chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Aphonia, COVID-19, Cough, Fatigue, Headache
Clinical narrative: I'm a teacher on Wednesday the 18th I started losing my voice and had an itchy voice. I started having some congestion and runny/itchy nose and a cough I even called my allergy specialist. I was told to take my ALLEGRA in the morning and then again at night. The medication did help for about four days then I went back to just taking it in the morning. I tested for the first time at a clinic, and it was negative for COVID-19 and then I was still feeling sick, so I tested again three days later at home and was positive for COVID-19. I called my work, and I took the 5 days off they required. I slept in for four days I had a headache, fatigue, cough, congestion, sneezing and drainage. I am still currently dealing with a dry cough, but I don't really feel bad.
Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Impaired work ability, Malaise, Nasal pruritus, Respiratory tract congestion, Rhinorrhoea
Clinical narrative: I'm a teacher on Wednesday the 18th I started losing my voice and had an itchy voice. I started having some congestion and runny/itchy nose and a cough I even called my allergy specialist. I was told to take my ALLEGRA in the morning and then again at night. The medication did help for about four days then I went back to just taking it in the morning. I tested for the first time at a clinic, and it was negative for COVID-19 and then I was still feeling sick, so I tested again three days later at home and was positive for COVID-19. I called my work, and I took the 5 days off they required. I slept in for four days I had a headache, fatigue, cough, congestion, sneezing and drainage. I am still currently dealing with a dry cough, but I don't really feel bad.
Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Sneezing, Somnolence, Throat irritation
Clinical narrative: I'm a teacher on Wednesday the 18th I started losing my voice and had an itchy voice. I started having some congestion and runny/itchy nose and a cough I even called my allergy specialist. I was told to take my ALLEGRA in the morning and then again at night. The medication did help for about four days then I went back to just taking it in the morning. I tested for the first time at a clinic, and it was negative for COVID-19 and then I was still feeling sick, so I tested again three days later at home and was positive for COVID-19. I called my work, and I took the 5 days off they required. I slept in for four days I had a headache, fatigue, cough, congestion, sneezing and drainage. I am still currently dealing with a dry cough, but I don't really feel bad.
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Eyelid function disorder, Facial paralysis, Gait disturbance, Impaired work ability, Laboratory test
Clinical narrative: 2nd dose Covid Moderna  4/19/21 lot#: 036B21A   started with an itchy left ear, postherpetic neuralgia on right side of head, paralyzed right face, vertigo can't handle. Trouble closing my eye, feel unsteady to walk and one year unable to work.
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Post herpetic neuralgia, Pruritus, Vertigo
Clinical narrative: 2nd dose Covid Moderna  4/19/21 lot#: 036B21A   started with an itchy left ear, postherpetic neuralgia on right side of head, paralyzed right face, vertigo can't handle. Trouble closing my eye, feel unsteady to walk and one year unable to work.
Age: 59.0
Sex: M
Vaccine: FLUA4
Symptoms: Product storage error
Clinical narrative: Vaccine storage temperature issue, health department advised to repeat.
Age: 39.0
Sex: F
Vaccine: HEP
Symptoms: Wrong product administered
Clinical narrative: accidently give Engerix instead of Heplisav-B
Age: 62.0
Sex: U
Vaccine: FLUA4
Symptoms: Product storage error
Clinical narrative: Vaccine storage temperature issue, health department advised to repeat.
Age: 47.0
Sex: F
Vaccine: COVID19-2
Symptoms: Biopsy vulva abnormal, Erythema, Inflammation, Mucosal erosion, Skin hyperplasia
Clinical narrative: Woke up 2 days after the vaccine (12/8/22)  and felt very irritated in the vulvar area. Looked with a mirror and had a very bright red oblong lesion that was about 3/4 inch x 1/4 inch in size on the left vulva. The area continued to feel worse and the area ulcerated a few days later and a kissing lesion was starting on the right vulva so I saw my dermatologist. She prescribed clobetasol ointment twice daily which I used for a week, but during a follow up call when I noted that it was more irritated since using it she recommended I discontinue using it until the gynecologist could do a biopsy. I had a left vulvar biopsy done on 1/26/2023. At that time, both lesions were still similar to when they were initially noticed.
Age: 47.0
Sex: F
Vaccine: COVID19-2
Symptoms: Vulval disorder, Vulval ulceration, Vulvovaginal discomfort
Clinical narrative: Woke up 2 days after the vaccine (12/8/22)  and felt very irritated in the vulvar area. Looked with a mirror and had a very bright red oblong lesion that was about 3/4 inch x 1/4 inch in size on the left vulva. The area continued to feel worse and the area ulcerated a few days later and a kissing lesion was starting on the right vulva so I saw my dermatologist. She prescribed clobetasol ointment twice daily which I used for a week, but during a follow up call when I noted that it was more irritated since using it she recommended I discontinue using it until the gynecologist could do a biopsy. I had a left vulvar biopsy done on 1/26/2023. At that time, both lesions were still similar to when they were initially noticed.
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Angiogram cerebral abnormal, Angiogram pulmonary normal, Asthenia, Atrial fibrillation
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood urine present, COVID-19, Carotid artery occlusion, Cerebral small vessel ischaemic disease, Cerebrovascular accident
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Cognitive disorder, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Confusional state, Cough
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Decreased appetite, Echocardiogram normal, Haematuria, Metabolic encephalopathy, Muscular weakness
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Thalamic infarction, Ultrasound Doppler normal, Urine analysis abnormal
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Angiogram cerebral, Angiogram cerebral abnormal, Angiogram pulmonary, Angiogram pulmonary normal
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Asthenia, Atrial fibrillation, Blood urine, Blood urine present, COVID-19
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Carotid artery occlusion, Cerebral small vessel ischaemic disease, Cerebrovascular accident, Cognitive disorder, Computerised tomogram
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Computerised tomogram head, Computerised tomogram head abnormal, Computerised tomogram thorax, Computerised tomogram thorax normal, Confusional state
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Cough, Decreased appetite, Echocardiogram, Echocardiogram normal, Haematuria
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Metabolic encephalopathy, Muscular weakness, SARS-CoV-2 test, SARS-CoV-2 test positive, Thalamic infarction
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 92.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Ultrasound Doppler, Ultrasound Doppler normal, Urine analysis, Urine analysis abnormal
Clinical narrative: Patient is a 93 y.o. male patient of a local MD with history of prostate cancer, bladder cancer, HTN presented to a local Medical Center with weakness, cough and found to have COVID 19 resp failure, hypoxia and possible acute CVA.   Acute hypoxic respiratory failure In setting of COVID-19 Requiring 2L NC on admission CTPA negative for PE No dvt on dopplers Antitussive/mucolytic, prn albuterol, mobilize, IS On 2-3L NC, wean as tolerated; may need some more time to wean as SNF Pulmonary followed    Covid-19 Virus Infection Date of onset of symptoms: 12/26 Symptoms present on admission: cough, weakness, poor appetite Date of covid positive test: 12/28 Vaccination status: vaccinated Imaging: CT chest no infiltrate Oxygen requirements on admission: 2L Current oxygen requirements: 2L Medical therapy: remdesivir completed continue dexamethasone Consultants following: pulm Anticipated special isolation end date: 1/6   Subacute right thalmic stroke Symptoms:  confusion, slight L arm weakness Etiology: likely small vessel disease Imaging:  ? CTH age indeterminant infarct R thalamus ? CTA H/N showed hronic right-ICA occlusion at the level of skull base with distal reconstitution at the cavernous segment Asa statin continued Neurology signed off PT/OT/SLP   Afib with RVR Spontaneously converted to NSR Started on low dose lopressor CHADS2VASC 5 TTE unremarkable Will need eliquis but has significant hematuria with bladder CA Acute metabolic encephalopathy Cognitive decline Aox1 on arrival, family reports suspicion of early dementia not diagnosed, worse confusion in recent days PTA Due to COVID +/- CVA contribution Delirium precautions; Otherwise as above Alert to self Add trazadone for sleep at night   Gross Hematuria Bladder mass History of bladder Ca Incidentally noted bladder mass on CT CAP, prevously noted on CT 2021 UA large blood, prior UA 2019 same Follows with an outside urologist "Dr." and has consistently expressed he does not want this treated further Monitor for gross hematuria with addition of antiplatelet, urology consult if needed
Age: 49.0
Sex: F
Vaccine: FLUA4
Symptoms: Product storage error
Clinical narrative: Vaccine storage temperature issue, health department advised to repeat.
Age: 60.0
Sex: F
Vaccine: COVID19-2
Symptoms: Extra dose administered, Pain, Pain in extremity
Clinical narrative: The LVN did not see that the patient had already received their COVID-19 bivalent booster since the information was documented at the back of the COVID-19 vaccine card and inadvertently administered the vaccine to the patient. The patient was observed for 5-10 mins post-vaccination. They were stable and did not exhibit any concerning s/sx that would have warranted additional medical attention. A follow-up call was conducted on 1/31 to check in on the patient and they said they were "fine" and aside from the arm soreness and body aches, no other concerning symptoms.
Age: 78.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Chest pain, Cough, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 01/01/23 presents to ED for "chest pain, fever, cough". PMHx of "HLD, ulcerative colitis, former tobacco use"
Age: 76.0
Sex: M
Vaccine: COVID19-2
Symptoms: Acute respiratory failure, Blood bicarbonate increased, Blood pH normal, COVID-19, Chest X-ray abnormal
Clinical narrative: Patient is a 76 y.o. male patient of MD with history of hypothyroidism, CAD, HLD, HTN, asthma, chronic cough, and former tobacco use.  Presents with SOB, chills, decreased appetite.   Acute hypercapnic/hypoxic respiratory failure HHF on admission  VBG w/ pH 7.36, pCO2 62.2, HCO3 34.9 CXR: left sided airspace disease, prominence of hilar region Respiratory status worse1/3-1/6 Now improving, weaned to NC on 1/11  Scheduled/PRN nebs, Pred taper  On NC, autopap at night  DC w oxygen, home O2 eval ordered for 1/13  Needs OP pulm f/u and PFT  Patient qualifies for home O2   Covid-19 Virus Infection Sx onset 12/27/22, positive 12/29/22  Out of isolation on 1/7/23  Was symptomatic w respiratory failure  Treated w remdesivir and steroids     Hypothyroidism Continue home Synthroid 88mcg   HTN Holding metoprolol, hyzaar in setting of sepsis Home meds: metoprolol 25mg at bedtime, hyzaar  Gradually reintroduce meds as able/needed Monitor BP    CAD HLD Daily ASA, Rosuvastatin   Asthma No formal PFT Consider PFT outpatient   GERD Endorses use of Nexium at home Protonix daily   Constipation  Last bowel movement on 01/12/23   Increase bowel regimen
Age: 76.0
Sex: M
Vaccine: COVID19-2
Symptoms: Chills, Constipation, Decreased appetite, Dyspnoea, Lung disorder
Clinical narrative: Patient is a 76 y.o. male patient of MD with history of hypothyroidism, CAD, HLD, HTN, asthma, chronic cough, and former tobacco use.  Presents with SOB, chills, decreased appetite.   Acute hypercapnic/hypoxic respiratory failure HHF on admission  VBG w/ pH 7.36, pCO2 62.2, HCO3 34.9 CXR: left sided airspace disease, prominence of hilar region Respiratory status worse1/3-1/6 Now improving, weaned to NC on 1/11  Scheduled/PRN nebs, Pred taper  On NC, autopap at night  DC w oxygen, home O2 eval ordered for 1/13  Needs OP pulm f/u and PFT  Patient qualifies for home O2   Covid-19 Virus Infection Sx onset 12/27/22, positive 12/29/22  Out of isolation on 1/7/23  Was symptomatic w respiratory failure  Treated w remdesivir and steroids     Hypothyroidism Continue home Synthroid 88mcg   HTN Holding metoprolol, hyzaar in setting of sepsis Home meds: metoprolol 25mg at bedtime, hyzaar  Gradually reintroduce meds as able/needed Monitor BP    CAD HLD Daily ASA, Rosuvastatin   Asthma No formal PFT Consider PFT outpatient   GERD Endorses use of Nexium at home Protonix daily   Constipation  Last bowel movement on 01/12/23   Increase bowel regimen
Age: 76.0
Sex: M
Vaccine: COVID19-2
Symptoms: Malaise, PCO2 increased, Respiratory failure, SARS-CoV-2 test positive, Sepsis
Clinical narrative: Patient is a 76 y.o. male patient of MD with history of hypothyroidism, CAD, HLD, HTN, asthma, chronic cough, and former tobacco use.  Presents with SOB, chills, decreased appetite.   Acute hypercapnic/hypoxic respiratory failure HHF on admission  VBG w/ pH 7.36, pCO2 62.2, HCO3 34.9 CXR: left sided airspace disease, prominence of hilar region Respiratory status worse1/3-1/6 Now improving, weaned to NC on 1/11  Scheduled/PRN nebs, Pred taper  On NC, autopap at night  DC w oxygen, home O2 eval ordered for 1/13  Needs OP pulm f/u and PFT  Patient qualifies for home O2   Covid-19 Virus Infection Sx onset 12/27/22, positive 12/29/22  Out of isolation on 1/7/23  Was symptomatic w respiratory failure  Treated w remdesivir and steroids     Hypothyroidism Continue home Synthroid 88mcg   HTN Holding metoprolol, hyzaar in setting of sepsis Home meds: metoprolol 25mg at bedtime, hyzaar  Gradually reintroduce meds as able/needed Monitor BP    CAD HLD Daily ASA, Rosuvastatin   Asthma No formal PFT Consider PFT outpatient   GERD Endorses use of Nexium at home Protonix daily   Constipation  Last bowel movement on 01/12/23   Increase bowel regimen
Age: 67.0
Sex: M
Vaccine: FLUA4
Symptoms: Product storage error
Clinical narrative: Vaccine storage temperature issue, health dept. advised to repeat.
Age: 87.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive
Clinical narrative: 01/01/23 presents to ED for "corona virus concern". PMHx of "hypertension, chronic diastolic congestive heart failure"
Age: 19.0
Sex: F
Vaccine: FLUA4
Symptoms: Product storage error
Clinical narrative: Vaccine storage temperature issue, health department advised to repeat.
Age: 90.0
Sex: F
Vaccine: COVID19-2
Symptoms: Angiogram cerebral, Arteriogram carotid, Blood test, Cerebrovascular accident, Chest X-ray
Clinical narrative: 5 days following  the vaccination,  Patient suffered an ischemic stroke.  It was initially thought perhaps a UTI, due to the signs (confusion, vomiting, headache).  But the urine sample came back negative so she was taken to the ER by ambulance, where CT-scans and 2 MRI's were done, confirming the stroke (multiple strokes in the brain, but very small) and no bleeding.  After 5 days in the hospital, she spent 3 weeks in a rehab and is now back at her Assisted Living facility.
Age: 90.0
Sex: F
Vaccine: COVID19-2
Symptoms: Computerised tomogram abdomen, Computerised tomogram head abnormal, Confusional state, Echocardiogram, Headache
Clinical narrative: 5 days following  the vaccination,  Patient suffered an ischemic stroke.  It was initially thought perhaps a UTI, due to the signs (confusion, vomiting, headache).  But the urine sample came back negative so she was taken to the ER by ambulance, where CT-scans and 2 MRI's were done, confirming the stroke (multiple strokes in the brain, but very small) and no bleeding.  After 5 days in the hospital, she spent 3 weeks in a rehab and is now back at her Assisted Living facility.
Age: 90.0
Sex: F
Vaccine: COVID19-2
Symptoms: Ischaemic stroke, Magnetic resonance imaging head abnormal, Scan with contrast, Urine analysis normal, Vomiting
Clinical narrative: 5 days following  the vaccination,  Patient suffered an ischemic stroke.  It was initially thought perhaps a UTI, due to the signs (confusion, vomiting, headache).  But the urine sample came back negative so she was taken to the ER by ambulance, where CT-scans and 2 MRI's were done, confirming the stroke (multiple strokes in the brain, but very small) and no bleeding.  After 5 days in the hospital, she spent 3 weeks in a rehab and is now back at her Assisted Living facility.
Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Ammonia normal, Atelectasis, Blood bicarbonate increased, Blood gases
Clinical narrative: Patient is a 68 y.o. female patient of, DO with history of chronic respiratory failure with hypoxia, anemia, cardiomegaly, duodenal ulcer, convulsions, hypothyroidism, muscle wasting, protein malnutrition presented to Hospital with cough, fatigue, and altered mental status.   Acute on Chronic Hypoxic and Hypercapnic Respiratory Failure Community acquired pneumonia COVID-19 Cough, fatigue, and altered mental status on presentation Requiring 6L O2 on admission, now weaned to 2 L(baseline 2-3L) Initial VBG with pCO2 elevate CT with mild right and trace left posterior lower lobe lung consolidation reflecting atelectasis or pneumonitis Similar presentation about 2 months ago Treat suspected PNA; completed steroids Lactic acid normal Urine antigens negative Tested positive for COVID 1/6. End iso 1/16.  MRSA screen negative. Vanco discontinued 1/07.  Augmentin at discharge.    Acute metabolic encephalopathy Uncertain etiology, possible related to PNA vs decreased respiratory drive with hypercapnia Some mild improvement with treatment in the ED Somnolent on exam VBG: pH 7.40, PCO2 66, HCO3 40.3, consistent with respiratory acidosis with metabolic compensation UDS negative, ammonia normal, other labs grossly normal Continue treatment of pneumonia as above Mental status improving and at baseline   Chronic congestive heart failure Cardiomegaly Echo 10/27 with LVEF 65%,  LV with grade 1 diastolic dysfunction BNP elevated but CXR clear.  Does not appear fluid overloaded on exam Continue home lasix and metoprolol  Holding K supplementation given initial  hyperkalemia TTE LVEF normal   Hyperkalemia - Resolved K 5.8 in the ED Treated in the ER, resolved   Duodenal Ulcer Gastritis Continue home PPI   Convulsions Continue Depakote
Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Blood lactic acid normal, Blood pH, Blood potassium increased, Brain natriuretic peptide increased, COVID-19
Clinical narrative: Patient is a 68 y.o. female patient of, DO with history of chronic respiratory failure with hypoxia, anemia, cardiomegaly, duodenal ulcer, convulsions, hypothyroidism, muscle wasting, protein malnutrition presented to Hospital with cough, fatigue, and altered mental status.   Acute on Chronic Hypoxic and Hypercapnic Respiratory Failure Community acquired pneumonia COVID-19 Cough, fatigue, and altered mental status on presentation Requiring 6L O2 on admission, now weaned to 2 L(baseline 2-3L) Initial VBG with pCO2 elevate CT with mild right and trace left posterior lower lobe lung consolidation reflecting atelectasis or pneumonitis Similar presentation about 2 months ago Treat suspected PNA; completed steroids Lactic acid normal Urine antigens negative Tested positive for COVID 1/6. End iso 1/16.  MRSA screen negative. Vanco discontinued 1/07.  Augmentin at discharge.    Acute metabolic encephalopathy Uncertain etiology, possible related to PNA vs decreased respiratory drive with hypercapnia Some mild improvement with treatment in the ED Somnolent on exam VBG: pH 7.40, PCO2 66, HCO3 40.3, consistent with respiratory acidosis with metabolic compensation UDS negative, ammonia normal, other labs grossly normal Continue treatment of pneumonia as above Mental status improving and at baseline   Chronic congestive heart failure Cardiomegaly Echo 10/27 with LVEF 65%,  LV with grade 1 diastolic dysfunction BNP elevated but CXR clear.  Does not appear fluid overloaded on exam Continue home lasix and metoprolol  Holding K supplementation given initial  hyperkalemia TTE LVEF normal   Hyperkalemia - Resolved K 5.8 in the ED Treated in the ER, resolved   Duodenal Ulcer Gastritis Continue home PPI   Convulsions Continue Depakote
Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiac failure congestive, Cardiomegaly, Chest X-ray normal, Computerised tomogram thorax abnormal, Condition aggravated
Clinical narrative: Patient is a 68 y.o. female patient of, DO with history of chronic respiratory failure with hypoxia, anemia, cardiomegaly, duodenal ulcer, convulsions, hypothyroidism, muscle wasting, protein malnutrition presented to Hospital with cough, fatigue, and altered mental status.   Acute on Chronic Hypoxic and Hypercapnic Respiratory Failure Community acquired pneumonia COVID-19 Cough, fatigue, and altered mental status on presentation Requiring 6L O2 on admission, now weaned to 2 L(baseline 2-3L) Initial VBG with pCO2 elevate CT with mild right and trace left posterior lower lobe lung consolidation reflecting atelectasis or pneumonitis Similar presentation about 2 months ago Treat suspected PNA; completed steroids Lactic acid normal Urine antigens negative Tested positive for COVID 1/6. End iso 1/16.  MRSA screen negative. Vanco discontinued 1/07.  Augmentin at discharge.    Acute metabolic encephalopathy Uncertain etiology, possible related to PNA vs decreased respiratory drive with hypercapnia Some mild improvement with treatment in the ED Somnolent on exam VBG: pH 7.40, PCO2 66, HCO3 40.3, consistent with respiratory acidosis with metabolic compensation UDS negative, ammonia normal, other labs grossly normal Continue treatment of pneumonia as above Mental status improving and at baseline   Chronic congestive heart failure Cardiomegaly Echo 10/27 with LVEF 65%,  LV with grade 1 diastolic dysfunction BNP elevated but CXR clear.  Does not appear fluid overloaded on exam Continue home lasix and metoprolol  Holding K supplementation given initial  hyperkalemia TTE LVEF normal   Hyperkalemia - Resolved K 5.8 in the ED Treated in the ER, resolved   Duodenal Ulcer Gastritis Continue home PPI   Convulsions Continue Depakote
Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Drug screen negative, Echocardiogram, Echocardiogram abnormal, Ejection fraction
Clinical narrative: Patient is a 68 y.o. female patient of, DO with history of chronic respiratory failure with hypoxia, anemia, cardiomegaly, duodenal ulcer, convulsions, hypothyroidism, muscle wasting, protein malnutrition presented to Hospital with cough, fatigue, and altered mental status.   Acute on Chronic Hypoxic and Hypercapnic Respiratory Failure Community acquired pneumonia COVID-19 Cough, fatigue, and altered mental status on presentation Requiring 6L O2 on admission, now weaned to 2 L(baseline 2-3L) Initial VBG with pCO2 elevate CT with mild right and trace left posterior lower lobe lung consolidation reflecting atelectasis or pneumonitis Similar presentation about 2 months ago Treat suspected PNA; completed steroids Lactic acid normal Urine antigens negative Tested positive for COVID 1/6. End iso 1/16.  MRSA screen negative. Vanco discontinued 1/07.  Augmentin at discharge.    Acute metabolic encephalopathy Uncertain etiology, possible related to PNA vs decreased respiratory drive with hypercapnia Some mild improvement with treatment in the ED Somnolent on exam VBG: pH 7.40, PCO2 66, HCO3 40.3, consistent with respiratory acidosis with metabolic compensation UDS negative, ammonia normal, other labs grossly normal Continue treatment of pneumonia as above Mental status improving and at baseline   Chronic congestive heart failure Cardiomegaly Echo 10/27 with LVEF 65%,  LV with grade 1 diastolic dysfunction BNP elevated but CXR clear.  Does not appear fluid overloaded on exam Continue home lasix and metoprolol  Holding K supplementation given initial  hyperkalemia TTE LVEF normal   Hyperkalemia - Resolved K 5.8 in the ED Treated in the ER, resolved   Duodenal Ulcer Gastritis Continue home PPI   Convulsions Continue Depakote