chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 42.0
Sex: F
Vaccine: FLU4
Symptoms: No adverse event, Product administered to patient of inappropriate age
Clinical narrative: By accident, a nurse gave this immunization to a 42-year-old female patient with no adverse event; Initial information received on 05-Jan-2024 regarding an unsolicited valid non-serious case received from a nurse.  This case involves a 42 years old female patient to whom by accident, a nurse gave influenza quadrival A-B high dose HV vaccine [Fluzone High-Dose Quadrivalent] for immunization with no adverse event.  The patient's past medical history, medical treatment(s), vaccination(s) and family history were not provided.   On an unknown date, the 42 years old female patient  received 0.7 ml  dose of suspect influenza quadrival A-B high dose HV vaccine (strength, formulation, lot number and expiry date:  not reported) via unknown route in unknown administration site for Immunization with no adverse event (product administered to patient of inappropriate age) (latency: on same day).  Information on the batch number was requested  This suspected adverse reaction report is submitted and classified as a medication error solely and exclusively to ensure the marketing authorization holder's compliance with the requirements set out in the Directive 2001/83/EC and Module VI of the Good Pharmacovigilance Practices. The classification as a medical error is in no way intended, nor should it be interpreted or construed as an allegation or claim made by the marketing authorization holder that any third party has contributed to or is to be held liable for the occurrence of this medication error.
Sex: U
Vaccine: COVID19
Symptoms: Chills, Oropharyngeal pain, Pyrexia
Clinical narrative: sore throat; chills; fever; This spontaneous case was reported by a patient and describes the occurrence of OROPHARYNGEAL PAIN (sore throat), CHILLS (chills) and PYREXIA (fever) in a patient of an unknown age and gender who received mRNA-1273.815 (SPIKEVAX 2023-2024) for COVID-19 prophylaxis.     No Medical History information was reported.    On 04-Jan-2024, the patient received dose of mRNA-1273.815 (SPIKEVAX 2023-2024) (unknown route) 1 dosage form. On 04-Jan-2024, the patient experienced OROPHARYNGEAL PAIN (sore throat), CHILLS (chills) and PYREXIA (fever). At the time of the report, OROPHARYNGEAL PAIN (sore throat), CHILLS (chills) and PYREXIA (fever) had not resolved.        The action taken with mRNA-1273.815 (SPIKEVAX 2023-2024) (Unknown) was unknown.       No concomitant medication was reported. The suspect product dosage text was reported as unknown. No treatment medication was reported.
Age: 70.0
Sex: F
Vaccine: VARZOS
Symptoms: Fatigue, Flushing, Hyperhidrosis, Pain
Clinical narrative: Extreme fatigue, body aches, sweating, flushed face
Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: N./A
Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: N.A
Age: 31.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Computerised tomogram, Decreased activity, Echocardiogram, Electrocardiogram, Fatigue
Clinical narrative: Developed myopericarditis around 8/29/2022. Required time off work, beta blockers, muscle relaxers, nitroglycerin tabs and rest to recover. Flare up of return of symptoms on 04/2023. Rest, nitro, IVF, blood thinner/ACS precautions. Patient clinically stable but with some lasting effects noticed such as fatigue, decreased activity tolerance as previous to diagnosis.
Age: 31.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Impaired work ability, Laboratory test, Myopericarditis, Scan
Clinical narrative: Developed myopericarditis around 8/29/2022. Required time off work, beta blockers, muscle relaxers, nitroglycerin tabs and rest to recover. Flare up of return of symptoms on 04/2023. Rest, nitro, IVF, blood thinner/ACS precautions. Patient clinically stable but with some lasting effects noticed such as fatigue, decreased activity tolerance as previous to diagnosis.
Age: 2.0
Sex: M
Vaccine: FLU4
Symptoms: Erythema, Otitis media, Swelling, Viral infection
Clinical narrative: 20 hrs after vaccine area was slightly swollen, red approximately 4 x 2.5" diameter Pt also had runny nose at time of vaccine At exam pt had left otitis media and viral illness
Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Dyspnoea
Clinical narrative: Patient felt dizziness and a little hard to breath for about 10 minutes. Patient removed mask and felt better.
Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Confusional state, Impaired driving ability, Transient acantholytic dermatosis
Clinical narrative: Grovers Disease; confusion with memory of past and present events; achey joints most noteable with trying to go to sleep; frequent short term confusion when driving my car.
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: None stated.
Age: 53.0
Sex: M
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: None stated.
Age: 51.0
Sex: F
Vaccine: VARZOS
Symptoms: Abdominal discomfort, Dizziness, Gait disturbance, Impaired driving ability
Clinical narrative: Dizziness, causing vague stomach upset and difficulty walking/driving
Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Expired product administered
Clinical narrative: None stated.
Age: 52.0
Sex: M
Vaccine: TD
Symptoms: Arthralgia, Fatigue, Headache, Inflammatory marker increased, Mobility decreased
Clinical narrative: Pain in muscles and joints, soar throat, fatigue, swelling and headache.  Difficulty moving around.  Difficulty moving arms, shoulders and knees. Pain in bottoms of both feet. Trouble with grip and grasping objects.
Age: 52.0
Sex: M
Vaccine: TD
Symptoms: Muscular weakness, Myalgia, Oropharyngeal pain, Pain in extremity, Rheumatoid arthritis
Clinical narrative: Pain in muscles and joints, soar throat, fatigue, swelling and headache.  Difficulty moving around.  Difficulty moving arms, shoulders and knees. Pain in bottoms of both feet. Trouble with grip and grasping objects.
Age: 52.0
Sex: M
Vaccine: TD
Symptoms: Swelling
Clinical narrative: Pain in muscles and joints, soar throat, fatigue, swelling and headache.  Difficulty moving around.  Difficulty moving arms, shoulders and knees. Pain in bottoms of both feet. Trouble with grip and grasping objects.
Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Anaemia, COVID-19, Fall, Haemoglobin normal, Melaena
Clinical narrative: Admit date: 12/23/2023  Discharge date: 1/2/2024    Attending Physician at the Time of Discharge: No att. providers found   Reason for Admission: ground level fall, anemia  Brief Summary of Hospital Stay: Patient is an 88-year-old male with a past medical history significant for coronary artery disease, atrial flutter, hypertension, hyperlipidemia, diabetes, heart failure reduced ejection fraction and BPH.  He presented to the emergency department due to a ground level fall and melena.  Patient was seen by General surgery team and had an EGD performed which showed esophageal ulcer with stigmata of recent bleeding.  He was started on 2 times a day PPI.  Eliquis therapy was discussed with the patient and family and they decided to stop this at this time due to his recent bleed.  His symptoms continued to improve over the course of his stay.  He was seen by PT/OT who recommended subacute rehab.  Hemoglobin remained stable and he was having brown bowel movements at time of discharge.  His stay was complicated by COVID infection and need to be out of quarantine prior to placement in rehab.  Patient will be discharged on a 2 times a day PPI with instructions to follow up with General surgery as well as his PCP.  I also ordered a complete blood count for next week to monitor his hemoglobin.  He was doing well on day of discharge, all questions were answered, patient transferred to rehab facility.
Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Oesophageal ulcer haemorrhage, Oesophagogastroduodenoscopy abnormal
Clinical narrative: Admit date: 12/23/2023  Discharge date: 1/2/2024    Attending Physician at the Time of Discharge: No att. providers found   Reason for Admission: ground level fall, anemia  Brief Summary of Hospital Stay: Patient is an 88-year-old male with a past medical history significant for coronary artery disease, atrial flutter, hypertension, hyperlipidemia, diabetes, heart failure reduced ejection fraction and BPH.  He presented to the emergency department due to a ground level fall and melena.  Patient was seen by General surgery team and had an EGD performed which showed esophageal ulcer with stigmata of recent bleeding.  He was started on 2 times a day PPI.  Eliquis therapy was discussed with the patient and family and they decided to stop this at this time due to his recent bleed.  His symptoms continued to improve over the course of his stay.  He was seen by PT/OT who recommended subacute rehab.  Hemoglobin remained stable and he was having brown bowel movements at time of discharge.  His stay was complicated by COVID infection and need to be out of quarantine prior to placement in rehab.  Patient will be discharged on a 2 times a day PPI with instructions to follow up with General surgery as well as his PCP.  I also ordered a complete blood count for next week to monitor his hemoglobin.  He was doing well on day of discharge, all questions were answered, patient transferred to rehab facility.
Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, COVID-19, Echocardiogram abnormal, Ejection fraction decreased, Orthostatic hypotension
Clinical narrative: Admit date: 12/27/2023  Discharge date: 01/03/24  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: NP  Reason for Admission: weakness  Hospital Course:  66 YO male with h/o CAD s/p CABG with subsequent PCI, PVD s/p multiple revascularization procedures, and ischemic cardiomyopathy recent admission from 12/4-7 for generalized weakness secondary to COVID reviewed admitted on 12/27 for generalized weakness and presyncopal event.  Presyncope due to orthostatic hypotension.  Echo showing somewhat decreased EF 25-30% from previous and Cardiology consulted and have started patient on Entresto .Patient developed fever and he was found to have a urinary tract infection.  He was treated with 2 days of ceftriaxone and will be discharged on Keflex. Discharged to SNF
Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Presyncope, Pyrexia, Urinary tract infection
Clinical narrative: Admit date: 12/27/2023  Discharge date: 01/03/24  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: NP  Reason for Admission: weakness  Hospital Course:  66 YO male with h/o CAD s/p CABG with subsequent PCI, PVD s/p multiple revascularization procedures, and ischemic cardiomyopathy recent admission from 12/4-7 for generalized weakness secondary to COVID reviewed admitted on 12/27 for generalized weakness and presyncopal event.  Presyncope due to orthostatic hypotension.  Echo showing somewhat decreased EF 25-30% from previous and Cardiology consulted and have started patient on Entresto .Patient developed fever and he was found to have a urinary tract infection.  He was treated with 2 days of ceftriaxone and will be discharged on Keflex. Discharged to SNF
Age: 51.0
Sex: M
Vaccine: VARZOS
Symptoms: Abdominal discomfort, Fatigue, Impaired work ability, Pain, Peripheral swelling
Clinical narrative: Arm was fine, within, 24 hours of shot 2 on Sat., , I developed stomach upset Sunday, then headaches on Monday, severe fatigue body ache on Tues accompanied by raised red blotches of skin on upper left thigh , diamond shaped. these blotches were slightly itchy, and skin was red... by weds am they are subsiding. feeling better by weds am
Age: 51.0
Sex: M
Vaccine: VARZOS
Symptoms: Rash macular, Rash pruritic
Clinical narrative: Arm was fine, within, 24 hours of shot 2 on Sat., , I developed stomach upset Sunday, then headaches on Monday, severe fatigue body ache on Tues accompanied by raised red blotches of skin on upper left thigh , diamond shaped. these blotches were slightly itchy, and skin was red... by weds am they are subsiding. feeling better by weds am
Age: 76.0
Sex: F
Vaccine: COVID19, PNC20, RSV
Symptoms: Back pain, Cough, Dyspnoea, Feeling hot, Feeling of body temperature change
Clinical narrative: She got her vaccines, her arm started hurting, the left arm.  She did not have any problem with the right arm, the RSV did not seem to have problems.  She felt sick, went to bed about 7:30 and did not sleep one wink, every single muscle in her body was just horrible, she could not lie still, could not stay in the same position more than a minute, tossed and turned all night long, and could not stand any part of her body all night long.  She had a slight headache, but could be due to starving as she had not had any food.  She also coughed all night long, really raspy type of cough, every time she moved she coughed.  All day yesterday she was like that all day.  She then started getting menopause symptoms of hot/cold.  Today everything went to her lower back, pain and her breathing is short little breaths at a time, but she feels like she is not breathing like she is supposed to be.  She was not able to get up to make her anything to eat, but ate a scrambled egg and had some quiche today.  She has not taken her temperature, but was pretty hot yesterday, but she is better today as far as that.    She is sweating a bunch and then that goes away and then she gets cold.  She has not gone to an UC or anything.    She had the Pfizer vaccines with the first two and had friends who had Moderna who had AE to that and questioned them about taking the Moderna vaccine and they informed you that it was fine to take the Moderna on top of the Pfizer, this is what pharmacist told her.  Pharmacy does not Pfizer shots anymore, they only have Moderna.  Her sister says that she has texted her a few times and normally answers the texts right away and asked her sister (three way conversation) if she had heart them and had hearing problems, and she affirmed it was not her hearing.  She is having trouble sleeping and did not sleep last night after midnight.  She just feels like she had a very bad flu.  The muscle pain is getting better some, and all the tenderness seems to go to her lower back, but is still not feeling well.  The arm is still a little sore, but improving.
Age: 76.0
Sex: F
Vaccine: COVID19, PNC20, RSV
Symptoms: Headache, Hyperhidrosis, Influenza like illness, Malaise, Mobility decreased
Clinical narrative: She got her vaccines, her arm started hurting, the left arm.  She did not have any problem with the right arm, the RSV did not seem to have problems.  She felt sick, went to bed about 7:30 and did not sleep one wink, every single muscle in her body was just horrible, she could not lie still, could not stay in the same position more than a minute, tossed and turned all night long, and could not stand any part of her body all night long.  She had a slight headache, but could be due to starving as she had not had any food.  She also coughed all night long, really raspy type of cough, every time she moved she coughed.  All day yesterday she was like that all day.  She then started getting menopause symptoms of hot/cold.  Today everything went to her lower back, pain and her breathing is short little breaths at a time, but she feels like she is not breathing like she is supposed to be.  She was not able to get up to make her anything to eat, but ate a scrambled egg and had some quiche today.  She has not taken her temperature, but was pretty hot yesterday, but she is better today as far as that.    She is sweating a bunch and then that goes away and then she gets cold.  She has not gone to an UC or anything.    She had the Pfizer vaccines with the first two and had friends who had Moderna who had AE to that and questioned them about taking the Moderna vaccine and they informed you that it was fine to take the Moderna on top of the Pfizer, this is what pharmacist told her.  Pharmacy does not Pfizer shots anymore, they only have Moderna.  Her sister says that she has texted her a few times and normally answers the texts right away and asked her sister (three way conversation) if she had heart them and had hearing problems, and she affirmed it was not her hearing.  She is having trouble sleeping and did not sleep last night after midnight.  She just feels like she had a very bad flu.  The muscle pain is getting better some, and all the tenderness seems to go to her lower back, but is still not feeling well.  The arm is still a little sore, but improving.
Age: 76.0
Sex: F
Vaccine: COVID19, PNC20, RSV
Symptoms: Myalgia, Pain in extremity, Sleep disorder, Tenderness
Clinical narrative: She got her vaccines, her arm started hurting, the left arm.  She did not have any problem with the right arm, the RSV did not seem to have problems.  She felt sick, went to bed about 7:30 and did not sleep one wink, every single muscle in her body was just horrible, she could not lie still, could not stay in the same position more than a minute, tossed and turned all night long, and could not stand any part of her body all night long.  She had a slight headache, but could be due to starving as she had not had any food.  She also coughed all night long, really raspy type of cough, every time she moved she coughed.  All day yesterday she was like that all day.  She then started getting menopause symptoms of hot/cold.  Today everything went to her lower back, pain and her breathing is short little breaths at a time, but she feels like she is not breathing like she is supposed to be.  She was not able to get up to make her anything to eat, but ate a scrambled egg and had some quiche today.  She has not taken her temperature, but was pretty hot yesterday, but she is better today as far as that.    She is sweating a bunch and then that goes away and then she gets cold.  She has not gone to an UC or anything.    She had the Pfizer vaccines with the first two and had friends who had Moderna who had AE to that and questioned them about taking the Moderna vaccine and they informed you that it was fine to take the Moderna on top of the Pfizer, this is what pharmacist told her.  Pharmacy does not Pfizer shots anymore, they only have Moderna.  Her sister says that she has texted her a few times and normally answers the texts right away and asked her sister (three way conversation) if she had heart them and had hearing problems, and she affirmed it was not her hearing.  She is having trouble sleeping and did not sleep last night after midnight.  She just feels like she had a very bad flu.  The muscle pain is getting better some, and all the tenderness seems to go to her lower back, but is still not feeling well.  The arm is still a little sore, but improving.
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Angina pectoris, Arteriosclerosis coronary artery, Benign prostatic hyperplasia, Bradycardia, COVID-19
Clinical narrative: Admit date: 12/23/2023  Discharge date: 1/3/2024   Admitting Physician:  MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician:  NP,   Reason for Admission: COVID infection.   Brief Summary of Hospital Stay:Patient a background of Vascular dementia without behavioral disturbance was demonstrating increased confusion.  This appeared to be an Encephalopathy due to COVID-19 virus as he was positive for a  COVID-19 virus infection and had signs of Sepsis.  He also has evidence of hypoxia so was started on DECADRON and REMDESIVIR.  Likely due to the latter her briefly had Elevated liver enzymes which are improving following discontinuation of the medicine.  No longer hypoxic.   Actively Managed Problems:Coronary artery disease involving native coronary artery of native heart with angina pectoris (Previous CABG, subsequent drug eluting stent to RCA 2019) no chest pain, on ASPIRIN.   Type 2 diabetes mellitus without complication, without long-term current use of insulin HbA1c of 5.7 on METFORMIN.   Essential hypertension, benign On LISINOPRIL and METOPROLOL the latter held briefly due to bradycardia that could have been due to REMDESIVIR.   Benign prostatic hyperplasia with urinary hesitancy   FINASTERIDE, TAMSULOSIN.  Dyslipidemia ATORVASTATIN  Depression SERTRALINE History of B12 deficiency Continue replacement Issues Requiring Follow Up: None.   Discharged to Skilled Nursing Facility
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Confusional state, Depression, Dyslipidaemia, Encephalopathy, Essential hypertension
Clinical narrative: Admit date: 12/23/2023  Discharge date: 1/3/2024   Admitting Physician:  MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician:  NP,   Reason for Admission: COVID infection.   Brief Summary of Hospital Stay:Patient a background of Vascular dementia without behavioral disturbance was demonstrating increased confusion.  This appeared to be an Encephalopathy due to COVID-19 virus as he was positive for a  COVID-19 virus infection and had signs of Sepsis.  He also has evidence of hypoxia so was started on DECADRON and REMDESIVIR.  Likely due to the latter her briefly had Elevated liver enzymes which are improving following discontinuation of the medicine.  No longer hypoxic.   Actively Managed Problems:Coronary artery disease involving native coronary artery of native heart with angina pectoris (Previous CABG, subsequent drug eluting stent to RCA 2019) no chest pain, on ASPIRIN.   Type 2 diabetes mellitus without complication, without long-term current use of insulin HbA1c of 5.7 on METFORMIN.   Essential hypertension, benign On LISINOPRIL and METOPROLOL the latter held briefly due to bradycardia that could have been due to REMDESIVIR.   Benign prostatic hyperplasia with urinary hesitancy   FINASTERIDE, TAMSULOSIN.  Dyslipidemia ATORVASTATIN  Depression SERTRALINE History of B12 deficiency Continue replacement Issues Requiring Follow Up: None.   Discharged to Skilled Nursing Facility
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Glycosylated haemoglobin normal, Hepatic enzyme increased, Hypoxia, SARS-CoV-2 test positive, Sepsis
Clinical narrative: Admit date: 12/23/2023  Discharge date: 1/3/2024   Admitting Physician:  MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician:  NP,   Reason for Admission: COVID infection.   Brief Summary of Hospital Stay:Patient a background of Vascular dementia without behavioral disturbance was demonstrating increased confusion.  This appeared to be an Encephalopathy due to COVID-19 virus as he was positive for a  COVID-19 virus infection and had signs of Sepsis.  He also has evidence of hypoxia so was started on DECADRON and REMDESIVIR.  Likely due to the latter her briefly had Elevated liver enzymes which are improving following discontinuation of the medicine.  No longer hypoxic.   Actively Managed Problems:Coronary artery disease involving native coronary artery of native heart with angina pectoris (Previous CABG, subsequent drug eluting stent to RCA 2019) no chest pain, on ASPIRIN.   Type 2 diabetes mellitus without complication, without long-term current use of insulin HbA1c of 5.7 on METFORMIN.   Essential hypertension, benign On LISINOPRIL and METOPROLOL the latter held briefly due to bradycardia that could have been due to REMDESIVIR.   Benign prostatic hyperplasia with urinary hesitancy   FINASTERIDE, TAMSULOSIN.  Dyslipidemia ATORVASTATIN  Depression SERTRALINE History of B12 deficiency Continue replacement Issues Requiring Follow Up: None.   Discharged to Skilled Nursing Facility
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Type 2 diabetes mellitus, Urinary hesitation
Clinical narrative: Admit date: 12/23/2023  Discharge date: 1/3/2024   Admitting Physician:  MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician:  NP,   Reason for Admission: COVID infection.   Brief Summary of Hospital Stay:Patient a background of Vascular dementia without behavioral disturbance was demonstrating increased confusion.  This appeared to be an Encephalopathy due to COVID-19 virus as he was positive for a  COVID-19 virus infection and had signs of Sepsis.  He also has evidence of hypoxia so was started on DECADRON and REMDESIVIR.  Likely due to the latter her briefly had Elevated liver enzymes which are improving following discontinuation of the medicine.  No longer hypoxic.   Actively Managed Problems:Coronary artery disease involving native coronary artery of native heart with angina pectoris (Previous CABG, subsequent drug eluting stent to RCA 2019) no chest pain, on ASPIRIN.   Type 2 diabetes mellitus without complication, without long-term current use of insulin HbA1c of 5.7 on METFORMIN.   Essential hypertension, benign On LISINOPRIL and METOPROLOL the latter held briefly due to bradycardia that could have been due to REMDESIVIR.   Benign prostatic hyperplasia with urinary hesitancy   FINASTERIDE, TAMSULOSIN.  Dyslipidemia ATORVASTATIN  Depression SERTRALINE History of B12 deficiency Continue replacement Issues Requiring Follow Up: None.   Discharged to Skilled Nursing Facility
Age: 94.0
Sex: M
Vaccine: COVID19-2
Symptoms: Asthenia, COVID-19, Dyspnoea, Fatigue, SARS-CoV-2 test positive
Clinical narrative: Admit date: 12/29/2023  Discharge date: 1/3/2024  Admitting Physician: DO   Attending Physician at the Time of Discharge: DO  Primary Care Physician: PA   Reason for Admission: SOB, generalized fatigue 2/2 COVID  Brief Summary of Hospital Stay:  Patient was admitted on 12/29/2023 with symptoms of shortness for breath, generalized weakness found to be COVID.  Relevant medical history of CKD3, acquired hypothyroidism, first-degree AV, hypertension, hyperlipidemia, gout.  On admission patient was stable.  He has not required any oxygenation throughout hospital visit despite positive COVID test.  There was no SIRS criteria met.  He did not develops fever, leukocytosis.  Symptomatic management was sufficient.  Patient remained generally weak, fatigued. PMnR was consulted and recommended inpatient rehab for strength and weakness.  Patient was discharged in stable condition to IPR
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Dyspnoea, Hypoxia, Influenza, Influenza virus test positive
Clinical narrative: Admit date: 12/31/2023  Discharge date: 1/4/2024   Attending Physician at the Time of Discharge: No att. providers found   Reason for Admission: Hypoxia with COVID and influenza  Brief Summary of Hospital Stay: Patient is a 75 y/o female with a past medical history significant for emphysema, pulmonary HTN, HLD, HTN, adrenal adenoma and CVA who presented to the ED on 12/31/23 due to worsening shortness of breath. She was found to be COVID and influenza positive. She was started on antibiotics, steroids, tamiflu and remdesivir. She did require oxygen therapy during her stay but was weaned off by time of discharge. O2 walk test was performed and patient did well on room air. She was doing well on day of discharge and wanted to go home. She will complete antibiotics, steroids and tamiflu outpatient. She will follow up with her PCP as well as pulmonology. All questions were answered and she was given strict return precautions to which she verbalized understanding.  Discharged to home
Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Walking distance test normal
Clinical narrative: Admit date: 12/31/2023  Discharge date: 1/4/2024   Attending Physician at the Time of Discharge: No att. providers found   Reason for Admission: Hypoxia with COVID and influenza  Brief Summary of Hospital Stay: Patient is a 75 y/o female with a past medical history significant for emphysema, pulmonary HTN, HLD, HTN, adrenal adenoma and CVA who presented to the ED on 12/31/23 due to worsening shortness of breath. She was found to be COVID and influenza positive. She was started on antibiotics, steroids, tamiflu and remdesivir. She did require oxygen therapy during her stay but was weaned off by time of discharge. O2 walk test was performed and patient did well on room air. She was doing well on day of discharge and wanted to go home. She will complete antibiotics, steroids and tamiflu outpatient. She will follow up with her PCP as well as pulmonology. All questions were answered and she was given strict return precautions to which she verbalized understanding.  Discharged to home
Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Breakthrough COVID-19
Clinical narrative: Covid-19 breakthrough Infection
Age: 96.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Atrial fibrillation, Blood sodium decreased, COVID-19, Hyponatraemia
Clinical narrative: Admit date: 12/29/2023  Discharge date: 1/4/2024   Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD  Reason for Admission: COVID  Brief Summary of Hospital Stay: Patient presented with Acute hypoxic respiratory failure which appears to be due to an COVID-19 virus infection.  Patient was only briefly hypoxic but was started on DECADRON with short course planned due to rapid resolution of hypoxia.    Active Problems: Hyponatremia  patient was receiving fluids but sodium was declining and they were stopped. Slow improvement added sodium chloride tablets and sodium came up to 134, discontinued tablets,.   Chronic atrial fibrillation ON APIXABAN Issues Requiring Follow Up:None.  Discharged to SNF
Age: 96.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoxia
Clinical narrative: Admit date: 12/29/2023  Discharge date: 1/4/2024   Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD  Reason for Admission: COVID  Brief Summary of Hospital Stay: Patient presented with Acute hypoxic respiratory failure which appears to be due to an COVID-19 virus infection.  Patient was only briefly hypoxic but was started on DECADRON with short course planned due to rapid resolution of hypoxia.    Active Problems: Hyponatremia  patient was receiving fluids but sodium was declining and they were stopped. Slow improvement added sodium chloride tablets and sodium came up to 134, discontinued tablets,.   Chronic atrial fibrillation ON APIXABAN Issues Requiring Follow Up:None.  Discharged to SNF
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Asthenia, Bacterial test positive, Blood creatinine increased, Blood osmolarity decreased
Clinical narrative: Admit date: 1/2/2024  Discharge date: 01/05/24  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD  Reason for Admission: weakness  Hospital Course: 76 y/o with hypertension, dysthymia and history of anal cancer s/p resection, chemo and radiation presents to the emergency department her abnormal labs.  Patient had labs performed today by her primary care physician the sodium of 118.  Otherwise, patient endorses generalized weakness with a nonproductive cough that started 12-29.  Patient endorses poor oral intake since then, no particular inciting event or alleviating or aggravating factors. Denies fevers, recently weight loss, worsening shortness of breath, dysuria or abdominal pain.             Upon presentation in the emergency department, patient was hemodynamically stable.  Repeat labs remarkable for a sodium of 115, serum osmolality of 248, urine osmolality 356.  Serum creatinine of 1.5 which is near baseline, urinalysis revealing many bacteria, nitrite positive.  Intensive care unit admission was requested due to her sodium levels. These issues were addressed while in the hospital.  1. Severe hyponatremia:  Patient was admitted to intensive care unit initially with sodium of 118.  Acute hyponatremia suspect 2/2 poor oral intake in the setting of chronic diuretic use.  Adjusted IV fluids.    She was initiated on sodium tablets 2 times a day.  Her latest sodium was 131.  She will be discharged on salt bath and hydrochlorothiazide will be stopped.  Recommended follow-up PCP in 1 week to check on electrolytes    2.COVID-19 (+): Patient endorses intermittent, non-productive cough. Remains on room air. 3.Dysthmia: Continue home diazepam as needed - Started nightly Remeron given complaint of headache, poor appetite, anxious mood and history of dysthymia  4.Essential hypertension:Holding home Hyzaar in setting of hyponatremia.  Started losartan  5. Urinary tract infection :  Treated with antibiotics for 3 days   6. Stage 3 CKD: avoid nephrotoxic agents  Blood pressure 130/82, pulse 63, temperature 36.5 °C (97.7 °F), temperature source Oral, resp. rate 18, height 1.575 m (5' 2.01"), weight 45.9 kg (101 lb 3.1 oz), SpO2 97%. Ears: hearing is intact Eyes: Icterus is not present Lungs: Breathing is not labored, is not using accessory muscles Heart: rate is regular, edema is not noted. Skin:  No new rash Neurological: No New Focal Deficits, speech is fluent Psychiatric:  Mood is stable  Issues Requiring Follow Up: (Who, what, when, and how communicated?)   Follow-up with PCP in 1 week to check electrolytes Discharged to home.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Blood sodium decreased, COVID-19, Cough, Decreased appetite, Diuretic therapy
Clinical narrative: Admit date: 1/2/2024  Discharge date: 01/05/24  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD  Reason for Admission: weakness  Hospital Course: 76 y/o with hypertension, dysthymia and history of anal cancer s/p resection, chemo and radiation presents to the emergency department her abnormal labs.  Patient had labs performed today by her primary care physician the sodium of 118.  Otherwise, patient endorses generalized weakness with a nonproductive cough that started 12-29.  Patient endorses poor oral intake since then, no particular inciting event or alleviating or aggravating factors. Denies fevers, recently weight loss, worsening shortness of breath, dysuria or abdominal pain.             Upon presentation in the emergency department, patient was hemodynamically stable.  Repeat labs remarkable for a sodium of 115, serum osmolality of 248, urine osmolality 356.  Serum creatinine of 1.5 which is near baseline, urinalysis revealing many bacteria, nitrite positive.  Intensive care unit admission was requested due to her sodium levels. These issues were addressed while in the hospital.  1. Severe hyponatremia:  Patient was admitted to intensive care unit initially with sodium of 118.  Acute hyponatremia suspect 2/2 poor oral intake in the setting of chronic diuretic use.  Adjusted IV fluids.    She was initiated on sodium tablets 2 times a day.  Her latest sodium was 131.  She will be discharged on salt bath and hydrochlorothiazide will be stopped.  Recommended follow-up PCP in 1 week to check on electrolytes    2.COVID-19 (+): Patient endorses intermittent, non-productive cough. Remains on room air. 3.Dysthmia: Continue home diazepam as needed - Started nightly Remeron given complaint of headache, poor appetite, anxious mood and history of dysthymia  4.Essential hypertension:Holding home Hyzaar in setting of hyponatremia.  Started losartan  5. Urinary tract infection :  Treated with antibiotics for 3 days   6. Stage 3 CKD: avoid nephrotoxic agents  Blood pressure 130/82, pulse 63, temperature 36.5 °C (97.7 °F), temperature source Oral, resp. rate 18, height 1.575 m (5' 2.01"), weight 45.9 kg (101 lb 3.1 oz), SpO2 97%. Ears: hearing is intact Eyes: Icterus is not present Lungs: Breathing is not labored, is not using accessory muscles Heart: rate is regular, edema is not noted. Skin:  No new rash Neurological: No New Focal Deficits, speech is fluent Psychiatric:  Mood is stable  Issues Requiring Follow Up: (Who, what, when, and how communicated?)   Follow-up with PCP in 1 week to check electrolytes Discharged to home.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Hyponatraemia, Hypophagia, Intensive care, Nitrite urine present
Clinical narrative: Admit date: 1/2/2024  Discharge date: 01/05/24  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD  Reason for Admission: weakness  Hospital Course: 76 y/o with hypertension, dysthymia and history of anal cancer s/p resection, chemo and radiation presents to the emergency department her abnormal labs.  Patient had labs performed today by her primary care physician the sodium of 118.  Otherwise, patient endorses generalized weakness with a nonproductive cough that started 12-29.  Patient endorses poor oral intake since then, no particular inciting event or alleviating or aggravating factors. Denies fevers, recently weight loss, worsening shortness of breath, dysuria or abdominal pain.             Upon presentation in the emergency department, patient was hemodynamically stable.  Repeat labs remarkable for a sodium of 115, serum osmolality of 248, urine osmolality 356.  Serum creatinine of 1.5 which is near baseline, urinalysis revealing many bacteria, nitrite positive.  Intensive care unit admission was requested due to her sodium levels. These issues were addressed while in the hospital.  1. Severe hyponatremia:  Patient was admitted to intensive care unit initially with sodium of 118.  Acute hyponatremia suspect 2/2 poor oral intake in the setting of chronic diuretic use.  Adjusted IV fluids.    She was initiated on sodium tablets 2 times a day.  Her latest sodium was 131.  She will be discharged on salt bath and hydrochlorothiazide will be stopped.  Recommended follow-up PCP in 1 week to check on electrolytes    2.COVID-19 (+): Patient endorses intermittent, non-productive cough. Remains on room air. 3.Dysthmia: Continue home diazepam as needed - Started nightly Remeron given complaint of headache, poor appetite, anxious mood and history of dysthymia  4.Essential hypertension:Holding home Hyzaar in setting of hyponatremia.  Started losartan  5. Urinary tract infection :  Treated with antibiotics for 3 days   6. Stage 3 CKD: avoid nephrotoxic agents  Blood pressure 130/82, pulse 63, temperature 36.5 °C (97.7 °F), temperature source Oral, resp. rate 18, height 1.575 m (5' 2.01"), weight 45.9 kg (101 lb 3.1 oz), SpO2 97%. Ears: hearing is intact Eyes: Icterus is not present Lungs: Breathing is not labored, is not using accessory muscles Heart: rate is regular, edema is not noted. Skin:  No new rash Neurological: No New Focal Deficits, speech is fluent Psychiatric:  Mood is stable  Issues Requiring Follow Up: (Who, what, when, and how communicated?)   Follow-up with PCP in 1 week to check electrolytes Discharged to home.
Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Urinary tract infection, Urine analysis abnormal, Urine osmolarity
Clinical narrative: Admit date: 1/2/2024  Discharge date: 01/05/24  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD  Reason for Admission: weakness  Hospital Course: 76 y/o with hypertension, dysthymia and history of anal cancer s/p resection, chemo and radiation presents to the emergency department her abnormal labs.  Patient had labs performed today by her primary care physician the sodium of 118.  Otherwise, patient endorses generalized weakness with a nonproductive cough that started 12-29.  Patient endorses poor oral intake since then, no particular inciting event or alleviating or aggravating factors. Denies fevers, recently weight loss, worsening shortness of breath, dysuria or abdominal pain.             Upon presentation in the emergency department, patient was hemodynamically stable.  Repeat labs remarkable for a sodium of 115, serum osmolality of 248, urine osmolality 356.  Serum creatinine of 1.5 which is near baseline, urinalysis revealing many bacteria, nitrite positive.  Intensive care unit admission was requested due to her sodium levels. These issues were addressed while in the hospital.  1. Severe hyponatremia:  Patient was admitted to intensive care unit initially with sodium of 118.  Acute hyponatremia suspect 2/2 poor oral intake in the setting of chronic diuretic use.  Adjusted IV fluids.    She was initiated on sodium tablets 2 times a day.  Her latest sodium was 131.  She will be discharged on salt bath and hydrochlorothiazide will be stopped.  Recommended follow-up PCP in 1 week to check on electrolytes    2.COVID-19 (+): Patient endorses intermittent, non-productive cough. Remains on room air. 3.Dysthmia: Continue home diazepam as needed - Started nightly Remeron given complaint of headache, poor appetite, anxious mood and history of dysthymia  4.Essential hypertension:Holding home Hyzaar in setting of hyponatremia.  Started losartan  5. Urinary tract infection :  Treated with antibiotics for 3 days   6. Stage 3 CKD: avoid nephrotoxic agents  Blood pressure 130/82, pulse 63, temperature 36.5 °C (97.7 °F), temperature source Oral, resp. rate 18, height 1.575 m (5' 2.01"), weight 45.9 kg (101 lb 3.1 oz), SpO2 97%. Ears: hearing is intact Eyes: Icterus is not present Lungs: Breathing is not labored, is not using accessory muscles Heart: rate is regular, edema is not noted. Skin:  No new rash Neurological: No New Focal Deficits, speech is fluent Psychiatric:  Mood is stable  Issues Requiring Follow Up: (Who, what, when, and how communicated?)   Follow-up with PCP in 1 week to check electrolytes Discharged to home.
Age: 37.0
Sex: F
Vaccine: COVID19
Symptoms: Breakthrough COVID-19
Clinical narrative: Covid-19 Breakthrough Infection
Age: 84.0
Sex: F
Vaccine: COVID19-2
Symptoms: Acute respiratory failure, Dysphagia, Facial paresis, Gastrostomy, Hemiparesis
Clinical narrative: Admit date: 12/15/2023  Discharge date: 1/5/2024     Reason for Admission: right MCA stroke  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 85 YO female presented with acute left-sided weakness (face, arm, leg paralysis).  Admitted with right MCA stroke.  Neurology consulted.  With severe dysphagia, Surgery consulted for PEG, placed 12/29.  Patient developed acute hypoxic respiratory failure due to aspiration pneumonia, completed antibiotics and now stable on room air.  Discharging to facility for further therapy.
Age: 84.0
Sex: F
Vaccine: COVID19-2
Symptoms: Middle cerebral artery stroke, Monoplegia, Muscular weakness, Pneumonia aspiration
Clinical narrative: Admit date: 12/15/2023  Discharge date: 1/5/2024     Reason for Admission: right MCA stroke  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures) 85 YO female presented with acute left-sided weakness (face, arm, leg paralysis).  Admitted with right MCA stroke.  Neurology consulted.  With severe dysphagia, Surgery consulted for PEG, placed 12/29.  Patient developed acute hypoxic respiratory failure due to aspiration pneumonia, completed antibiotics and now stable on room air.  Discharging to facility for further therapy.
Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Aspiration pleural cavity, Blood culture positive, Blood lactate dehydrogenase increased, COVID-19, Computerised tomogram thorax abnormal
Clinical narrative: Admit date: 12/31/2023  Discharge date: 1/5/2024   Admitting Physician: DO   Attending Physician at the Time of Discharge: DO  Primary Care Physician: MD  Hospital Course: 81 YO female with medical history notable for   Advanced Alzheimer,  recent COVID infection, poor oral intake, failure to thrive, impaired mobility, hypothyroidism, normocytic anemia who presented to Hospital for   Increasing shortness of breath and cough as well as decreased responsiveness.  Patient had COVID-19 infection roughly around November, patient's symptoms initially improving, however gradually worsening before admission.  Patient was nonsmoker largely bed-bound. Per son, patient has a small decubitus rash and now enlarging.  Patient is nonverbal at baseline, able to respond to pain.  On admission, patient afebrile, hemodynamically stable, in room air.  Lab shows leukocytosis with neutrophil predominant. CT pulmonary, results shows  Pulmonary emboli in the segmental branches to the right upper lobe. Borderline right heart strain. Heterogenous consolidation in the left lower lobe with multiple low-attenuation areas suspicious for underlying infiltrative mass or areas of liquefaction. Moderate partially loculated left pleural effusion insinuating in the left fissure. Mild mediastinal lymphadenopathy. RVP return COVID positive, patient was blood culture later returns Staphylococcus hominis/ epidermidis 2/2.  Patient also found urine culture shows E coli and Enterococcus faecalis. Patient was placed on Unasyn and vancomycin since then  Concerning necrotizing pneumonia  with a parapneumonic effusion, urinary tract infection, decubitus ulcer.  Patient underwent thoracentesis, results shows neutrophil predominant LDH elevated exudate. Patient was later placed only on Unasyn as the blood infection seemed to be just a contaminant. Patient continued to be stable and after being seen by pulmonology, the plan was to continue antibiotic course for 4 weeks of antibiotics, and to have a repeat chest CT in 6 weeks from discharge. This plan was discussed with the patient's son and he expressed understanding. Patient was discharged in stable condition.  Discharged to Home
Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Culture urine positive, Decubitus ulcer, Dyspnoea, Enterococcus test positive
Clinical narrative: Admit date: 12/31/2023  Discharge date: 1/5/2024   Admitting Physician: DO   Attending Physician at the Time of Discharge: DO  Primary Care Physician: MD  Hospital Course: 81 YO female with medical history notable for   Advanced Alzheimer,  recent COVID infection, poor oral intake, failure to thrive, impaired mobility, hypothyroidism, normocytic anemia who presented to Hospital for   Increasing shortness of breath and cough as well as decreased responsiveness.  Patient had COVID-19 infection roughly around November, patient's symptoms initially improving, however gradually worsening before admission.  Patient was nonsmoker largely bed-bound. Per son, patient has a small decubitus rash and now enlarging.  Patient is nonverbal at baseline, able to respond to pain.  On admission, patient afebrile, hemodynamically stable, in room air.  Lab shows leukocytosis with neutrophil predominant. CT pulmonary, results shows  Pulmonary emboli in the segmental branches to the right upper lobe. Borderline right heart strain. Heterogenous consolidation in the left lower lobe with multiple low-attenuation areas suspicious for underlying infiltrative mass or areas of liquefaction. Moderate partially loculated left pleural effusion insinuating in the left fissure. Mild mediastinal lymphadenopathy. RVP return COVID positive, patient was blood culture later returns Staphylococcus hominis/ epidermidis 2/2.  Patient also found urine culture shows E coli and Enterococcus faecalis. Patient was placed on Unasyn and vancomycin since then  Concerning necrotizing pneumonia  with a parapneumonic effusion, urinary tract infection, decubitus ulcer.  Patient underwent thoracentesis, results shows neutrophil predominant LDH elevated exudate. Patient was later placed only on Unasyn as the blood infection seemed to be just a contaminant. Patient continued to be stable and after being seen by pulmonology, the plan was to continue antibiotic course for 4 weeks of antibiotics, and to have a repeat chest CT in 6 weeks from discharge. This plan was discussed with the patient's son and he expressed understanding. Patient was discharged in stable condition.  Discharged to Home