chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 19.0
Sex: M
Vaccine: COVID19
Symptoms: Cough, Duodenitis, Headache, Hypoglycaemia, Laboratory test
Clinical narrative: Hospital Course: 1. Acute, recurrent abdominal pain. Lipase was just under twice the upper limit of normal. He was having epigastric area pain, which was worse with eating. Ordered for IV fluids, anti-emetics, and pain control. GI service consulted and acute pancreatitis was considered doubtful.  Pain resolved on follow-up today. Underwent EGD which noted duodenitis signs. Biopsies were taken. He is stable for discharge home with outpatient GI follow-up regarding biopsy results and further care plan. 2. Acute hypoglycemia. Resolved. Monitored labs. Encouraged PO intake. 3. Recent covid-19 infection. Had headache on 7-31 followed by runny nose and cough. These symptoms resolved. He tested positive at home on 8-1.Discussed with epidemiology and released from covid isolation. No specific treatment is currently needed.  4. Autistic spectrum disorder. He is to have outpatient follow-up. 5. DVT prophylaxis. He is low risk and ambulatory. Disposition: He is stable for discharge home with outpatient follow-up. Discussed management plan with patient at bedside and mother earlier today.
Age: 19.0
Sex: M
Vaccine: COVID19
Symptoms: Lipase abnormal, Oesophagogastroduodenoscopy abnormal, Rhinorrhoea, SARS-CoV-2 test positive
Clinical narrative: Hospital Course: 1. Acute, recurrent abdominal pain. Lipase was just under twice the upper limit of normal. He was having epigastric area pain, which was worse with eating. Ordered for IV fluids, anti-emetics, and pain control. GI service consulted and acute pancreatitis was considered doubtful.  Pain resolved on follow-up today. Underwent EGD which noted duodenitis signs. Biopsies were taken. He is stable for discharge home with outpatient GI follow-up regarding biopsy results and further care plan. 2. Acute hypoglycemia. Resolved. Monitored labs. Encouraged PO intake. 3. Recent covid-19 infection. Had headache on 7-31 followed by runny nose and cough. These symptoms resolved. He tested positive at home on 8-1.Discussed with epidemiology and released from covid isolation. No specific treatment is currently needed.  4. Autistic spectrum disorder. He is to have outpatient follow-up. 5. DVT prophylaxis. He is low risk and ambulatory. Disposition: He is stable for discharge home with outpatient follow-up. Discussed management plan with patient at bedside and mother earlier today.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Blood creatinine increased, COVID-19, Presyncope, Procalcitonin increased, Respiratory symptom
Clinical narrative: 78-year-old male presents to the emergency department 8/11/2022 after experiencing syncopal episode.  Patient was doing quite well at his home until this past weekend when he started to have mild upper respiratory symptoms.  At home COVID test was positive.  Patient was started on Paxil but on 8/8/2022.  Patient took 3 doses prior to his arrival.  Patient apparently had a syncopal episode the night before his presentation and he remained on the floor overnight.  When patient was seen in the emergency department patient has evidence of rhabdomyolysis with increased creatinine.  Patient was started on IV fluids.  His procalcitonin was also elevated and patient was still on antibiotics for possible community-acquired. pneumonia.   Patient was seen by infectious disease.  He was started on IV azithromycin and Rocephin as well as Decadron and remdesivir.  Patient finished 5-day course of remdesivir.  Cardiology also evaluated the patient, believing that his syncopal episode was most likely vasovagal attack with no further work-up needed at this time patient was seen by physical therapy patient declined subacute rehab placement.  Patient requested home care which was set up by care management. Patient was cleared by all specialties.
Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Rhabdomyolysis, SARS-CoV-2 test positive, Syncope
Clinical narrative: 78-year-old male presents to the emergency department 8/11/2022 after experiencing syncopal episode.  Patient was doing quite well at his home until this past weekend when he started to have mild upper respiratory symptoms.  At home COVID test was positive.  Patient was started on Paxil but on 8/8/2022.  Patient took 3 doses prior to his arrival.  Patient apparently had a syncopal episode the night before his presentation and he remained on the floor overnight.  When patient was seen in the emergency department patient has evidence of rhabdomyolysis with increased creatinine.  Patient was started on IV fluids.  His procalcitonin was also elevated and patient was still on antibiotics for possible community-acquired. pneumonia.   Patient was seen by infectious disease.  He was started on IV azithromycin and Rocephin as well as Decadron and remdesivir.  Patient finished 5-day course of remdesivir.  Cardiology also evaluated the patient, believing that his syncopal episode was most likely vasovagal attack with no further work-up needed at this time patient was seen by physical therapy patient declined subacute rehab placement.  Patient requested home care which was set up by care management. Patient was cleared by all specialties.
Age: 82.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: Anticoagulant therapy, Asthenia, Bradycardia, COVID-19, Cardiac stress test normal
Clinical narrative: 83y.o. female who presentswith PMH of TIA, HTN, CVA with residual LLE weakness, parkinsonism presented to the ER with generalized weakness and was found to have COVID infection along with elevated troponins, bradycardia and prolonged QTC.  Infectious disease was consulted and remdesivir 4 doses were given with improvement in her symptoms.  Cardiology was consulted for possible NSTEMI versus viral myocarditis.  Was treated with IV heparin infusion for 48 hours, echocardiogram was stable with preserved EF without wall motion abnormalities.  Once out of isolation, stress test was done which was negative for any reversible ischemia.  PT OT evaluation and PMNR evaluation was done and recommended subacute rehab which was negative for any reversible ischemia.  PT OT evaluation and PMNR evaluation was done and recommended subacute rehab which was arranged on discharge.
Age: 82.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: Echocardiogram, Ejection fraction, Electrocardiogram QT prolonged, SARS-CoV-2 test positive, Troponin increased
Clinical narrative: 83y.o. female who presentswith PMH of TIA, HTN, CVA with residual LLE weakness, parkinsonism presented to the ER with generalized weakness and was found to have COVID infection along with elevated troponins, bradycardia and prolonged QTC.  Infectious disease was consulted and remdesivir 4 doses were given with improvement in her symptoms.  Cardiology was consulted for possible NSTEMI versus viral myocarditis.  Was treated with IV heparin infusion for 48 hours, echocardiogram was stable with preserved EF without wall motion abnormalities.  Once out of isolation, stress test was done which was negative for any reversible ischemia.  PT OT evaluation and PMNR evaluation was done and recommended subacute rehab which was negative for any reversible ischemia.  PT OT evaluation and PMNR evaluation was done and recommended subacute rehab which was arranged on discharge.
Age: 82.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Chest pain, SARS-CoV-2 test positive
Clinical narrative: 83y.o. female who presentswith PMH of TIA, HTN, CVA with residual LLE weakness, parkinsonism presented to the ER with generalized weakness and was found to have COVID infection along with elevated troponins, bradycardia and prolonged QTC.  Infectious disease was consulted and remdesivir 4 doses were given with improvement in her symptoms.  Cardiology was consulted for possible NSTEMI versus viral myocarditis.  Was treated with IV heparin infusion for 48 hours, echocardiogram was stable with preserved EF without wall motion abnormalities.  Once out of isolation, stress test was done which was negative for any reversible ischemia.  PT OT evaluation and PMNR evaluation was done and recommended subacute rehab which was negative for any reversible ischemia.  PT OT evaluation and PMNR evaluation was done and recommended subacute rehab which was arranged on discharge.
Age: 78.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Asymptomatic COVID-19, Blood potassium increased, Electrocardiogram normal, Hyperkalaemia, SARS-CoV-2 test positive
Clinical narrative: 79y.o. female with pmh of CKD stage 3 likely from DM/HTN nephropathy who presents with hyperkalemia. She was sent by PCP, Dr, who noted office labs with K 6.6. In EC, pt hemodynamically stable K was 5.8- she was given dextrose, insulin, kayexalate EKG with no significant changes She denies any chest pain, shortness of breath, palpitations, nausea, vomiting, fever or chills. Found to be COVID positive- asymptomatic  Deemed medically stable for discharge negative for any reversible ischemia.  PT OT evaluation and PMNR evaluation was done and recommended subacute rehab which was arranged on discharge.
Age: 18.0
Sex: F
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: ADMINISTERED EXPIRED VACCINE
Age: 85.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Chest X-ray normal, Cough, Fatigue, Hypertension
Clinical narrative: 86y.o.  female w/ PMHx of AML, Endometrial cancer, HTN, Hypothyroidism, Afib on xarelto  CC of fatigue and fever, which has been going on for today.  Patient states that she did to test at home that came back positive for COVID-19.  Patient had an appointment with her oncologist who advised for her to come into the hospital for treatment. She was febrile, hypertensive and had mild cough without any hypoxia or pneumonia on CXR. She was seen by ID and oncologist. All options for acute covid infection in immunocompromised pt were discussed and pt decided conservative supportive care approach. She stayed a few days and fever went down and didn't have any clinical deterioration. She was discharged home.
Age: 85.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 86y.o.  female w/ PMHx of AML, Endometrial cancer, HTN, Hypothyroidism, Afib on xarelto  CC of fatigue and fever, which has been going on for today.  Patient states that she did to test at home that came back positive for COVID-19.  Patient had an appointment with her oncologist who advised for her to come into the hospital for treatment. She was febrile, hypertensive and had mild cough without any hypoxia or pneumonia on CXR. She was seen by ID and oncologist. All options for acute covid infection in immunocompromised pt were discussed and pt decided conservative supportive care approach. She stayed a few days and fever went down and didn't have any clinical deterioration. She was discharged home.
Age: 72.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Agitation, Asymptomatic COVID-19, Enterocutaneous fistula, SARS-CoV-2 test positive
Clinical narrative: Admitted for agiation, admitted for ECF placement. Found to be covid +, no sx. No tx needed. Remained in isolation. Insurance denied SAR, was d/c home.
Age: 63.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Adrenocortical insufficiency acute, COVID-19, Electrolyte imbalance, SARS-CoV-2 test positive
Clinical narrative: Patient admitted with COVID-19 that precipitated adrenal crisis, initially received IV hydrocortisone converted to oral therapy, patient has corrected electrolytes and has been given clearance for discharge per endocrinology.
Age: 47.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, SARS-CoV-2 test positive, Skin irritation, Stoma site irritation
Clinical narrative: 48 y.o. female who presented with peristomal skin irritation. Ostomy nursing evaluated the patient and taught her how to use a new appliance. Diet was advanced to regular diet and patient was taking sufficient PO intake to maintain hydration.Patient was ambulating. The patient was deemed stable for discharge on 8/14/22.
Age: 62.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Cough, Dyspnoea, Fatigue, Pyrexia
Clinical narrative: 63y.o. female with HX of T2DM, PE, HLD, and Hypertension presented to the ED with c/o shortness of breath, cough, and fever. Patient was on a one week cruise and returned 7 days ago. 5 days ago, she developed cough, fatigue, fever, and difficulty in breathing. She took a at home covid test which was positive today. Patient is Vaccinated X3 with booster a couple weeks ago. Denies chest pain and reports improvement in her breathing. Denies fevers, chills, nausea, emesis, sore throat, edema, and chest pain. Discussed with ID, plan of care discussed with RN, letter typed for patient's employer. Medically stable for discharge, she is agreeable
Age: 62.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: 63y.o. female with HX of T2DM, PE, HLD, and Hypertension presented to the ED with c/o shortness of breath, cough, and fever. Patient was on a one week cruise and returned 7 days ago. 5 days ago, she developed cough, fatigue, fever, and difficulty in breathing. She took a at home covid test which was positive today. Patient is Vaccinated X3 with booster a couple weeks ago. Denies chest pain and reports improvement in her breathing. Denies fevers, chills, nausea, emesis, sore throat, edema, and chest pain. Discussed with ID, plan of care discussed with RN, letter typed for patient's employer. Medically stable for discharge, she is agreeable
Age: 59.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Endotracheal intubation, Fall, Intensive care, Mental status changes
Clinical narrative: 60y.o. female patient, presented to the EC yesterday with altered mental status, the patient sustained a fall at home.  On evaluation the hospital she was found to have traumatic frontal and parietal occipital subarachnoid hemorrhage and left acute subdural hematoma.  She is currently in the ICU setting, she is intubated.  She has a past medical history for metastatic breast cancer with involvement in the brain, suboccipital craniotomy tumor resection in 2003.  History of hyperlipidemia, type 2 diabetes.
Age: 59.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Subarachnoid haemorrhage, Subdural haematoma
Clinical narrative: 60y.o. female patient, presented to the EC yesterday with altered mental status, the patient sustained a fall at home.  On evaluation the hospital she was found to have traumatic frontal and parietal occipital subarachnoid hemorrhage and left acute subdural hematoma.  She is currently in the ICU setting, she is intubated.  She has a past medical history for metastatic breast cancer with involvement in the brain, suboccipital craniotomy tumor resection in 2003.  History of hyperlipidemia, type 2 diabetes.
Age: 69.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Chest X-ray normal, Chills, Fall, SARS-CoV-2 test positive
Clinical narrative: 70y.o. female with a medical history significant for Extranodal Marginal Zone Bcell Lymphoma, on  rituxan with bendamustine,  and pulmonary sarcoidosis who presented with chief complaint of fall. Acute covid-19 infection. She had chills earlier in week. She was not hypoxic and stable from respiratory standpoint. Chest x-ray was negative for acute findings. She is immune compromised from chemotherapy. Consulted service. Finished 3 day course of remdesivir. She has been vaccinated. She requires extended 20 day isolation protocol due to immune status; this will end on 9-1-2022. She is stable on room air for discharge home.
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: ADMINISTERED EXPIRED VACCINE.
Age: 48.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Ageusia, Anosmia, Bacterial test positive, Blood lactic acid abnormal, COVID-19
Clinical narrative: 49y.o. female presenting with palpitations, chest pressure. Upon presentation she had significant lactic acidosis 7.0. She also tested positive for COVID, however she was recently positive less than 2 months ago, CT chest was negative for PE as well as any signs of viral pneumonia. She was given large fluid resuscitation in the EC. Her lactic acid improved to normal levels. Additionally, cardiac work-up including troponin and EKG was negative. She had some bacteria on UA, however no urinary symptoms, fever, leukocytosis. Antibiotics were not given. By the following day, she had improved almost completely with fluid resuscitation alone. Noted procalcitonin 0.9, however without signs of active infection she was managed expectantly. She was then stable for discharge home with instructions to maintain aggressive oral hydration. She was additionally given information on isolating for positive COVID test. I attempted to contact microbiology lab to obtain cycle threshold from her positive test, however I was unable to contact them. Patient was recommended for continued COVID isolation at home with repeat testing. If she has 2 consecutive negative rapid tests, this is reassuring that her PCR was a hold over from previous positive infection and isolation can be successfully removed. On a final note, patient asked for appetite stimulant. She stated that cannabis-derived appetite stimulants were not successful for her in the past including Marinol. Main barrier to her nutrition is her lack of taste and smell which is secondary to previous chemotherapy. She was given a trial of low-dose Remeron. Patient was discharged home in stable condition with no restrictions on diet or activity to continue medications and follow up with physicians as listed below.
Age: 48.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Chest discomfort, Computerised tomogram thorax normal, Electrocardiogram normal, Lactic acidosis, Palpitations
Clinical narrative: 49y.o. female presenting with palpitations, chest pressure. Upon presentation she had significant lactic acidosis 7.0. She also tested positive for COVID, however she was recently positive less than 2 months ago, CT chest was negative for PE as well as any signs of viral pneumonia. She was given large fluid resuscitation in the EC. Her lactic acid improved to normal levels. Additionally, cardiac work-up including troponin and EKG was negative. She had some bacteria on UA, however no urinary symptoms, fever, leukocytosis. Antibiotics were not given. By the following day, she had improved almost completely with fluid resuscitation alone. Noted procalcitonin 0.9, however without signs of active infection she was managed expectantly. She was then stable for discharge home with instructions to maintain aggressive oral hydration. She was additionally given information on isolating for positive COVID test. I attempted to contact microbiology lab to obtain cycle threshold from her positive test, however I was unable to contact them. Patient was recommended for continued COVID isolation at home with repeat testing. If she has 2 consecutive negative rapid tests, this is reassuring that her PCR was a hold over from previous positive infection and isolation can be successfully removed. On a final note, patient asked for appetite stimulant. She stated that cannabis-derived appetite stimulants were not successful for her in the past including Marinol. Main barrier to her nutrition is her lack of taste and smell which is secondary to previous chemotherapy. She was given a trial of low-dose Remeron. Patient was discharged home in stable condition with no restrictions on diet or activity to continue medications and follow up with physicians as listed below.
Age: 48.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Procalcitonin, SARS-CoV-2 test positive, Troponin normal, Urine analysis
Clinical narrative: 49y.o. female presenting with palpitations, chest pressure. Upon presentation she had significant lactic acidosis 7.0. She also tested positive for COVID, however she was recently positive less than 2 months ago, CT chest was negative for PE as well as any signs of viral pneumonia. She was given large fluid resuscitation in the EC. Her lactic acid improved to normal levels. Additionally, cardiac work-up including troponin and EKG was negative. She had some bacteria on UA, however no urinary symptoms, fever, leukocytosis. Antibiotics were not given. By the following day, she had improved almost completely with fluid resuscitation alone. Noted procalcitonin 0.9, however without signs of active infection she was managed expectantly. She was then stable for discharge home with instructions to maintain aggressive oral hydration. She was additionally given information on isolating for positive COVID test. I attempted to contact microbiology lab to obtain cycle threshold from her positive test, however I was unable to contact them. Patient was recommended for continued COVID isolation at home with repeat testing. If she has 2 consecutive negative rapid tests, this is reassuring that her PCR was a hold over from previous positive infection and isolation can be successfully removed. On a final note, patient asked for appetite stimulant. She stated that cannabis-derived appetite stimulants were not successful for her in the past including Marinol. Main barrier to her nutrition is her lack of taste and smell which is secondary to previous chemotherapy. She was given a trial of low-dose Remeron. Patient was discharged home in stable condition with no restrictions on diet or activity to continue medications and follow up with physicians as listed below.
Age: 46.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Ageusia, Angiogram pulmonary normal, Anosmia, COVID-19, Chest pain
Clinical narrative: 47y.o. female with PMH of asthma, who presented to the hospital complaining of chest pain and shortness of breath. She also complains of cough, body aches and sore throat for last few days . She came to the ER for evaluation. She was tested positive for COVID . She was placed on oxygen 2 L NC and was admitted with consult to pulmonary and ID. She was placed on po steroids and started on paxlovid by ID. She had low grade fever yesterday. No N/V/D or abdominal pain . CTA PE negative for any acute process or PE, she is feeling better now, on RA , labs stable, D dimer improving , we will discharge her home today after home o2 eval. Will discharge on paxlovid for 4 more days and prednisone for three days. managed expectantly. She was then stable for discharge home with instructions to maintain aggressive oral hydration. She was additionally given information on isolating for positive COVID test. I attempted to contact microbiology lab to obtain cycle threshold from her positive test, however I was unable to contact them. Patient was recommended for continued COVID isolation at home with repeat testing. If she has 2 consecutive negative rapid tests, this is reassuring that her PCR was a hold over from previous positive infection and isolation can be successfully removed. On a final note, patient asked for appetite stimulant. She stated that cannabis-derived appetite stimulants were not successful for her in the past including Marinol. Main barrier to her nutrition is her lack of taste and smell which is secondary to previous chemotherapy. She was given a trial of low-dose Remeron. Patient was discharged home in stable condition with no restrictions on diet or activity to continue medications and follow up with physicians as listed below.
Age: 46.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Cough, Dyspnoea, Fibrin D dimer, Laboratory test, Malnutrition
Clinical narrative: 47y.o. female with PMH of asthma, who presented to the hospital complaining of chest pain and shortness of breath. She also complains of cough, body aches and sore throat for last few days . She came to the ER for evaluation. She was tested positive for COVID . She was placed on oxygen 2 L NC and was admitted with consult to pulmonary and ID. She was placed on po steroids and started on paxlovid by ID. She had low grade fever yesterday. No N/V/D or abdominal pain . CTA PE negative for any acute process or PE, she is feeling better now, on RA , labs stable, D dimer improving , we will discharge her home today after home o2 eval. Will discharge on paxlovid for 4 more days and prednisone for three days. managed expectantly. She was then stable for discharge home with instructions to maintain aggressive oral hydration. She was additionally given information on isolating for positive COVID test. I attempted to contact microbiology lab to obtain cycle threshold from her positive test, however I was unable to contact them. Patient was recommended for continued COVID isolation at home with repeat testing. If she has 2 consecutive negative rapid tests, this is reassuring that her PCR was a hold over from previous positive infection and isolation can be successfully removed. On a final note, patient asked for appetite stimulant. She stated that cannabis-derived appetite stimulants were not successful for her in the past including Marinol. Main barrier to her nutrition is her lack of taste and smell which is secondary to previous chemotherapy. She was given a trial of low-dose Remeron. Patient was discharged home in stable condition with no restrictions on diet or activity to continue medications and follow up with physicians as listed below.
Age: 46.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Oropharyngeal pain, Pain, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 47y.o. female with PMH of asthma, who presented to the hospital complaining of chest pain and shortness of breath. She also complains of cough, body aches and sore throat for last few days . She came to the ER for evaluation. She was tested positive for COVID . She was placed on oxygen 2 L NC and was admitted with consult to pulmonary and ID. She was placed on po steroids and started on paxlovid by ID. She had low grade fever yesterday. No N/V/D or abdominal pain . CTA PE negative for any acute process or PE, she is feeling better now, on RA , labs stable, D dimer improving , we will discharge her home today after home o2 eval. Will discharge on paxlovid for 4 more days and prednisone for three days. managed expectantly. She was then stable for discharge home with instructions to maintain aggressive oral hydration. She was additionally given information on isolating for positive COVID test. I attempted to contact microbiology lab to obtain cycle threshold from her positive test, however I was unable to contact them. Patient was recommended for continued COVID isolation at home with repeat testing. If she has 2 consecutive negative rapid tests, this is reassuring that her PCR was a hold over from previous positive infection and isolation can be successfully removed. On a final note, patient asked for appetite stimulant. She stated that cannabis-derived appetite stimulants were not successful for her in the past including Marinol. Main barrier to her nutrition is her lack of taste and smell which is secondary to previous chemotherapy. She was given a trial of low-dose Remeron. Patient was discharged home in stable condition with no restrictions on diet or activity to continue medications and follow up with physicians as listed below.
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Abdominal lymphadenopathy, Angiogram pulmonary abnormal, Blood electrolytes normal, COVID-19, Computerised tomogram abdomen abnormal
Clinical narrative: 90y.o. male with a past medical history of HTN, BPH, Dementia, CLL (Diagnosed 10 years back, never received treatment, followed with Dr per wife) was brought to local Hospital with shortness of breath.  He had runny nose 10 days ago but was doing okay at home.  Initially taken to urgent care where he was advised to watch his oxygen saturation.  His oxygen saturation at home was measured in the mid 80s when he complained about some shortness of breath and high heart rate he was brought to the hospital and was later diagnosed with COVID. We are consulted because of the history of CLL.  CLL was diagnosed roughly 10 years back and he followed with Dr. at the HCF  Never received treatment for CLL was monitored only for his wife. On admission, vitals stable and has been saturating well on 2 L nasal cannula, normal electrolytes, WBC count 31.5, normal hemoglobin, platelet 147.  Differentials showed normal neutrophil, 27.3% lymphocytes.  D-dimer 3970.  CTA chest showed no pulmonary embolism, small right-sided pleural effusion, diastolic and hilar lymphadenopathy.  CT abdomen pelvis showed tensive intra-abdominal and pelvic adenopathy within the retroperitoneum and left common iliac region, mild splenomegaly. Discharge to: Home with Home Care/Medical Equiment and/or Supplies
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Differential white blood cell count, Dyspnoea, Fibrin D dimer, Haemoglobin normal, Heart rate increased
Clinical narrative: 90y.o. male with a past medical history of HTN, BPH, Dementia, CLL (Diagnosed 10 years back, never received treatment, followed with Dr per wife) was brought to local Hospital with shortness of breath.  He had runny nose 10 days ago but was doing okay at home.  Initially taken to urgent care where he was advised to watch his oxygen saturation.  His oxygen saturation at home was measured in the mid 80s when he complained about some shortness of breath and high heart rate he was brought to the hospital and was later diagnosed with COVID. We are consulted because of the history of CLL.  CLL was diagnosed roughly 10 years back and he followed with Dr. at the HCF  Never received treatment for CLL was monitored only for his wife. On admission, vitals stable and has been saturating well on 2 L nasal cannula, normal electrolytes, WBC count 31.5, normal hemoglobin, platelet 147.  Differentials showed normal neutrophil, 27.3% lymphocytes.  D-dimer 3970.  CTA chest showed no pulmonary embolism, small right-sided pleural effusion, diastolic and hilar lymphadenopathy.  CT abdomen pelvis showed tensive intra-abdominal and pelvic adenopathy within the retroperitoneum and left common iliac region, mild splenomegaly. Discharge to: Home with Home Care/Medical Equiment and/or Supplies
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Hilar lymphadenopathy, Lymphocyte percentage, Neutrophil percentage, Platelet count decreased, Pleural effusion
Clinical narrative: 90y.o. male with a past medical history of HTN, BPH, Dementia, CLL (Diagnosed 10 years back, never received treatment, followed with Dr per wife) was brought to local Hospital with shortness of breath.  He had runny nose 10 days ago but was doing okay at home.  Initially taken to urgent care where he was advised to watch his oxygen saturation.  His oxygen saturation at home was measured in the mid 80s when he complained about some shortness of breath and high heart rate he was brought to the hospital and was later diagnosed with COVID. We are consulted because of the history of CLL.  CLL was diagnosed roughly 10 years back and he followed with Dr. at the HCF  Never received treatment for CLL was monitored only for his wife. On admission, vitals stable and has been saturating well on 2 L nasal cannula, normal electrolytes, WBC count 31.5, normal hemoglobin, platelet 147.  Differentials showed normal neutrophil, 27.3% lymphocytes.  D-dimer 3970.  CTA chest showed no pulmonary embolism, small right-sided pleural effusion, diastolic and hilar lymphadenopathy.  CT abdomen pelvis showed tensive intra-abdominal and pelvic adenopathy within the retroperitoneum and left common iliac region, mild splenomegaly. Discharge to: Home with Home Care/Medical Equiment and/or Supplies
Age: 88.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Rhinorrhoea, SARS-CoV-2 test positive, Splenomegaly, White blood cell count increased
Clinical narrative: 90y.o. male with a past medical history of HTN, BPH, Dementia, CLL (Diagnosed 10 years back, never received treatment, followed with Dr per wife) was brought to local Hospital with shortness of breath.  He had runny nose 10 days ago but was doing okay at home.  Initially taken to urgent care where he was advised to watch his oxygen saturation.  His oxygen saturation at home was measured in the mid 80s when he complained about some shortness of breath and high heart rate he was brought to the hospital and was later diagnosed with COVID. We are consulted because of the history of CLL.  CLL was diagnosed roughly 10 years back and he followed with Dr. at the HCF  Never received treatment for CLL was monitored only for his wife. On admission, vitals stable and has been saturating well on 2 L nasal cannula, normal electrolytes, WBC count 31.5, normal hemoglobin, platelet 147.  Differentials showed normal neutrophil, 27.3% lymphocytes.  D-dimer 3970.  CTA chest showed no pulmonary embolism, small right-sided pleural effusion, diastolic and hilar lymphadenopathy.  CT abdomen pelvis showed tensive intra-abdominal and pelvic adenopathy within the retroperitoneum and left common iliac region, mild splenomegaly. Discharge to: Home with Home Care/Medical Equiment and/or Supplies
Age: 70.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Asthenia, COVID-19, Compression garment application, Fluid intake reduced, Hyperkalaemia
Clinical narrative: 72y.o. male with orthostatic hypotension presents with generalized weakness from home. He has not been eating or drinking much at home and felt weaker. He was admitted with covid 19 as well. He declined any treatment for covid 19. He remained on room air without respiratory issues. He had hyponatremia and hyperkalemia which improved. He was followed by psychiatry as well as nephrology. He had orthostatic hypotension which improved gradually with midodrine and salt tabs as well ace wraps and cmopression stalkings. Discussed if comprssion stalkings were to tight not to wear. He did have ace bandages used as wraps aslo which helped. Patient is deemed medically stable for discharge
Age: 70.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Hyponatraemia, Hypophagia, Interchange of vaccine products, Orthostatic hypotension, SARS-CoV-2 test positive
Clinical narrative: 72y.o. male with orthostatic hypotension presents with generalized weakness from home. He has not been eating or drinking much at home and felt weaker. He was admitted with covid 19 as well. He declined any treatment for covid 19. He remained on room air without respiratory issues. He had hyponatremia and hyperkalemia which improved. He was followed by psychiatry as well as nephrology. He had orthostatic hypotension which improved gradually with midodrine and salt tabs as well ace wraps and cmopression stalkings. Discussed if comprssion stalkings were to tight not to wear. He did have ace bandages used as wraps aslo which helped. Patient is deemed medically stable for discharge
Age: 91.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, Chills, Cough, Dyspnoea, Fatigue
Clinical narrative: 92 y.o. female with PMHx of CHF, CAD, HTN, hypothyroidism presented to the hospital with 3 days of worsening shortness of breath, fever/chills, myalgias, fatigue, and an intermitted cough. Had not been taking home Lasix since she started feeling sick. She was COVID positive on admission and started on Paxlovid. Shortness of breath improved with IV lasix. She was transitioned back to her home Lasix 40 mg qD. She was somewhat hypotensive during her admission and her carvedilol, lisinopril, spironolactone, IMDUR, prn Nitrostat were held. These will be discontinued at discharge and she will need to follow up with her PCP in 2-3 days to discuss resuming these.
Age: 91.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Hypotension, Malaise, Myalgia, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 92 y.o. female with PMHx of CHF, CAD, HTN, hypothyroidism presented to the hospital with 3 days of worsening shortness of breath, fever/chills, myalgias, fatigue, and an intermitted cough. Had not been taking home Lasix since she started feeling sick. She was COVID positive on admission and started on Paxlovid. Shortness of breath improved with IV lasix. She was transitioned back to her home Lasix 40 mg qD. She was somewhat hypotensive during her admission and her carvedilol, lisinopril, spironolactone, IMDUR, prn Nitrostat were held. These will be discontinued at discharge and she will need to follow up with her PCP in 2-3 days to discuss resuming these.
Age: 47.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Asthenia, COVID-19, Electroencephalogram normal, Electromyogram normal, Feeling abnormal
Clinical narrative: The patient was admitted to the hospital with episodes of weakness, paresthesia, brain fog of unclear etiology, who had unremarkable MRI of the brain, MRI of the C-spine, MRI of the thoracic spine, EMG, EEG, and various laboratory studies. The patient has been followed closely by a HCF for neurologic disorder who suspects a component of functional/psychomotor component in the patient's presentation, but would benefit from an outpatient ambulatory EEG that can be facilitated through outpatient Neurology followup.  The patient does have antibodies for myasthenia gravis that are still pending at time of this dictation, but suspicion is low. The patient continues to have improvement in functional status, who was seen by PT, OT who recommends no outpatient therapy this time secondary to improvement. Case discussed with the patient's sister, advocate and recommend follow up with Neurology and get a tertiary opinion at another HCF.
Age: 47.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Laboratory test normal, Magnetic resonance imaging head normal, Magnetic resonance imaging spinal normal, Nervous system disorder, Paraesthesia
Clinical narrative: The patient was admitted to the hospital with episodes of weakness, paresthesia, brain fog of unclear etiology, who had unremarkable MRI of the brain, MRI of the C-spine, MRI of the thoracic spine, EMG, EEG, and various laboratory studies. The patient has been followed closely by a HCF for neurologic disorder who suspects a component of functional/psychomotor component in the patient's presentation, but would benefit from an outpatient ambulatory EEG that can be facilitated through outpatient Neurology followup.  The patient does have antibodies for myasthenia gravis that are still pending at time of this dictation, but suspicion is low. The patient continues to have improvement in functional status, who was seen by PT, OT who recommends no outpatient therapy this time secondary to improvement. Case discussed with the patient's sister, advocate and recommend follow up with Neurology and get a tertiary opinion at another HCF.
Age: 47.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: The patient was admitted to the hospital with episodes of weakness, paresthesia, brain fog of unclear etiology, who had unremarkable MRI of the brain, MRI of the C-spine, MRI of the thoracic spine, EMG, EEG, and various laboratory studies. The patient has been followed closely by a HCF for neurologic disorder who suspects a component of functional/psychomotor component in the patient's presentation, but would benefit from an outpatient ambulatory EEG that can be facilitated through outpatient Neurology followup.  The patient does have antibodies for myasthenia gravis that are still pending at time of this dictation, but suspicion is low. The patient continues to have improvement in functional status, who was seen by PT, OT who recommends no outpatient therapy this time secondary to improvement. Case discussed with the patient's sister, advocate and recommend follow up with Neurology and get a tertiary opinion at another HCF.
Age: 61.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Abdominal pain, COVID-19, Delirium, Diarrhoea, Imaging procedure abnormal
Clinical narrative: 62y.o. female with history of cerebral palsy who presented on 8/13/2022 with abdominal pain, N/D for 2 days.  Findings on imaging consistent with SBO.  Pt underwent procedure listed above which they tolerated well without complication, see operative report for full details.  Patient recovered well. Hospital course significant for delerium, post op care.  On POD#6, pain controlled, pt tolerating diet, voiding and ambulating independently, ready for discharge to facility.
Age: 61.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Nausea, SARS-CoV-2 test positive, Small intestinal obstruction
Clinical narrative: 62y.o. female with history of cerebral palsy who presented on 8/13/2022 with abdominal pain, N/D for 2 days.  Findings on imaging consistent with SBO.  Pt underwent procedure listed above which they tolerated well without complication, see operative report for full details.  Patient recovered well. Hospital course significant for delerium, post op care.  On POD#6, pain controlled, pt tolerating diet, voiding and ambulating independently, ready for discharge to facility.
Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: ADMINISTERED EXPIRED VACCINE
Age: 69.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Pyrexia, SARS-CoV-2 test positive, Tachycardia
Clinical narrative: Patient was admitted with COVID-19 with fever and tachycardia.  Fever has resolved.  No more tachycardia.  Patient feels well.  Eager to go home.  Discussed with infectious disease.  Okay to discharge him home 8/15.
Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: COVID-19, Chest X-ray abnormal, Hypoxia, SARS-CoV-2 test positive
Clinical narrative: 62y.o. female with a history of CAD, COPD/asthma, and cardiac arrest 3/2022 c/b anoxic brain injury (nonverbal at baseline) and chronic respiratory failure s/p tracheostomy (3L trach collar at home) who presented from ECF 3/14 with hypoxia. She was found to be COVID positive. She was admitted to the medical floor on trach collar but than had increased oxygen requirements requiring transfer to higher level of care. A CXR was obtained that demonstrated concern for left bronchial mucus plug. The patient is known to have a #6 uncuffed Shiley. Overall long term prognosis is poor. Have been seen by palliative care and hospice in the past, however, family had desired in the past to continue with full code.
Age: 78.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Exposure to SARS-CoV-2, Micrographic skin surgery, Nausea, Respiratory tract congestion
Clinical narrative: 80-year-old female presented to the hospital with nausea and congestion.  Patient played dominoes in her apartment complex with some friends a little over a week ago that friend was positive called her over the weekend to let her know she was positive however patient went for her mohs surgery to her left lateral forehead on the eighth.  Patient had mild congestion at that time.  Congestion progressed and Wednesday patient tested herself on the 10th and tested positive for COVID.  Patient states she thought it was all with cold.  She denied any sore throat but she admits to significant head congestion.  Patient came to the emergency room on the 14th.  Patient spoke with her primary received prescription for Paxlovid. Patient states she took the pills on Wednesday she took half the pills on Thursday and then stopped because they made her nauseated.  Patient presented over the weekend.  Initially was placed on oxygen but is currently on room air.  She received hydration in the emergency room and patient is feeling better infectious disease has been asked to comment. ID service does not recommend steroids or antivirals. Patient stable from a cardiac standpoint without plans for any further cardiac work-up/intervention, follow-up with primary cardiologist upon discharge for further treatment.
Age: 78.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: SARS-CoV-2 test positive, Upper respiratory tract congestion
Clinical narrative: 80-year-old female presented to the hospital with nausea and congestion.  Patient played dominoes in her apartment complex with some friends a little over a week ago that friend was positive called her over the weekend to let her know she was positive however patient went for her mohs surgery to her left lateral forehead on the eighth.  Patient had mild congestion at that time.  Congestion progressed and Wednesday patient tested herself on the 10th and tested positive for COVID.  Patient states she thought it was all with cold.  She denied any sore throat but she admits to significant head congestion.  Patient came to the emergency room on the 14th.  Patient spoke with her primary received prescription for Paxlovid. Patient states she took the pills on Wednesday she took half the pills on Thursday and then stopped because they made her nauseated.  Patient presented over the weekend.  Initially was placed on oxygen but is currently on room air.  She received hydration in the emergency room and patient is feeling better infectious disease has been asked to comment. ID service does not recommend steroids or antivirals. Patient stable from a cardiac standpoint without plans for any further cardiac work-up/intervention, follow-up with primary cardiologist upon discharge for further treatment.
Age: 65.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: COVID-19, Confusional state, Cough, Diabetic ketoacidosis, Dyspnoea
Clinical narrative: 66-year-old female brought into the emergency room history of diabetes difficulty with breathing, nausea and vomiting last 2 to 3 days.  Patient a little more awake and alert than on admission.  Patient is still confused about how long she has been in the hospital.  History of camping with their motor home in Park the week of 24 July.  There for 3 to 4 days with her grandchildren.  Apparently one of the grandchildren started to feel ill on the way home 27th 28th.  Patient has been home with some respiratory distress.  Patient was tested at home 8/10 tested positive they called primary care and was given a prescription for Paxlovid. Patient states she took it on the 10th 11th and 12th and on the morning of admission here.  Patient had progressive nausea and vomiting over the last 2 to 3 days.  Patient was noted to require O2 in the ER placed on 2 L with progression over the next 24 hours.  Patient has been evaluated by MICU, currently on 6 to 7 L.  Breathing better.  Patient maintained on the floor.  Infectious diseases been asked to assist.  Patient able to call her husband to verify dates.  Infectious disease has been asked to assist.  Patient has cough shortness of breath does not require home O2 normally. She was found to have COVID and was in DKA. She received dexamethasone 6 mg daily, now complete.
Age: 65.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Intensive care, Nausea, Respiratory distress, SARS-CoV-2 test positive, Vomiting
Clinical narrative: 66-year-old female brought into the emergency room history of diabetes difficulty with breathing, nausea and vomiting last 2 to 3 days.  Patient a little more awake and alert than on admission.  Patient is still confused about how long she has been in the hospital.  History of camping with their motor home in Park the week of 24 July.  There for 3 to 4 days with her grandchildren.  Apparently one of the grandchildren started to feel ill on the way home 27th 28th.  Patient has been home with some respiratory distress.  Patient was tested at home 8/10 tested positive they called primary care and was given a prescription for Paxlovid. Patient states she took it on the 10th 11th and 12th and on the morning of admission here.  Patient had progressive nausea and vomiting over the last 2 to 3 days.  Patient was noted to require O2 in the ER placed on 2 L with progression over the next 24 hours.  Patient has been evaluated by MICU, currently on 6 to 7 L.  Breathing better.  Patient maintained on the floor.  Infectious diseases been asked to assist.  Patient able to call her husband to verify dates.  Infectious disease has been asked to assist.  Patient has cough shortness of breath does not require home O2 normally. She was found to have COVID and was in DKA. She received dexamethasone 6 mg daily, now complete.