chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Essential hypertension, Hyponatraemia, Klebsiella test positive, Magnetic resonance imaging head, Mental status changes
Clinical narrative: Admit Date:  7/28/2022   Discharge Date:   7/31/2022   Discharge Diagnosis:  Principal Problem:   Acute metabolic encephalopathy Active Problems:   Hyponatremia   UTI (urinary tract infection)   COVID-19 virus detected   Type 2 diabetes mellitus   Essential hypertension     Hospital Course:  75 year old female who was treated with Paxlovid on 7/18 for Covid-19 infection was admitted on 7/28 after developing encephalopathy from UTI. She also had hyponatremia. She did not require treatment with either Remdesivir or steroids. She has been on Rocephin since admission and mental status improved. Neurology saw her and ruled out stroke after MRI showed no acute findings. Urine culture grew pan sensitive Klebsiella and E coli. Na is stable at 130. She will be discharged home today in stable condition on oral antibiotic. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.2 °F (36.2 °C) Heart Rate (Monitor): 61 Pulse: 67 BP: 143/75 Respirations: 14 SpO2: 97 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO NEUROLOGY IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   MRI head, CT head   Operations: none   Disposition:  Home    Discharge Condition:  Fair
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Metabolic encephalopathy, Type 2 diabetes mellitus, Urinary tract infection
Clinical narrative: Admit Date:  7/28/2022   Discharge Date:   7/31/2022   Discharge Diagnosis:  Principal Problem:   Acute metabolic encephalopathy Active Problems:   Hyponatremia   UTI (urinary tract infection)   COVID-19 virus detected   Type 2 diabetes mellitus   Essential hypertension     Hospital Course:  75 year old female who was treated with Paxlovid on 7/18 for Covid-19 infection was admitted on 7/28 after developing encephalopathy from UTI. She also had hyponatremia. She did not require treatment with either Remdesivir or steroids. She has been on Rocephin since admission and mental status improved. Neurology saw her and ruled out stroke after MRI showed no acute findings. Urine culture grew pan sensitive Klebsiella and E coli. Na is stable at 130. She will be discharged home today in stable condition on oral antibiotic. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.2 °F (36.2 °C) Heart Rate (Monitor): 61 Pulse: 67 BP: 143/75 Respirations: 14 SpO2: 97 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO NEUROLOGY IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   MRI head, CT head   Operations: none   Disposition:  Home    Discharge Condition:  Fair
Age: 12.0
Sex: M
Vaccine: MNQ
Symptoms: Incorrect route of product administration
Clinical narrative: The vaccine was administered subcutaneously and not intramuscularly.
Age: 52.0
Sex: F
Vaccine: VARZOS
Symptoms: Asthenia, Headache, Nausea, Pain, Pyrexia
Clinical narrative: Fever body aches weakness nausea headache
Age: 25.0
Sex: M
Vaccine: SMALLMNK
Symptoms: Inflammation, Injection site erythema, Injection site mass, Pruritus
Clinical narrative: 3cm focal erythematous lump at injection site. Surrounding tissue (3cm in all directions) remains inflamed. The erythematous injection site lump has remained since the time of vaccination and has not receded. Itchiness occurs spontaneously. Surrounding inflammation has progressed from minimal to moderate and is starting to diminish (7 days post op) but lump remains unchanged.
Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Anticoagulant therapy, Asthenia, COVID-19, Computerised tomogram head normal, Computerised tomogram thorax abnormal
Clinical narrative: DISCHARGE SUMMARY:   MRN:  Name:  Age: 83 y.o. Birthday:   Admit Date: 7/28/2022  2:48 PM Discharge Date:  8/4/2022 Unit:  Admitting Physician:  Discharge Physician:  MD   Discharge Diagnosis: Principal Problem:   Acute metabolic encephalopathy Active Problems:   HTN (hypertension)   Acute cystitis without hematuria   Weakness generalized   COVID-19 virus infection       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 83 y.o. female with a history of neuropathy with the lot of problems with ambulation presented after a fall earlier today and she could not get up from the floor. Neighbor recommended to come to the emergency room and get evaluated. Denies any blackout. She hit her head somewhere. CT head negative. Confused here. Brother at bedside and helped with some of the history. She was diagnosed with UTI recently and was sent home on Omnicef. Urine culture came back resistant to cephalosporin and patient was started on Cipro yesterday. Not sure what makes symptoms better or worse. Patient denies any dysuria, UTI symptoms, fever, chills, pain or any other concerning symptoms. Admitted for further evaluation."     Hospital Course: Patient is a 83 y.o. female who presented with confusion, weakness.  She was managed for the following:   * Acute metabolic encephalopathy Acute Pulmonary Embolism - likely provoked by active COVID-19 infection.  CT PE study with left lower lobe segmental PE.   BLE US with possible LLE DVT.   Continue po eliquis, will need 6 months anticoagulation.  Follow-up with PCP.    COVID-19 infection - stable, on room air.  Completed remdesivir 5 days.     Acute UTI - completed course of macrobid during admission.     Debility - PT consulted, recommend SNF.  Pt will discharge to HCF for short term placement.     Acute metabolic encephalopathy - delirium due to acute illness with UTI and COVID-19 infection.  Confusion resolved.          Physical Exam on the Date of Discharge: Blood pressure 135/53, pulse (!) 49, temperature 97.8 °F (36.6 °C), temperature source Oral, resp. rate 18, height 5' 2" (157.5 cm), weight 50.5 kg (111 lb 4.8 oz), SpO2 100 %. General - NAD, appears stated age, frail elderly female HEENT - EOMI, PER, MMM, Chest - lungs clear bilaterally Heart - RRR, NS1S2 Abdomen - Soft, non-tender,  Extremities - warm,  Psych - AAOx3, Skin -  dry   Discharge Condition: improved   Disposition: SNF
Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Confusional state, Culture urine positive, Cystitis, Fall, Head injury
Clinical narrative: DISCHARGE SUMMARY:   MRN:  Name:  Age: 83 y.o. Birthday:   Admit Date: 7/28/2022  2:48 PM Discharge Date:  8/4/2022 Unit:  Admitting Physician:  Discharge Physician:  MD   Discharge Diagnosis: Principal Problem:   Acute metabolic encephalopathy Active Problems:   HTN (hypertension)   Acute cystitis without hematuria   Weakness generalized   COVID-19 virus infection       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 83 y.o. female with a history of neuropathy with the lot of problems with ambulation presented after a fall earlier today and she could not get up from the floor. Neighbor recommended to come to the emergency room and get evaluated. Denies any blackout. She hit her head somewhere. CT head negative. Confused here. Brother at bedside and helped with some of the history. She was diagnosed with UTI recently and was sent home on Omnicef. Urine culture came back resistant to cephalosporin and patient was started on Cipro yesterday. Not sure what makes symptoms better or worse. Patient denies any dysuria, UTI symptoms, fever, chills, pain or any other concerning symptoms. Admitted for further evaluation."     Hospital Course: Patient is a 83 y.o. female who presented with confusion, weakness.  She was managed for the following:   * Acute metabolic encephalopathy Acute Pulmonary Embolism - likely provoked by active COVID-19 infection.  CT PE study with left lower lobe segmental PE.   BLE US with possible LLE DVT.   Continue po eliquis, will need 6 months anticoagulation.  Follow-up with PCP.    COVID-19 infection - stable, on room air.  Completed remdesivir 5 days.     Acute UTI - completed course of macrobid during admission.     Debility - PT consulted, recommend SNF.  Pt will discharge to HCF for short term placement.     Acute metabolic encephalopathy - delirium due to acute illness with UTI and COVID-19 infection.  Confusion resolved.          Physical Exam on the Date of Discharge: Blood pressure 135/53, pulse (!) 49, temperature 97.8 °F (36.6 °C), temperature source Oral, resp. rate 18, height 5' 2" (157.5 cm), weight 50.5 kg (111 lb 4.8 oz), SpO2 100 %. General - NAD, appears stated age, frail elderly female HEENT - EOMI, PER, MMM, Chest - lungs clear bilaterally Heart - RRR, NS1S2 Abdomen - Soft, non-tender,  Extremities - warm,  Psych - AAOx3, Skin -  dry   Discharge Condition: improved   Disposition: SNF
Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertension, Illness, Metabolic encephalopathy, Pulmonary embolism, Ultrasound Doppler abnormal
Clinical narrative: DISCHARGE SUMMARY:   MRN:  Name:  Age: 83 y.o. Birthday:   Admit Date: 7/28/2022  2:48 PM Discharge Date:  8/4/2022 Unit:  Admitting Physician:  Discharge Physician:  MD   Discharge Diagnosis: Principal Problem:   Acute metabolic encephalopathy Active Problems:   HTN (hypertension)   Acute cystitis without hematuria   Weakness generalized   COVID-19 virus infection       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 83 y.o. female with a history of neuropathy with the lot of problems with ambulation presented after a fall earlier today and she could not get up from the floor. Neighbor recommended to come to the emergency room and get evaluated. Denies any blackout. She hit her head somewhere. CT head negative. Confused here. Brother at bedside and helped with some of the history. She was diagnosed with UTI recently and was sent home on Omnicef. Urine culture came back resistant to cephalosporin and patient was started on Cipro yesterday. Not sure what makes symptoms better or worse. Patient denies any dysuria, UTI symptoms, fever, chills, pain or any other concerning symptoms. Admitted for further evaluation."     Hospital Course: Patient is a 83 y.o. female who presented with confusion, weakness.  She was managed for the following:   * Acute metabolic encephalopathy Acute Pulmonary Embolism - likely provoked by active COVID-19 infection.  CT PE study with left lower lobe segmental PE.   BLE US with possible LLE DVT.   Continue po eliquis, will need 6 months anticoagulation.  Follow-up with PCP.    COVID-19 infection - stable, on room air.  Completed remdesivir 5 days.     Acute UTI - completed course of macrobid during admission.     Debility - PT consulted, recommend SNF.  Pt will discharge to HCF for short term placement.     Acute metabolic encephalopathy - delirium due to acute illness with UTI and COVID-19 infection.  Confusion resolved.          Physical Exam on the Date of Discharge: Blood pressure 135/53, pulse (!) 49, temperature 97.8 °F (36.6 °C), temperature source Oral, resp. rate 18, height 5' 2" (157.5 cm), weight 50.5 kg (111 lb 4.8 oz), SpO2 100 %. General - NAD, appears stated age, frail elderly female HEENT - EOMI, PER, MMM, Chest - lungs clear bilaterally Heart - RRR, NS1S2 Abdomen - Soft, non-tender,  Extremities - warm,  Psych - AAOx3, Skin -  dry   Discharge Condition: improved   Disposition: SNF
Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Urinary tract infection
Clinical narrative: DISCHARGE SUMMARY:   MRN:  Name:  Age: 83 y.o. Birthday:   Admit Date: 7/28/2022  2:48 PM Discharge Date:  8/4/2022 Unit:  Admitting Physician:  Discharge Physician:  MD   Discharge Diagnosis: Principal Problem:   Acute metabolic encephalopathy Active Problems:   HTN (hypertension)   Acute cystitis without hematuria   Weakness generalized   COVID-19 virus infection       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 83 y.o. female with a history of neuropathy with the lot of problems with ambulation presented after a fall earlier today and she could not get up from the floor. Neighbor recommended to come to the emergency room and get evaluated. Denies any blackout. She hit her head somewhere. CT head negative. Confused here. Brother at bedside and helped with some of the history. She was diagnosed with UTI recently and was sent home on Omnicef. Urine culture came back resistant to cephalosporin and patient was started on Cipro yesterday. Not sure what makes symptoms better or worse. Patient denies any dysuria, UTI symptoms, fever, chills, pain or any other concerning symptoms. Admitted for further evaluation."     Hospital Course: Patient is a 83 y.o. female who presented with confusion, weakness.  She was managed for the following:   * Acute metabolic encephalopathy Acute Pulmonary Embolism - likely provoked by active COVID-19 infection.  CT PE study with left lower lobe segmental PE.   BLE US with possible LLE DVT.   Continue po eliquis, will need 6 months anticoagulation.  Follow-up with PCP.    COVID-19 infection - stable, on room air.  Completed remdesivir 5 days.     Acute UTI - completed course of macrobid during admission.     Debility - PT consulted, recommend SNF.  Pt will discharge to HCF for short term placement.     Acute metabolic encephalopathy - delirium due to acute illness with UTI and COVID-19 infection.  Confusion resolved.          Physical Exam on the Date of Discharge: Blood pressure 135/53, pulse (!) 49, temperature 97.8 °F (36.6 °C), temperature source Oral, resp. rate 18, height 5' 2" (157.5 cm), weight 50.5 kg (111 lb 4.8 oz), SpO2 100 %. General - NAD, appears stated age, frail elderly female HEENT - EOMI, PER, MMM, Chest - lungs clear bilaterally Heart - RRR, NS1S2 Abdomen - Soft, non-tender,  Extremities - warm,  Psych - AAOx3, Skin -  dry   Discharge Condition: improved   Disposition: SNF
Age: 54.0
Sex: F
Vaccine: FLUC4
Symptoms: Blepharitis, Blood alkaline phosphatase increased, Computerised tomogram liver abnormal, Feeling abnormal, Head discomfort
Clinical narrative: Flu shot on 12-18-2017. On 1-2-2018, brain fog/brain tightness, low body temperature avg 97.4, eyelid dermatitis. Lab tests on 1-15-2018 revealed elevated alkaline phosphatase of 121 which then normalized by next lab test in 4-2018. Body temperature never rises above 97.8 to present (always had normal body temps before).  Brain fog is constantly present since the flu shot.  MRI of brain was normal on 9-18-2018. CT scan of liver on 7-28-2021 revealed hepatomegaly of 17.5 cm (was normal years earlier).
Age: 54.0
Sex: F
Vaccine: FLUC4
Symptoms: Hepatomegaly, Laboratory test, Magnetic resonance imaging head normal
Clinical narrative: Flu shot on 12-18-2017. On 1-2-2018, brain fog/brain tightness, low body temperature avg 97.4, eyelid dermatitis. Lab tests on 1-15-2018 revealed elevated alkaline phosphatase of 121 which then normalized by next lab test in 4-2018. Body temperature never rises above 97.8 to present (always had normal body temps before).  Brain fog is constantly present since the flu shot.  MRI of brain was normal on 9-18-2018. CT scan of liver on 7-28-2021 revealed hepatomegaly of 17.5 cm (was normal years earlier).
Age: 42.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Fatigue, Miosis
Clinical narrative: The night of the vaccine, patient experienced severe fatigue which she described as similar to coming out of anesthesia. She also felt faint and reports that she had a pulse of 172 when she checked.  She also noticed she had pinpoint  pupils with normal room lighting.
Age: 1.0
Sex: M
Vaccine: VARCEL
Symptoms: Rash erythematous
Clinical narrative: Child received vaccine on 8/03/22. Mom noticed red, bumpy spot on child on 8/31/22. Spots continued to appear over next couple days. Was seen in office on 9/03/22 with spots covering whole body. Provider confirmed diagnosis of vaccine-induced varicella.
Age: 26.0
Sex: F
Vaccine: FLUC4
Symptoms: Dizziness, Tunnel vision
Clinical narrative: Feeling of fainting and tunnel vision post vaccination. Patient did not faint.
Age: 57.0
Sex: F
Vaccine: UNK
Symptoms: Chills, Erythema, Feeling hot, Headache, Malaise
Clinical narrative: Headache nausea chills malaise arm swelling and redness. Hot arm
Age: 57.0
Sex: F
Vaccine: UNK
Symptoms: Nausea, Peripheral swelling
Clinical narrative: Headache nausea chills malaise arm swelling and redness. Hot arm
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Blood creatinine increased, Blood loss anaemia, COVID-19, Chronic kidney disease
Clinical narrative: Physician Discharge Summary   Patient ID: 70 y.o.   Admit Date:  7/29/2022   Discharge Date: 8/3/22   Principal Dx/ Final Dx: Acute blood loss anemia   Relevant Inpt Dx: Principal Problem:   Acute blood loss anemia Active Problems:   Acute renal failure with tubular necrosis   COVID-19 virus detected   Hypertension   Diabetes mellitus       HPI:   Hospital Course:   This 70 year old man was admitted with anemia.  He was transfused.  He was seen by GI.  EGD no ulcers.  Colonoscopy showed diverticulosis.  Likely anemia from diverticular bleeding.  Hgb today is stable at 7.6.  Repeat cbc weekly   He also had acute renal failure on ckd 3b.  He was seen by nephrology.   He did improve and today his creatinine is 2.1.  He has been cleared by nephrology for discharge and will get weekly cbc.  He had cozaar added for htn and is on lasix prn.  Weekly bmp.     He did test positive for covid but did not require acute treatment for it.   He does have lymphedema and was seen by wound care for this   @HOSPDCED@   Consults:   IP CONSULT TO NEPHROLOGY IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO WOUND CARE IP CONSULT TO SOCIAL WORK       Disposition:  home   Discharge Condition:  fair
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Colonoscopy abnormal, Diabetes mellitus, Diverticulum, Diverticulum intestinal haemorrhagic, Haemoglobin decreased
Clinical narrative: Physician Discharge Summary   Patient ID: 70 y.o.   Admit Date:  7/29/2022   Discharge Date: 8/3/22   Principal Dx/ Final Dx: Acute blood loss anemia   Relevant Inpt Dx: Principal Problem:   Acute blood loss anemia Active Problems:   Acute renal failure with tubular necrosis   COVID-19 virus detected   Hypertension   Diabetes mellitus       HPI:   Hospital Course:   This 70 year old man was admitted with anemia.  He was transfused.  He was seen by GI.  EGD no ulcers.  Colonoscopy showed diverticulosis.  Likely anemia from diverticular bleeding.  Hgb today is stable at 7.6.  Repeat cbc weekly   He also had acute renal failure on ckd 3b.  He was seen by nephrology.   He did improve and today his creatinine is 2.1.  He has been cleared by nephrology for discharge and will get weekly cbc.  He had cozaar added for htn and is on lasix prn.  Weekly bmp.     He did test positive for covid but did not require acute treatment for it.   He does have lymphedema and was seen by wound care for this   @HOSPDCED@   Consults:   IP CONSULT TO NEPHROLOGY IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO WOUND CARE IP CONSULT TO SOCIAL WORK       Disposition:  home   Discharge Condition:  fair
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Hypertension, Lymphoedema, Oesophagogastroduodenoscopy normal, Renal tubular necrosis, SARS-CoV-2 test positive
Clinical narrative: Physician Discharge Summary   Patient ID: 70 y.o.   Admit Date:  7/29/2022   Discharge Date: 8/3/22   Principal Dx/ Final Dx: Acute blood loss anemia   Relevant Inpt Dx: Principal Problem:   Acute blood loss anemia Active Problems:   Acute renal failure with tubular necrosis   COVID-19 virus detected   Hypertension   Diabetes mellitus       HPI:   Hospital Course:   This 70 year old man was admitted with anemia.  He was transfused.  He was seen by GI.  EGD no ulcers.  Colonoscopy showed diverticulosis.  Likely anemia from diverticular bleeding.  Hgb today is stable at 7.6.  Repeat cbc weekly   He also had acute renal failure on ckd 3b.  He was seen by nephrology.   He did improve and today his creatinine is 2.1.  He has been cleared by nephrology for discharge and will get weekly cbc.  He had cozaar added for htn and is on lasix prn.  Weekly bmp.     He did test positive for covid but did not require acute treatment for it.   He does have lymphedema and was seen by wound care for this   @HOSPDCED@   Consults:   IP CONSULT TO NEPHROLOGY IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO WOUND CARE IP CONSULT TO SOCIAL WORK       Disposition:  home   Discharge Condition:  fair
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Transfusion
Clinical narrative: Physician Discharge Summary   Patient ID: 70 y.o.   Admit Date:  7/29/2022   Discharge Date: 8/3/22   Principal Dx/ Final Dx: Acute blood loss anemia   Relevant Inpt Dx: Principal Problem:   Acute blood loss anemia Active Problems:   Acute renal failure with tubular necrosis   COVID-19 virus detected   Hypertension   Diabetes mellitus       HPI:   Hospital Course:   This 70 year old man was admitted with anemia.  He was transfused.  He was seen by GI.  EGD no ulcers.  Colonoscopy showed diverticulosis.  Likely anemia from diverticular bleeding.  Hgb today is stable at 7.6.  Repeat cbc weekly   He also had acute renal failure on ckd 3b.  He was seen by nephrology.   He did improve and today his creatinine is 2.1.  He has been cleared by nephrology for discharge and will get weekly cbc.  He had cozaar added for htn and is on lasix prn.  Weekly bmp.     He did test positive for covid but did not require acute treatment for it.   He does have lymphedema and was seen by wound care for this   @HOSPDCED@   Consults:   IP CONSULT TO NEPHROLOGY IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO WOUND CARE IP CONSULT TO SOCIAL WORK       Disposition:  home   Discharge Condition:  fair
Age: 93.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Asthenia, Bronchiectasis, COVID-19, Cough
Clinical narrative: Physician Discharge Summary   Patient ID:   94 y.o.    Admit Date:  7/29/2022   Discharge Date: 8/2/22   Principal Dx/ Final Dx: Acute hypoxemic respiratory failure   Relevant Inpt Dx: Principal Problem:   Acute hypoxemic respiratory failure Active Problems:   Bronchiectasis without complication   Generalized weakness   COVID-19 virus detected       HPI:   Hospital Course:   This elderly woman was admitted with weakness.  She had cough and sob.  This was felt to be due to a combination of covid and a flair of bronchiectasis.  She was treated with remdesivir and steroids and antibiotics and is improved.  She still has some rhonchi today but air movement is better.  She will taper steroids and complete antibiotics orally.  Her oxygen saturation this am is 99% on 2 liters oxygen and she will be assessed off of oxygen before discharge.  Follow up with pcp.              Consults:   IP CONSULT TO SOCIAL WORK       Disposition:  SNF   Discharge Condition:  fair
Age: 93.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Rhonchi
Clinical narrative: Physician Discharge Summary   Patient ID:   94 y.o.    Admit Date:  7/29/2022   Discharge Date: 8/2/22   Principal Dx/ Final Dx: Acute hypoxemic respiratory failure   Relevant Inpt Dx: Principal Problem:   Acute hypoxemic respiratory failure Active Problems:   Bronchiectasis without complication   Generalized weakness   COVID-19 virus detected       HPI:   Hospital Course:   This elderly woman was admitted with weakness.  She had cough and sob.  This was felt to be due to a combination of covid and a flair of bronchiectasis.  She was treated with remdesivir and steroids and antibiotics and is improved.  She still has some rhonchi today but air movement is better.  She will taper steroids and complete antibiotics orally.  Her oxygen saturation this am is 99% on 2 liters oxygen and she will be assessed off of oxygen before discharge.  Follow up with pcp.              Consults:   IP CONSULT TO SOCIAL WORK       Disposition:  SNF   Discharge Condition:  fair
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain upper, Adhesion, Adnexa uteri mass, Blood glucose, COVID-19
Clinical narrative: 67 y.o.    Admit Date:  7/30/2022   Discharge Date: 8/2/22   Principal Dx/ Final Dx: Epigastric pain   Relevant Inpt Dx: Principal Problem:   Epigastric pain Active Problems:   Essential hypertension   History of Hodgkin's disease   Type 2 diabetes mellitus without complication, without long-term current use of insulin   Adnexal mass   COVID-19 virus detected       HPI:   Hospital Course:   This 67 year old woman was admitted with upper abdominal pain.  She was seen by GI and surgery.  EGD showed hiatal hernia.  HIDA scan consistent with cholecystitis.  She had laparoscopic cholecystectomy.  At time of surgery gall bladder was gangrenous.  She is doing well and will follow up with pcp and surgery.   Imaging also showed adnexal mass.  She was seen by hospitalist ob/gyn.  Ca125 was 18.1.  This was not addressed at time of surgery due to inflamed GB and adhesions.  She will follow up with ob/gyn            Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO GENERAL SURGERY IP CONSULT TO OB GYN       Disposition:  home   Discharge Condition:  fair   Discharge Medications:   Current Discharge Medication List   START taking these medications   Details oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet Take 1 Tablet by mouth Every 6 hours as needed for Pain for up to 5 days. Qty: 20 Tablet, Refills: 0   Associated Diagnoses: Acute cholecystitis     CONTINUE these medications which have NOT CHANGED   Details ketoconazole (NIZORAL) 2 % cream Apply once a day to breast, rub in gently. Qty: 30 g, Refills: 2   Associated Diagnoses: Intertrigo   blood sugar diagnostic test strips Check glucose daily.   esomeprazole (NEXIUM) 20 mg DR capsule Take  by mouth.   Irbesartan 300 mg Tab     levothyroxine (SYNTHROID) 150 mcg tablet     metoprolol (TOPROL-XL) 50 mg     Hydrochlorothiazide (MICROZIDE) 12.5 mg capsule Take 1 Cap by mouth Daily. Qty: 90 Cap, Refills: 3   Associated Diagnoses: Essential hypertension   metFORMIN (GLUCOPHAGE) 500 mg tablet Take 1 Tab by mouth Daily. Qty: 90 Tab, Refills: 3   Associated Diagnoses: Type 2 diabetes mellitus without complication, without long-term current use of insulin     STOP taking these medications     mupirocin calcium (BACTROBAN) 2 % CREAM Comments:  Reason for Stopping:
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Cholecystitis, Cholecystitis acute, Cholecystitis infective, Essential hypertension, Gallbladder operation
Clinical narrative: 67 y.o.    Admit Date:  7/30/2022   Discharge Date: 8/2/22   Principal Dx/ Final Dx: Epigastric pain   Relevant Inpt Dx: Principal Problem:   Epigastric pain Active Problems:   Essential hypertension   History of Hodgkin's disease   Type 2 diabetes mellitus without complication, without long-term current use of insulin   Adnexal mass   COVID-19 virus detected       HPI:   Hospital Course:   This 67 year old woman was admitted with upper abdominal pain.  She was seen by GI and surgery.  EGD showed hiatal hernia.  HIDA scan consistent with cholecystitis.  She had laparoscopic cholecystectomy.  At time of surgery gall bladder was gangrenous.  She is doing well and will follow up with pcp and surgery.   Imaging also showed adnexal mass.  She was seen by hospitalist ob/gyn.  Ca125 was 18.1.  This was not addressed at time of surgery due to inflamed GB and adhesions.  She will follow up with ob/gyn            Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO GENERAL SURGERY IP CONSULT TO OB GYN       Disposition:  home   Discharge Condition:  fair   Discharge Medications:   Current Discharge Medication List   START taking these medications   Details oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet Take 1 Tablet by mouth Every 6 hours as needed for Pain for up to 5 days. Qty: 20 Tablet, Refills: 0   Associated Diagnoses: Acute cholecystitis     CONTINUE these medications which have NOT CHANGED   Details ketoconazole (NIZORAL) 2 % cream Apply once a day to breast, rub in gently. Qty: 30 g, Refills: 2   Associated Diagnoses: Intertrigo   blood sugar diagnostic test strips Check glucose daily.   esomeprazole (NEXIUM) 20 mg DR capsule Take  by mouth.   Irbesartan 300 mg Tab     levothyroxine (SYNTHROID) 150 mcg tablet     metoprolol (TOPROL-XL) 50 mg     Hydrochlorothiazide (MICROZIDE) 12.5 mg capsule Take 1 Cap by mouth Daily. Qty: 90 Cap, Refills: 3   Associated Diagnoses: Essential hypertension   metFORMIN (GLUCOPHAGE) 500 mg tablet Take 1 Tab by mouth Daily. Qty: 90 Tab, Refills: 3   Associated Diagnoses: Type 2 diabetes mellitus without complication, without long-term current use of insulin     STOP taking these medications     mupirocin calcium (BACTROBAN) 2 % CREAM Comments:  Reason for Stopping:
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Hepatobiliary scan abnormal, Hiatus hernia, Intertrigo, Laboratory test, Oesophagogastroduodenoscopy abnormal
Clinical narrative: 67 y.o.    Admit Date:  7/30/2022   Discharge Date: 8/2/22   Principal Dx/ Final Dx: Epigastric pain   Relevant Inpt Dx: Principal Problem:   Epigastric pain Active Problems:   Essential hypertension   History of Hodgkin's disease   Type 2 diabetes mellitus without complication, without long-term current use of insulin   Adnexal mass   COVID-19 virus detected       HPI:   Hospital Course:   This 67 year old woman was admitted with upper abdominal pain.  She was seen by GI and surgery.  EGD showed hiatal hernia.  HIDA scan consistent with cholecystitis.  She had laparoscopic cholecystectomy.  At time of surgery gall bladder was gangrenous.  She is doing well and will follow up with pcp and surgery.   Imaging also showed adnexal mass.  She was seen by hospitalist ob/gyn.  Ca125 was 18.1.  This was not addressed at time of surgery due to inflamed GB and adhesions.  She will follow up with ob/gyn            Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO GENERAL SURGERY IP CONSULT TO OB GYN       Disposition:  home   Discharge Condition:  fair   Discharge Medications:   Current Discharge Medication List   START taking these medications   Details oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet Take 1 Tablet by mouth Every 6 hours as needed for Pain for up to 5 days. Qty: 20 Tablet, Refills: 0   Associated Diagnoses: Acute cholecystitis     CONTINUE these medications which have NOT CHANGED   Details ketoconazole (NIZORAL) 2 % cream Apply once a day to breast, rub in gently. Qty: 30 g, Refills: 2   Associated Diagnoses: Intertrigo   blood sugar diagnostic test strips Check glucose daily.   esomeprazole (NEXIUM) 20 mg DR capsule Take  by mouth.   Irbesartan 300 mg Tab     levothyroxine (SYNTHROID) 150 mcg tablet     metoprolol (TOPROL-XL) 50 mg     Hydrochlorothiazide (MICROZIDE) 12.5 mg capsule Take 1 Cap by mouth Daily. Qty: 90 Cap, Refills: 3   Associated Diagnoses: Essential hypertension   metFORMIN (GLUCOPHAGE) 500 mg tablet Take 1 Tab by mouth Daily. Qty: 90 Tab, Refills: 3   Associated Diagnoses: Type 2 diabetes mellitus without complication, without long-term current use of insulin     STOP taking these medications     mupirocin calcium (BACTROBAN) 2 % CREAM Comments:  Reason for Stopping:
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: 67 y.o.    Admit Date:  7/30/2022   Discharge Date: 8/2/22   Principal Dx/ Final Dx: Epigastric pain   Relevant Inpt Dx: Principal Problem:   Epigastric pain Active Problems:   Essential hypertension   History of Hodgkin's disease   Type 2 diabetes mellitus without complication, without long-term current use of insulin   Adnexal mass   COVID-19 virus detected       HPI:   Hospital Course:   This 67 year old woman was admitted with upper abdominal pain.  She was seen by GI and surgery.  EGD showed hiatal hernia.  HIDA scan consistent with cholecystitis.  She had laparoscopic cholecystectomy.  At time of surgery gall bladder was gangrenous.  She is doing well and will follow up with pcp and surgery.   Imaging also showed adnexal mass.  She was seen by hospitalist ob/gyn.  Ca125 was 18.1.  This was not addressed at time of surgery due to inflamed GB and adhesions.  She will follow up with ob/gyn            Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO GENERAL SURGERY IP CONSULT TO OB GYN       Disposition:  home   Discharge Condition:  fair   Discharge Medications:   Current Discharge Medication List   START taking these medications   Details oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet Take 1 Tablet by mouth Every 6 hours as needed for Pain for up to 5 days. Qty: 20 Tablet, Refills: 0   Associated Diagnoses: Acute cholecystitis     CONTINUE these medications which have NOT CHANGED   Details ketoconazole (NIZORAL) 2 % cream Apply once a day to breast, rub in gently. Qty: 30 g, Refills: 2   Associated Diagnoses: Intertrigo   blood sugar diagnostic test strips Check glucose daily.   esomeprazole (NEXIUM) 20 mg DR capsule Take  by mouth.   Irbesartan 300 mg Tab     levothyroxine (SYNTHROID) 150 mcg tablet     metoprolol (TOPROL-XL) 50 mg     Hydrochlorothiazide (MICROZIDE) 12.5 mg capsule Take 1 Cap by mouth Daily. Qty: 90 Cap, Refills: 3   Associated Diagnoses: Essential hypertension   metFORMIN (GLUCOPHAGE) 500 mg tablet Take 1 Tab by mouth Daily. Qty: 90 Tab, Refills: 3   Associated Diagnoses: Type 2 diabetes mellitus without complication, without long-term current use of insulin     STOP taking these medications     mupirocin calcium (BACTROBAN) 2 % CREAM Comments:  Reason for Stopping:
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Acute myocardial infarction, Angiogram pulmonary abnormal, Asthenia, Atrial fibrillation, Back pain
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Blood calcium decreased, Blood chloride increased, Blood creatinine increased, Blood glucose normal, Blood osmolarity decreased
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Blood potassium normal, Blood sodium normal, Blood urea increased, COVID-19, Carbon dioxide normal
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Cardiac failure congestive, Chronic left ventricular failure, Condition aggravated, Echocardiogram normal, Ejection fraction normal
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Essential hypertension, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Heart rate irregular
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Intervertebral disc degeneration, Laboratory test, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Mean cell volume decreased
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Mean platelet volume normal, Metabolic function test, Platelet count decreased, Pleural effusion, Red blood cell count decreased
Clinical narrative: 78 y.o.   Admit Date:  7/30/2022   Discharge Date:  8/2/2022   Principal Diagnoses:  Principal Problem:   Paroxysmal atrial fibrillation with RVR Active Problems:   NSTEMI (non-ST elevated myocardial infarction)   COVID-19 virus infection   Type 2 diabetes mellitus, without long-term current use of insulin   Essential hypertension   Chronic combined systolic and diastolic heart failure     Discharge Diagnosis:  NSTEMI Paroxysmal afib with RVR COVID 19 infection Essential HTN Type II DM Chronic systolic and diastolic CHF Back pain from DDD   Hospital Course: to ED with back pain and weakness. In AFib in ED, RVR, this is new. COVID + also. Troponin up. CTA chest pleural effusion, no PE. Echo normal EF. Xray lumbar and thoracic spine DDD. Seen by cardiology, recommends heparin drip 48 hours then OAC. He declined further ischemic workup. Declined nursing facility and home health.  Vitals:   08/02/22 1211 BP: 122/66 Pulse: 60 Resp: 18 Temp: 98.3 °F (36.8 °C)   Alert no distress Lungs clear Heart irregular Abdomen soft No edema CBC:  Lab Results Component Value Date/Time   WBC 2.3 08/02/2022 0510   RBC 3.29 08/02/2022 0510   HGB 8.5 08/02/2022 0510   HCT 26.0 08/02/2022 0510   MCV 79.2 08/02/2022 0510   MCH 26.0 08/02/2022 0510   MCHC 32.8 08/02/2022 0510   RDW 19.4 08/02/2022 0510   MPV 10.1 08/02/2022 0510   PLATELETCNT 84 08/02/2022 0510   BMP:  Lab Results Component Value Date/Time   SODIUM 139 08/02/2022 0510   POTASSIUM 3.5 08/02/2022 0510   CHLORIDE 107 08/02/2022 0510   CO2 23 08/02/2022 0510   GLUCOSE 128 08/02/2022 0510   BUN 23 08/02/2022 0510   CREATININE 1.3 08/02/2022 0510   CALCIUM 7.8 08/02/2022 0510   OSMOLALITY 283 08/02/2022 0510   BC 18 08/02/2022 0510   Will replace K+ before d/c Seen by cardiology    Disposition:  home   Discharge Condition: stable