Rocephin and Doxy, given procal was slightly high. . She was given Remdesevir and steroids. She had mild AKI which has resolved. She has chronic Afib which was controlled, she is not on AC.  Today she is doing well. Lungs are clear. Sats are good. Suspect COVID penumonia and not bacterial but will give short course of Doxy to empirically cover for bacterial PNA.  Of note, she was noted to have aspiration - SLP consulted and SLP recommends pt remain on current diet recommendations of NDD Level 2 (mechanically altered) (IDDSI 5) with nectar-thick liquids (IDDSI 2). Pt continues to demonstrate overt s/s of aspiration with thin liquid trials. Will need Op VFSS.  Discharged to Home.