chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19 pneumonia, Chest X-ray abnormal, Cough, Dyspnoea, Electrocardiogram
Clinical narrative: Narrative:  COVID infection following COVID vaccine series 02/25, Pfizer, dose #1 03/18, Pfizer, dose #2 08/01 pt cc: cough, dyspnea, malaise, wheezing, chest congestion, low backache unknown exposure: unknown 08/09 COVID swab, result: detected 08/12 SARS-COV-2 TOTAL AB SPIKE SEMI QN>2500.00 08/09 ekg sr 84, qtc 441, no acute changes 08/09 ABG i-pH 7.40, i-PCO2 30.6, i-PO2 50, i-HCO3 19.1, SpO2 84 08/09 Admit to medicine dx: Acute Hypoxic Respiratory Failure due to Covid 19 Pneumonia LOS: 8 days 08/09 BNP 12.1 08/09 LIPASE 28 08/09 CRP 10.970 08/09 PROCALCITONIN <0.05 08/09 CXR impression: The exam is limited by poor timing of the contrast bolus and respiratory motion artifact. Given these limitations, no central pulmonary embolism is visualized. -Patchy and groundglass opacities in the mid/lower lungs, most compatible with multifocal infection. Imaging features of Covid-19 pneumonia are present. Other processes such as influenza pneumonia and organizing pneumonia, as can be seen with drug toxicity and connective tissue disease, can cause a similar imaging pattern. 08/09 CXR impression: Support devices: None identified Mediastinum: Normal cardiac size. No central pulmonary vascular enlargement. Lungs and pleura: Left lower lobe infiltrate is identified. Small infiltrate versus atelectasis in the right lower lobe is seen. Clinical correlation is recommended. Bones: Unchanged 08/10 SARS-COV-2-IgG 0.07 08/10 FIBRINOGEN 491 08/10 ESR 81 08/10 DDIMER 0.24 08/18 FIBRINOGEN 212 08/18 DDIMER <0.22 08/18 ESR 44 08/31 CXR impression: No acute cardiopulmonary abnormality. Interval resolution of LEFT lower lobe pneumonia identified earlier this month.
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Fibrin D dimer, Lipase normal, Lung infiltration, Lung opacity, Malaise
Clinical narrative: Narrative:  COVID infection following COVID vaccine series 02/25, Pfizer, dose #1 03/18, Pfizer, dose #2 08/01 pt cc: cough, dyspnea, malaise, wheezing, chest congestion, low backache unknown exposure: unknown 08/09 COVID swab, result: detected 08/12 SARS-COV-2 TOTAL AB SPIKE SEMI QN>2500.00 08/09 ekg sr 84, qtc 441, no acute changes 08/09 ABG i-pH 7.40, i-PCO2 30.6, i-PO2 50, i-HCO3 19.1, SpO2 84 08/09 Admit to medicine dx: Acute Hypoxic Respiratory Failure due to Covid 19 Pneumonia LOS: 8 days 08/09 BNP 12.1 08/09 LIPASE 28 08/09 CRP 10.970 08/09 PROCALCITONIN <0.05 08/09 CXR impression: The exam is limited by poor timing of the contrast bolus and respiratory motion artifact. Given these limitations, no central pulmonary embolism is visualized. -Patchy and groundglass opacities in the mid/lower lungs, most compatible with multifocal infection. Imaging features of Covid-19 pneumonia are present. Other processes such as influenza pneumonia and organizing pneumonia, as can be seen with drug toxicity and connective tissue disease, can cause a similar imaging pattern. 08/09 CXR impression: Support devices: None identified Mediastinum: Normal cardiac size. No central pulmonary vascular enlargement. Lungs and pleura: Left lower lobe infiltrate is identified. Small infiltrate versus atelectasis in the right lower lobe is seen. Clinical correlation is recommended. Bones: Unchanged 08/10 SARS-COV-2-IgG 0.07 08/10 FIBRINOGEN 491 08/10 ESR 81 08/10 DDIMER 0.24 08/18 FIBRINOGEN 212 08/18 DDIMER <0.22 08/18 ESR 44 08/31 CXR impression: No acute cardiopulmonary abnormality. Interval resolution of LEFT lower lobe pneumonia identified earlier this month.
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: PCO2 decreased, PO2 decreased, Pneumonia, Procalcitonin, Red blood cell sedimentation rate increased
Clinical narrative: Narrative:  COVID infection following COVID vaccine series 02/25, Pfizer, dose #1 03/18, Pfizer, dose #2 08/01 pt cc: cough, dyspnea, malaise, wheezing, chest congestion, low backache unknown exposure: unknown 08/09 COVID swab, result: detected 08/12 SARS-COV-2 TOTAL AB SPIKE SEMI QN>2500.00 08/09 ekg sr 84, qtc 441, no acute changes 08/09 ABG i-pH 7.40, i-PCO2 30.6, i-PO2 50, i-HCO3 19.1, SpO2 84 08/09 Admit to medicine dx: Acute Hypoxic Respiratory Failure due to Covid 19 Pneumonia LOS: 8 days 08/09 BNP 12.1 08/09 LIPASE 28 08/09 CRP 10.970 08/09 PROCALCITONIN <0.05 08/09 CXR impression: The exam is limited by poor timing of the contrast bolus and respiratory motion artifact. Given these limitations, no central pulmonary embolism is visualized. -Patchy and groundglass opacities in the mid/lower lungs, most compatible with multifocal infection. Imaging features of Covid-19 pneumonia are present. Other processes such as influenza pneumonia and organizing pneumonia, as can be seen with drug toxicity and connective tissue disease, can cause a similar imaging pattern. 08/09 CXR impression: Support devices: None identified Mediastinum: Normal cardiac size. No central pulmonary vascular enlargement. Lungs and pleura: Left lower lobe infiltrate is identified. Small infiltrate versus atelectasis in the right lower lobe is seen. Clinical correlation is recommended. Bones: Unchanged 08/10 SARS-COV-2-IgG 0.07 08/10 FIBRINOGEN 491 08/10 ESR 81 08/10 DDIMER 0.24 08/18 FIBRINOGEN 212 08/18 DDIMER <0.22 08/18 ESR 44 08/31 CXR impression: No acute cardiopulmonary abnormality. Interval resolution of LEFT lower lobe pneumonia identified earlier this month.
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Respiratory tract congestion, SARS-CoV-2 antibody test, SARS-CoV-2 test positive, Wheezing
Clinical narrative: Narrative:  COVID infection following COVID vaccine series 02/25, Pfizer, dose #1 03/18, Pfizer, dose #2 08/01 pt cc: cough, dyspnea, malaise, wheezing, chest congestion, low backache unknown exposure: unknown 08/09 COVID swab, result: detected 08/12 SARS-COV-2 TOTAL AB SPIKE SEMI QN>2500.00 08/09 ekg sr 84, qtc 441, no acute changes 08/09 ABG i-pH 7.40, i-PCO2 30.6, i-PO2 50, i-HCO3 19.1, SpO2 84 08/09 Admit to medicine dx: Acute Hypoxic Respiratory Failure due to Covid 19 Pneumonia LOS: 8 days 08/09 BNP 12.1 08/09 LIPASE 28 08/09 CRP 10.970 08/09 PROCALCITONIN <0.05 08/09 CXR impression: The exam is limited by poor timing of the contrast bolus and respiratory motion artifact. Given these limitations, no central pulmonary embolism is visualized. -Patchy and groundglass opacities in the mid/lower lungs, most compatible with multifocal infection. Imaging features of Covid-19 pneumonia are present. Other processes such as influenza pneumonia and organizing pneumonia, as can be seen with drug toxicity and connective tissue disease, can cause a similar imaging pattern. 08/09 CXR impression: Support devices: None identified Mediastinum: Normal cardiac size. No central pulmonary vascular enlargement. Lungs and pleura: Left lower lobe infiltrate is identified. Small infiltrate versus atelectasis in the right lower lobe is seen. Clinical correlation is recommended. Bones: Unchanged 08/10 SARS-COV-2-IgG 0.07 08/10 FIBRINOGEN 491 08/10 ESR 81 08/10 DDIMER 0.24 08/18 FIBRINOGEN 212 08/18 DDIMER <0.22 08/18 ESR 44 08/31 CXR impression: No acute cardiopulmonary abnormality. Interval resolution of LEFT lower lobe pneumonia identified earlier this month.
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Atelectasis, Computerised tomogram thorax normal, Death, Dyspnoea, Hypervolaemia
Clinical narrative: Narrative:  86yo male on 9/7/21 was discharged from hospital admission to home hospice. Pt died at home on 9/8/21. From pt's medical records to determin cause of death: Problem list- "hcap toxic metabolic encephalopathy chronic respiratory failure dysphagia transaminitis hyponatremia chf dm foley catheter status anemia merkel cell carcinoma of ear constipation presented to e.r. w/ labored breathing and lethargy likely aspiration pna infectious w/u neg ct chest 8/25/21 bilat pleural effusions w/ associated atelectasis sats ok on 3 liters oxygen home oxygen eval completed and patient qualifies left pleural effusion felt likely parapneumonic or due to volume overload IR consulted to drain? hospital acquired pna on prolonged abx, completed course of zosyn and had vanc transitioned to doxycycline recs to finish 7-10 days of abx d/ced home w/ home hospice" Pt had received covid vaccines on 2/26/21 & 3/23/21. Pt's death is not related to covid vaccines.
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Lethargy, Pleural effusion, Pneumonia, Pneumonia aspiration
Clinical narrative: Narrative:  86yo male on 9/7/21 was discharged from hospital admission to home hospice. Pt died at home on 9/8/21. From pt's medical records to determin cause of death: Problem list- "hcap toxic metabolic encephalopathy chronic respiratory failure dysphagia transaminitis hyponatremia chf dm foley catheter status anemia merkel cell carcinoma of ear constipation presented to e.r. w/ labored breathing and lethargy likely aspiration pna infectious w/u neg ct chest 8/25/21 bilat pleural effusions w/ associated atelectasis sats ok on 3 liters oxygen home oxygen eval completed and patient qualifies left pleural effusion felt likely parapneumonic or due to volume overload IR consulted to drain? hospital acquired pna on prolonged abx, completed course of zosyn and had vanc transitioned to doxycycline recs to finish 7-10 days of abx d/ced home w/ home hospice" Pt had received covid vaccines on 2/26/21 & 3/23/21. Pt's death is not related to covid vaccines.
Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Dyspnoea, Pruritus
Clinical narrative: Narrative: First dose of Pfizer COVID-19 Vaccine was administered to patient on 9/14/21. Within several minutes of administration, patient noted to have itching on chest and upper back, subsequently of administration, patient noted to have itching on chest and upper back, subsequently followed by shortness of breath and repeated episodes of coughing. She was given PO diphenhydramine 50mg at approximately 1204 and IM epinephrine 0.5 mg in right lateral thigh at 1212. Shortly after, patient stated decrease in itching and improved breathing. Patient was sent to the emergency room for further evaluation of potential allergic reaction due to vaccine. EMS arrived, applied non-rebreather, and transported patient to hospital at 1233. No discharge summary from hospital available at time of writing of this note. Progress note from 9/16/21 states that patient was treated briefly in the ER and released home.
Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Death
Clinical narrative: Narrative:  Pt was a 68 YO female with PMH of ascites, hep C, HCC, HTN cirrhosis of the liver, PVD, and CVA. No details available in chart regarding cause of death.
Age: 92.0
Sex: M
Vaccine: COVID19
Symptoms: Death
Clinical narrative: Narrative:  92yo male died at Hospital, no information on cause of death. Pt had received covid vaccines on 1/20/21 & 2/26/2021. Likely pt's death is not related to covid vaccines given advanced age and long distance of time btwn date of vaccines administered and date of death.
Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Disease risk factor, Vaccine breakthrough infection
Clinical narrative: Narrative:  Breakthrough COVID infection which increased the risk for pulmonary embolism which caused the patient to be hospitalized
Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory distress syndrome, Acute respiratory failure, Death, Pneumonia aspiration, SARS-CoV-2 test negative
Clinical narrative: Narrative:  73YO MALE died inpatient . Death was caused by: Septic Shock and Acute Hypoxic Respiratory Failure secondary to acute respiratory distress syndrome and aspiration pneumonia. Patient was covid negative per 5 different covid lab testsfrom 8/7/20 through 9/8/21. Pt had received covid vaccinations on 2/17/21 & 3/10/21 at non-agency hospital. Death is not related to covid vaccinations.
Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Septic shock
Clinical narrative: Narrative:  73YO MALE died inpatient . Death was caused by: Septic Shock and Acute Hypoxic Respiratory Failure secondary to acute respiratory distress syndrome and aspiration pneumonia. Patient was covid negative per 5 different covid lab testsfrom 8/7/20 through 9/8/21. Pt had received covid vaccinations on 2/17/21 & 3/10/21 at non-agency hospital. Death is not related to covid vaccinations.
Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Anaemia, Blood creatinine increased, COVID-19, Chronic kidney disease
Clinical narrative: Narrative: ADMISSION DATE: 8/7/21 DISCHARGE DATE: 8/11/21 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Acute COVID 19 infection AKI on chronic stage IIIA CKD - resolved Acute on chronic anemia due to menorrhagia Hyperkalemia - resolved Type II DM HISTORY OF PRESENT ILLNESS : Patient is a 45 year old with a PMH notable for CAD, CRI, GERD, Hypertension, DM Type 2, Leiomyoma, Gastrooparesis, depression, shoulder pain, insomnia admitted via ED for Covid positive and acute on chronic renal insufficiency with hyperkalemia. Patient who was recently exposed to her Covid positive daughter presents for evaluation of increased sinus pressure, sore throat and cough that started on Tuesday. She was vaccinated with Pfizer/Covid vaccine on June 9 and July 6. She denies any shortness of breath, chest pain, vomiting or diarrhea. She also reports right thigh pain secondary to falling out of bed and hitting her right upper thigh. Per patient a large bruise had developed on her leg and she has pain with movement and elevation of right leg. Patient states she applied muscle cream to leg with minimal relief. HOSPITAL COURSE: a 45 yo woman with a hx of Stage IIIA CKD, CAD, anemia, HTN, Type II DM complicated by gastroparesis s/p pacer, who was admitted on 8/9/21 with AKI and an acute COVID 19 infection. She was admitted to the medical floor on airborne precautions. Although a chest CT showed evidence of ground glass opacities, decadron and remdesvir were not started since the patient had no hypoxia during this hospitalization. Pt with AKI on chronic stage IIIA CKD, cr on admission was 3.1 which improved to 2.2 with IVF hydration. Pt with acute on chronic anemia, hgb dropped to 7.0 due to menorrhagia.S/P tx of 2 unit prbc this admission with repeat hgb 10. Plan for outpt follow up with Gyn.
Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram thorax abnormal, Condition aggravated, Contusion, Cough, Exposure to SARS-CoV-2
Clinical narrative: Narrative: ADMISSION DATE: 8/7/21 DISCHARGE DATE: 8/11/21 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Acute COVID 19 infection AKI on chronic stage IIIA CKD - resolved Acute on chronic anemia due to menorrhagia Hyperkalemia - resolved Type II DM HISTORY OF PRESENT ILLNESS : Patient is a 45 year old with a PMH notable for CAD, CRI, GERD, Hypertension, DM Type 2, Leiomyoma, Gastrooparesis, depression, shoulder pain, insomnia admitted via ED for Covid positive and acute on chronic renal insufficiency with hyperkalemia. Patient who was recently exposed to her Covid positive daughter presents for evaluation of increased sinus pressure, sore throat and cough that started on Tuesday. She was vaccinated with Pfizer/Covid vaccine on June 9 and July 6. She denies any shortness of breath, chest pain, vomiting or diarrhea. She also reports right thigh pain secondary to falling out of bed and hitting her right upper thigh. Per patient a large bruise had developed on her leg and she has pain with movement and elevation of right leg. Patient states she applied muscle cream to leg with minimal relief. HOSPITAL COURSE: a 45 yo woman with a hx of Stage IIIA CKD, CAD, anemia, HTN, Type II DM complicated by gastroparesis s/p pacer, who was admitted on 8/9/21 with AKI and an acute COVID 19 infection. She was admitted to the medical floor on airborne precautions. Although a chest CT showed evidence of ground glass opacities, decadron and remdesvir were not started since the patient had no hypoxia during this hospitalization. Pt with AKI on chronic stage IIIA CKD, cr on admission was 3.1 which improved to 2.2 with IVF hydration. Pt with acute on chronic anemia, hgb dropped to 7.0 due to menorrhagia.S/P tx of 2 unit prbc this admission with repeat hgb 10. Plan for outpt follow up with Gyn.
Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Fall, Haemoglobin decreased, Heavy menstrual bleeding, Hyperkalaemia, Limb injury
Clinical narrative: Narrative: ADMISSION DATE: 8/7/21 DISCHARGE DATE: 8/11/21 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Acute COVID 19 infection AKI on chronic stage IIIA CKD - resolved Acute on chronic anemia due to menorrhagia Hyperkalemia - resolved Type II DM HISTORY OF PRESENT ILLNESS : Patient is a 45 year old with a PMH notable for CAD, CRI, GERD, Hypertension, DM Type 2, Leiomyoma, Gastrooparesis, depression, shoulder pain, insomnia admitted via ED for Covid positive and acute on chronic renal insufficiency with hyperkalemia. Patient who was recently exposed to her Covid positive daughter presents for evaluation of increased sinus pressure, sore throat and cough that started on Tuesday. She was vaccinated with Pfizer/Covid vaccine on June 9 and July 6. She denies any shortness of breath, chest pain, vomiting or diarrhea. She also reports right thigh pain secondary to falling out of bed and hitting her right upper thigh. Per patient a large bruise had developed on her leg and she has pain with movement and elevation of right leg. Patient states she applied muscle cream to leg with minimal relief. HOSPITAL COURSE: a 45 yo woman with a hx of Stage IIIA CKD, CAD, anemia, HTN, Type II DM complicated by gastroparesis s/p pacer, who was admitted on 8/9/21 with AKI and an acute COVID 19 infection. She was admitted to the medical floor on airborne precautions. Although a chest CT showed evidence of ground glass opacities, decadron and remdesvir were not started since the patient had no hypoxia during this hospitalization. Pt with AKI on chronic stage IIIA CKD, cr on admission was 3.1 which improved to 2.2 with IVF hydration. Pt with acute on chronic anemia, hgb dropped to 7.0 due to menorrhagia.S/P tx of 2 unit prbc this admission with repeat hgb 10. Plan for outpt follow up with Gyn.
Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Lung opacity, Oropharyngeal pain, Pain, Pain in extremity, Paranasal sinus discomfort
Clinical narrative: Narrative: ADMISSION DATE: 8/7/21 DISCHARGE DATE: 8/11/21 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Acute COVID 19 infection AKI on chronic stage IIIA CKD - resolved Acute on chronic anemia due to menorrhagia Hyperkalemia - resolved Type II DM HISTORY OF PRESENT ILLNESS : Patient is a 45 year old with a PMH notable for CAD, CRI, GERD, Hypertension, DM Type 2, Leiomyoma, Gastrooparesis, depression, shoulder pain, insomnia admitted via ED for Covid positive and acute on chronic renal insufficiency with hyperkalemia. Patient who was recently exposed to her Covid positive daughter presents for evaluation of increased sinus pressure, sore throat and cough that started on Tuesday. She was vaccinated with Pfizer/Covid vaccine on June 9 and July 6. She denies any shortness of breath, chest pain, vomiting or diarrhea. She also reports right thigh pain secondary to falling out of bed and hitting her right upper thigh. Per patient a large bruise had developed on her leg and she has pain with movement and elevation of right leg. Patient states she applied muscle cream to leg with minimal relief. HOSPITAL COURSE: a 45 yo woman with a hx of Stage IIIA CKD, CAD, anemia, HTN, Type II DM complicated by gastroparesis s/p pacer, who was admitted on 8/9/21 with AKI and an acute COVID 19 infection. She was admitted to the medical floor on airborne precautions. Although a chest CT showed evidence of ground glass opacities, decadron and remdesvir were not started since the patient had no hypoxia during this hospitalization. Pt with AKI on chronic stage IIIA CKD, cr on admission was 3.1 which improved to 2.2 with IVF hydration. Pt with acute on chronic anemia, hgb dropped to 7.0 due to menorrhagia.S/P tx of 2 unit prbc this admission with repeat hgb 10. Plan for outpt follow up with Gyn.
Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Red blood cell transfusion, SARS-CoV-2 test positive
Clinical narrative: Narrative: ADMISSION DATE: 8/7/21 DISCHARGE DATE: 8/11/21 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Acute COVID 19 infection AKI on chronic stage IIIA CKD - resolved Acute on chronic anemia due to menorrhagia Hyperkalemia - resolved Type II DM HISTORY OF PRESENT ILLNESS : Patient is a 45 year old with a PMH notable for CAD, CRI, GERD, Hypertension, DM Type 2, Leiomyoma, Gastrooparesis, depression, shoulder pain, insomnia admitted via ED for Covid positive and acute on chronic renal insufficiency with hyperkalemia. Patient who was recently exposed to her Covid positive daughter presents for evaluation of increased sinus pressure, sore throat and cough that started on Tuesday. She was vaccinated with Pfizer/Covid vaccine on June 9 and July 6. She denies any shortness of breath, chest pain, vomiting or diarrhea. She also reports right thigh pain secondary to falling out of bed and hitting her right upper thigh. Per patient a large bruise had developed on her leg and she has pain with movement and elevation of right leg. Patient states she applied muscle cream to leg with minimal relief. HOSPITAL COURSE: a 45 yo woman with a hx of Stage IIIA CKD, CAD, anemia, HTN, Type II DM complicated by gastroparesis s/p pacer, who was admitted on 8/9/21 with AKI and an acute COVID 19 infection. She was admitted to the medical floor on airborne precautions. Although a chest CT showed evidence of ground glass opacities, decadron and remdesvir were not started since the patient had no hypoxia during this hospitalization. Pt with AKI on chronic stage IIIA CKD, cr on admission was 3.1 which improved to 2.2 with IVF hydration. Pt with acute on chronic anemia, hgb dropped to 7.0 due to menorrhagia.S/P tx of 2 unit prbc this admission with repeat hgb 10. Plan for outpt follow up with Gyn.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Alanine aminotransferase normal, Anion gap, Anxiety, Aspartate aminotransferase normal
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin, Blood calcium decreased
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Blood chloride normal, Blood creatinine increased, Blood glucose normal, Blood potassium normal, Blood sodium decreased
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Blood thyroid stimulating hormone, Blood urea normal, COVID-19, Carbon dioxide decreased, Chest X-ray abnormal
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Cough, Decreased appetite, Gait disturbance, Glomerular filtration rate normal
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Glycosylated haemoglobin normal, Granulocyte percentage, Haematocrit decreased, Haemoglobin decreased, Hyperlipidaemia
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Hypertension, Hyponatraemia, Hypophagia, Hypovolaemia, Inappropriate antidiuretic hormone secretion
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Laboratory test, Loss of personal independence in daily activities, Lung hyperinflation, Lung infiltration, Malaise
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume normal, Mean platelet volume decreased, Muscle spasms
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Platelet count normal, Protein total normal, Red blood cell count decreased, Red cell distribution width normal, Rhinorrhoea
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Thyroxine, Thyroxine free, White blood cell count normal
Clinical narrative: Narrative:  ADMISSION DATE: 09/09/2021 DISCHARGE DATE: 09/13/2021 DISCHARGE TYPE: Regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Hyponatremia: COVID 19: Hyperlipidemia HTN: Leg Cramps AKI: Resolved Anxiety: HISTORY OF PRESENT ILLNESS: pleasant 78 year old male with a past medical history significant for CVA< tremor, HTN and hyperlipidemia. He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had been diagnosed with COVID at outside facility in mid-August ~ 19th. Initially he had been doing okay but over the past 1 week or so he has felt progressively worse. Today he felt so weak he had trouble dressing himself and thus came to the ED for evaluation. Also of note over this same timeline he was started on duloxetine and this was dose was just recently doubled in the past few days as part of the initial upward titration. He has no shortness of breath, he does have some cough, + runny nose. No nausea, no vomiting. Admits to very poor intake. Of note he was fully vaccinated in Feb 2021. HOSPITAL COURSE: He presented to the ED with complaints of ongoing anorexia, weakness, poor intake, gait instability and overall just not doing well. He had a Sodium level of 118 and found to be asymptomatic from COVID. He was treated with IVF and his Sodium rose from 118 to 129. PATIENT has requested to be d/c home today. He will f/up with his PCP to continue to f/up on Sodium level. Duloxetine was stop due to possible side effect with SIADH of his sodium level. Hyponatremia: slowly improving, 127 this morning - ?medication induced SIADH vs hypovolemic hyponatremia - Holding Duloxetine - On IV Fluids, will continue for one more day COVID 19: (+) 9/9/21 - On room air - Supportive care for now Hyperlipidemia - cont. atorvastatin HTN: BP elevated. - Lisinopril 40mg daily continued - Could consider adding Coreg next at low dose for BP control - Elevated currently in the hospital setting, though he has a lot of anxiety Leg Cramp - Dopplers pending to r/o DVT in the setting of COVID - tylenol and or tramadol for pain AKI: Resolved - Admission Cr 1.4, now 1.1 Anxiety: - Restarted home Ativan at 1mg TID as needed
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Dyspnoea, Productive cough, Vaccine breakthrough infection
Clinical narrative: Narrative:  Breakthrough Covid-19: presents w/ worsening SOB and cough productive of scant clear sputum for ~2 weeks.