chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Blood sodium decreased, Blood urea normal, C-reactive protein increased, COVID-19, Cerebral atrophy
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Chronic sinusitis, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Condition aggravated, Differential white blood cell count normal
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Electrocardiogram normal, Eosinophil count decreased, Eosinophil percentage decreased, Exposure to SARS-CoV-2, Fall
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Fibrin D dimer increased, Full blood count normal, Glomerular filtration rate normal, Haematocrit decreased
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin decreased, Immature granulocyte count, Lymphocyte count, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Metabolic function test normal, Monocyte count decreased
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Monocyte percentage increased, Neutrophil count, Neutrophil percentage increased, Platelet count normal, Red blood cell count normal
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Red blood cell nucleated morphology, Red cell distribution width increased, SARS-CoV-2 test positive, Sick relative
Clinical narrative: Patient is a 72 y.o. male who presented to emergency department with complaints of generalized weakness.  He has a past medical history of Alzheimer's dementia- end stage, chronic obstructive pulmonary disease, mutation of bilateral arms below the elbow, and prosthetic left eye. Patient presented with complaints of generalized weakness.  At baseline, he does have dementia which limits assessment ability.  Per his daughter, he has had multiple falls recently.  She states that he ambulates independently, however, very slowly.  Upon examination, patient has no specific complaints.  Patient's daughter has concerns that his wife, who is his primary caregiver is unable to care for the patient because she herself has COVID-19.  In the emergency department, patient's vital signs were stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  COVID-19 was positive.  EKG shows normal sinus rhythm.  CT scan of the head showed chronic maxillary sinusitis and chronic generalized brain atrophy.  CT of the chest showed no acute abnormalities.  Suspect generalized weakness secondary to COVID-19.  Patient has been transferred and admitted to Hospital further evaluation management of generalized weakness.   Patient was evaluated and qualified for monoclonal antibodies. Patient's daughter was at bedside and reported ability to care for patient 24/7 until spouse was able to continue normal care. Risk and benefits discussed with daughter who agreed upon infusion and discharge home when safe. Patient received therapy without interactions.    The patient was evaluated by PT and OT, both therapists recommended subacute rehab and a walker for home use. This was discussed with the patient and daughter; the daughter plans to bring him to her home with 24 hour care until his wife (primary caregiver) is recovered from COVID infection.  The patient continues on room air, he has some fatigue, but is otherwise stable.  The patient will be discharged in the care of his daughter until he can return home.
Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Flushing, Hyperhidrosis, Nausea, Vomiting
Clinical narrative: Systemic: Dizziness / Lightheadness-Medium, Systemic: Flushed / Sweating-Medium, Systemic: Nausea-Medium, Systemic: Vomiting-Mild, Additional Details: Patient refused benedryl or epinephrine. Patietn also refused to go t hospital. patient was monitored from onset of symptoms at 11:58 till 13:02. Patient's vitals were stable BP 111/74 HR 81. Patient escorted home with husband. Instructed to go to hospital is symptoms worsen or or if symptoms do not subside.
Age: 20.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Abdominal pain, COVID-19, Complication of device insertion, Computerised tomogram abdomen abnormal, Condition aggravated
Clinical narrative: Hospitalized 11/7/2021; COVID-19 positive 11/7/2021; fully vaccinated  Discharge Summary MD (Physician) Surgery BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 11/7/2021 Discharge Date: 11/08/2021    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Small bowel obstruction (HCC) [K56.609]   HOSPITAL COURSE: Patient was seen at the emergency department for crampy abdominal pain, nausea and vomiting.  CT showed a chronic bowel obstruction and patient was transferred to hospital for further management.  Patient was incidentally found to be COVID positive and the monoclonal antibody infusion clinic was contacted.  Patient met criteria and was given the monoclonal antibody during her inpatient stay.  Patient was unable to tolerate placement of an NG tube but was still having bowel movements.  A gastrografin challenge was performed which showed passage of the contrast into the colon.  Her pain improved and she was able to tolerate regular food prior to discharge.  Although she has a known history of Crohn's disease, patient had no leukocytosis or signs of active crohn's disease on CT.  Given the chronic nature of the obstruction with evidence of fecalization expect an acute on chronic exacerbation of a possible crohn's stricture which should be investigated further.
Age: 20.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Food intolerance, Gastrointestinal tube insertion, Intestinal obstruction, Laboratory test, Nausea
Clinical narrative: Hospitalized 11/7/2021; COVID-19 positive 11/7/2021; fully vaccinated  Discharge Summary MD (Physician) Surgery BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 11/7/2021 Discharge Date: 11/08/2021    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Small bowel obstruction (HCC) [K56.609]   HOSPITAL COURSE: Patient was seen at the emergency department for crampy abdominal pain, nausea and vomiting.  CT showed a chronic bowel obstruction and patient was transferred to hospital for further management.  Patient was incidentally found to be COVID positive and the monoclonal antibody infusion clinic was contacted.  Patient met criteria and was given the monoclonal antibody during her inpatient stay.  Patient was unable to tolerate placement of an NG tube but was still having bowel movements.  A gastrografin challenge was performed which showed passage of the contrast into the colon.  Her pain improved and she was able to tolerate regular food prior to discharge.  Although she has a known history of Crohn's disease, patient had no leukocytosis or signs of active crohn's disease on CT.  Given the chronic nature of the obstruction with evidence of fecalization expect an acute on chronic exacerbation of a possible crohn's stricture which should be investigated further.
Age: 20.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Small intestinal obstruction, Vomiting
Clinical narrative: Hospitalized 11/7/2021; COVID-19 positive 11/7/2021; fully vaccinated  Discharge Summary MD (Physician) Surgery BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 11/7/2021 Discharge Date: 11/08/2021    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Small bowel obstruction (HCC) [K56.609]   HOSPITAL COURSE: Patient was seen at the emergency department for crampy abdominal pain, nausea and vomiting.  CT showed a chronic bowel obstruction and patient was transferred to hospital for further management.  Patient was incidentally found to be COVID positive and the monoclonal antibody infusion clinic was contacted.  Patient met criteria and was given the monoclonal antibody during her inpatient stay.  Patient was unable to tolerate placement of an NG tube but was still having bowel movements.  A gastrografin challenge was performed which showed passage of the contrast into the colon.  Her pain improved and she was able to tolerate regular food prior to discharge.  Although she has a known history of Crohn's disease, patient had no leukocytosis or signs of active crohn's disease on CT.  Given the chronic nature of the obstruction with evidence of fecalization expect an acute on chronic exacerbation of a possible crohn's stricture which should be investigated further.
Age: 67.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Cellulitis, Infection, Injection site pain, Injection site swelling
Clinical narrative: Site: Pain at Injection Site-Medium, Site: Swelling at Injection Site-Medium, Error: Infection / Cellulitis (diagnosed by MD)-
Age: 67.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Erythema, Extra dose administered, Injection site cellulitis, Injection site infection, Peripheral swelling
Clinical narrative: Site: Pain at Injection Site-Medium, Site: Swelling at Injection Site-Medium, Error: Infection / Cellulitis (diagnosed by MD)-
Age: 67.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Skin warm
Clinical narrative: Site: Pain at Injection Site-Medium, Site: Swelling at Injection Site-Medium, Error: Infection / Cellulitis (diagnosed by MD)-
Age: 47.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect product formulation administered
Clinical narrative: Error: Wrong Vaccine Formulation  (ex. different manufact. initial and booster)-
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Bacterial test negative, Basophil count, Basophil percentage decreased, Bilirubin urine
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Blood albumin decreased, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin normal, Blood calcium normal
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Blood chloride increased, Blood creatinine increased, Blood culture negative, Blood glucose increased, Blood potassium normal
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Blood sodium normal, Blood urea increased, Blood urine absent, C-reactive protein increased, COVID-19
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19 pneumonia, Cardiomegaly, Chest X-ray abnormal, Chronic kidney disease, Condition aggravated
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Decreased appetite, Differential white blood cell count, Dyspnoea, Electrocardiogram PR interval
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request
Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Electrocardiogram QT interval, Electrocardiogram normal, Eosinophil count decreased, Eosinophil percentage decreased, Exposure to SARS-CoV-2
Clinical narrative: Patient is a 70-year-old female with past medical history significant for hypertension, CKD stage 3, PE/DVT/Coumadin, diet-controlled diabetes presents to the hospital on 11/03 with complaints of cough.  Apparently her husband also was diagnosed to have COVID-19 and she has noticed increasing shortness of breath cough and weakness and hence presented to the hospital. Patient was noted to have COVID-19, home with the test, chest x-ray showed pneumonia consistent with COVID-19, she was hypoxic needing supplemental oxygen.  She was also noted to have acute kidney injury on top of her chronic kidney disease. COVID-19 pneumonia along with acute hypoxic respiratory failure:  Patient is vaccinated.  Patient was started on Decadron which she received 5 doses of and will finish 10 day course post discharge.  She was started on remdesivir which she received 3 doses of prior to discontinuation.  With supportive therapy, patient was able to be weaned down to room air prior to discharge.  She did have other associated symptoms of poor appetite, poor oral intake (also complicated by the fact that she hated hospital food), generalized weakness etc.. Physical therapy did see her in consultation and recommended subacute rehab which she declined.  She was counseled about risks of falls with home discharge.  Care management arrange home health physical therapy. Acute kidney injury resolved with IV fluid resuscitation, she was strongly encouraged to keep up with oral intake after discharge.  She had poor oral intake while in the hospital. I was not able to speak to her husband who also is admitted in the hospital with COVID-19 and did not seem be doing well as he  sounded distressed. I obtained son's phone number from patient's phone and reached out twice to leave a voice message requesting a call back if any questions. Patient is alert oriented well and is her own decision maker, she seemed insightful of her health issues.  She makes the decision about going home today with physical therapy in spite of my above counseling regarding rehab.  I went over her discharge instructions including following up with PCP in about a week to obtain follow-up labs including INR at that visit. Patient would resume all her home medications, in addition she will take dexamethasone for 5 days. On the day of discharge, patient appeared to be much more clear, which is improvement from 2 days back.  She was aware of her health issues, medications etc.. Only thing she is focusing on the day of discharge is that she wants to go home.  She declined subacute rehab.  She is somewhat irritable, confrontational and really not open for any counseling. Tried to reach out son, left a voice message saying that patient is being discharged per her request