chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 79.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Electrocardiogram PR prolongation, Electrocardiogram T wave abnormal, Electrolyte depletion, Electrolyte substitution therapy, Fall
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/29/2023 Discharge Date: 9/3/2023 Discharge Disposition:  home health care svc  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 80y/o male with a past medical history of BH. CAD, dilantin toxicity, epilepsy, dilantin toxicity, neuropathy, and sleep apnea who presented for increasing weakness.   Patients symptoms began 3 days prior to admission with increasing weakness and confusion, intermittent fevers, balance issues, and a fall  without LOC or head injury. Patient additionally began to develop a cough prior to presentation to the ED. With patient' s change from baseline, family called EMS to bring patient in. Upon evaluation, patient was put on 2L of oxygen on the way to the ED. Patient did not wear oxygen at baseline. In the Emergency Department, patient presented with a fever of 101.8, tachypnea, and SpO2 at 91% on 2L NC. Basic labs were ordered and revealed a mild normocytic anemia with hgb 13.2, elevated CRP of 24.1, and a mild hyponatremia 133 but were otherwise benign. 4-plex was completed and came back COVID positive. Patient was placed in respiratory precautions. EKG findings demonstrated increased PR interval from known first degree AV block, PACs, and T wave abnormality, but not significantly different from previous findings. CXR revealed mild pulmonary vascular congestion but no signs of pneumonia. D-dimer was slightly elevated at 660. Hospitalist team was contacted for further evaluation.    Upon admission patient was started on remdesivir and lasix. Patient was placed in seizure precautions with his history of having seizures 1-2 times weekly. PT/OT evaluation recommending SAR, but on day 2 of admission noting that pt is improving and could potentially progress to home. Pt had a controlled fall on the morning of 9/1/2023 where he misstepped from the practice stairs, and PT was able to lower him to the ground. He sustained no injuries. On reevaluation on day of dc felt safe for dc home with HHC physical therapy . Rec on dc 2 person assist with stairs and standby assist with other ambulation.  Electrolytes were monitored and repleted PRN throughout the admission. Patient clinically improved and hemodynamically stable for discharge.  Discussed plan of care discharge with patient including outpatient follow-up PCP within 7 days. Patient voiced understanding was agreeable with plan of care discharge
Age: 79.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Fibrin D dimer increased, Haemoglobin, Hyponatraemia, Normocytic anaemia, Pulmonary congestion
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/29/2023 Discharge Date: 9/3/2023 Discharge Disposition:  home health care svc  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 80y/o male with a past medical history of BH. CAD, dilantin toxicity, epilepsy, dilantin toxicity, neuropathy, and sleep apnea who presented for increasing weakness.   Patients symptoms began 3 days prior to admission with increasing weakness and confusion, intermittent fevers, balance issues, and a fall  without LOC or head injury. Patient additionally began to develop a cough prior to presentation to the ED. With patient' s change from baseline, family called EMS to bring patient in. Upon evaluation, patient was put on 2L of oxygen on the way to the ED. Patient did not wear oxygen at baseline. In the Emergency Department, patient presented with a fever of 101.8, tachypnea, and SpO2 at 91% on 2L NC. Basic labs were ordered and revealed a mild normocytic anemia with hgb 13.2, elevated CRP of 24.1, and a mild hyponatremia 133 but were otherwise benign. 4-plex was completed and came back COVID positive. Patient was placed in respiratory precautions. EKG findings demonstrated increased PR interval from known first degree AV block, PACs, and T wave abnormality, but not significantly different from previous findings. CXR revealed mild pulmonary vascular congestion but no signs of pneumonia. D-dimer was slightly elevated at 660. Hospitalist team was contacted for further evaluation.    Upon admission patient was started on remdesivir and lasix. Patient was placed in seizure precautions with his history of having seizures 1-2 times weekly. PT/OT evaluation recommending SAR, but on day 2 of admission noting that pt is improving and could potentially progress to home. Pt had a controlled fall on the morning of 9/1/2023 where he misstepped from the practice stairs, and PT was able to lower him to the ground. He sustained no injuries. On reevaluation on day of dc felt safe for dc home with HHC physical therapy . Rec on dc 2 person assist with stairs and standby assist with other ambulation.  Electrolytes were monitored and repleted PRN throughout the admission. Patient clinically improved and hemodynamically stable for discharge.  Discussed plan of care discharge with patient including outpatient follow-up PCP within 7 days. Patient voiced understanding was agreeable with plan of care discharge
Age: 79.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Pyrexia, SARS-CoV-2 test positive, Supraventricular extrasystoles
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/29/2023 Discharge Date: 9/3/2023 Discharge Disposition:  home health care svc  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 80y/o male with a past medical history of BH. CAD, dilantin toxicity, epilepsy, dilantin toxicity, neuropathy, and sleep apnea who presented for increasing weakness.   Patients symptoms began 3 days prior to admission with increasing weakness and confusion, intermittent fevers, balance issues, and a fall  without LOC or head injury. Patient additionally began to develop a cough prior to presentation to the ED. With patient' s change from baseline, family called EMS to bring patient in. Upon evaluation, patient was put on 2L of oxygen on the way to the ED. Patient did not wear oxygen at baseline. In the Emergency Department, patient presented with a fever of 101.8, tachypnea, and SpO2 at 91% on 2L NC. Basic labs were ordered and revealed a mild normocytic anemia with hgb 13.2, elevated CRP of 24.1, and a mild hyponatremia 133 but were otherwise benign. 4-plex was completed and came back COVID positive. Patient was placed in respiratory precautions. EKG findings demonstrated increased PR interval from known first degree AV block, PACs, and T wave abnormality, but not significantly different from previous findings. CXR revealed mild pulmonary vascular congestion but no signs of pneumonia. D-dimer was slightly elevated at 660. Hospitalist team was contacted for further evaluation.    Upon admission patient was started on remdesivir and lasix. Patient was placed in seizure precautions with his history of having seizures 1-2 times weekly. PT/OT evaluation recommending SAR, but on day 2 of admission noting that pt is improving and could potentially progress to home. Pt had a controlled fall on the morning of 9/1/2023 where he misstepped from the practice stairs, and PT was able to lower him to the ground. He sustained no injuries. On reevaluation on day of dc felt safe for dc home with HHC physical therapy . Rec on dc 2 person assist with stairs and standby assist with other ambulation.  Electrolytes were monitored and repleted PRN throughout the admission. Patient clinically improved and hemodynamically stable for discharge.  Discussed plan of care discharge with patient including outpatient follow-up PCP within 7 days. Patient voiced understanding was agreeable with plan of care discharge
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiac function test, Headache, Heart rate increased, Immediate post-injection reaction, Neoplasm malignant
Clinical narrative: Immediately receiving the shot, my arm started to shake and tremble and I had a 10/10 headache.  This lasted for a day.  Then March 25th, 2022, just 7 months later, I started having severe tachycardia where my heart would spike while I was sitting from 50BPM all the way to 212PM.  I went to the ER once and then had follow up visits with a cardiologist.  He cannot figure out what is going on.   I am a Naturopath physician and have been able to manage the symptoms as long as I take Hawthorne.  Most recently and the reason why I'm finally reporting here is because I was diagnosed on November 8th, 2023 with high guide invasive carcinoma.    I have historically had few medical issues until the date I took the shot.  I am an avid runner and have won half marathons prior to taking this shot.
Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Tachycardia, Tremor
Clinical narrative: Immediately receiving the shot, my arm started to shake and tremble and I had a 10/10 headache.  This lasted for a day.  Then March 25th, 2022, just 7 months later, I started having severe tachycardia where my heart would spike while I was sitting from 50BPM all the way to 212PM.  I went to the ER once and then had follow up visits with a cardiologist.  He cannot figure out what is going on.   I am a Naturopath physician and have been able to manage the symptoms as long as I take Hawthorne.  Most recently and the reason why I'm finally reporting here is because I was diagnosed on November 8th, 2023 with high guide invasive carcinoma.    I have historically had few medical issues until the date I took the shot.  I am an avid runner and have won half marathons prior to taking this shot.
Age: 74.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Asthenia, Blood culture negative, COVID-19, Chest X-ray abnormal, Culture negative
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/29/2023 Discharge Date: Sep 2, 2023 Discharge Disposition:  home health care svc  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: History of bacteremia [Z87.898] Community acquired pneumonia of left lower lobe of lung [J18.9] Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC) [A41.9] COVID [U07.1] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 75 y.o. male with chronic combined CHF (LVEF 23%), NICM, hx endocarditis in setting of MRSA bacteremia treated in March 2023 on suppressive doxycycline, and chronic back pain.    Patient presented after 7 days weakness, fatigue, fever. He was septic, COVID-19 positive, and CXR with questionable subtle pneumonia in LLL.   Patient remained on room air during his hospitalization. He was treated with Remdesivir (ends on 9/3/23) and supportive care. With concern for possible pneumonia the patient received Ceftriaxone IV and was continued on his home suppressive doxycycline. The patient was febrile overnight on 8/30. Infectious work up included negative legionella antigen, negative strep pneumoniae antigen, blood cultures remained negative and sputum cultures remained negative.   PT/OT assessed the patient and recommended home with home health/PT/OT. Patient was discharged in stable condition on 9/2/23
Age: 74.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Endocarditis, Fatigue, Legionella test, Pneumonia, Pyrexia
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/29/2023 Discharge Date: Sep 2, 2023 Discharge Disposition:  home health care svc  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: History of bacteremia [Z87.898] Community acquired pneumonia of left lower lobe of lung [J18.9] Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC) [A41.9] COVID [U07.1] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 75 y.o. male with chronic combined CHF (LVEF 23%), NICM, hx endocarditis in setting of MRSA bacteremia treated in March 2023 on suppressive doxycycline, and chronic back pain.    Patient presented after 7 days weakness, fatigue, fever. He was septic, COVID-19 positive, and CXR with questionable subtle pneumonia in LLL.   Patient remained on room air during his hospitalization. He was treated with Remdesivir (ends on 9/3/23) and supportive care. With concern for possible pneumonia the patient received Ceftriaxone IV and was continued on his home suppressive doxycycline. The patient was febrile overnight on 8/30. Infectious work up included negative legionella antigen, negative strep pneumoniae antigen, blood cultures remained negative and sputum cultures remained negative.   PT/OT assessed the patient and recommended home with home health/PT/OT. Patient was discharged in stable condition on 9/2/23
Age: 74.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: SARS-CoV-2 test positive, Sepsis, Sputum culture, Staphylococcal bacteraemia, Streptococcus test negative
Clinical narrative: BRIEF OVERVIEW: Admission Date: 8/29/2023 Discharge Date: Sep 2, 2023 Discharge Disposition:  home health care svc  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: History of bacteremia [Z87.898] Community acquired pneumonia of left lower lobe of lung [J18.9] Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC) [A41.9] COVID [U07.1] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 75 y.o. male with chronic combined CHF (LVEF 23%), NICM, hx endocarditis in setting of MRSA bacteremia treated in March 2023 on suppressive doxycycline, and chronic back pain.    Patient presented after 7 days weakness, fatigue, fever. He was septic, COVID-19 positive, and CXR with questionable subtle pneumonia in LLL.   Patient remained on room air during his hospitalization. He was treated with Remdesivir (ends on 9/3/23) and supportive care. With concern for possible pneumonia the patient received Ceftriaxone IV and was continued on his home suppressive doxycycline. The patient was febrile overnight on 8/30. Infectious work up included negative legionella antigen, negative strep pneumoniae antigen, blood cultures remained negative and sputum cultures remained negative.   PT/OT assessed the patient and recommended home with home health/PT/OT. Patient was discharged in stable condition on 9/2/23
Age: 72.0
Sex: M
Vaccine: COVID19-2
Symptoms: Atrial fibrillation, Condition aggravated
Clinical narrative: atrial fibrillation
Age: 87.0
Sex: F
Vaccine: COVID19-2
Symptoms: Asthenia, Cough, Headache, Malaise, Nausea
Clinical narrative: Hospitalized 9/23/22-9/27/22 Weakness, malaise, nausea, headache, cough, tachypneia, debility,
Age: 87.0
Sex: F
Vaccine: COVID19-2
Symptoms: Tachypnoea
Clinical narrative: Hospitalized 9/23/22-9/27/22 Weakness, malaise, nausea, headache, cough, tachypneia, debility,
Age: 75.0
Sex: F
Vaccine: COVID19, RSV
Symptoms: Headache, Influenza like illness, Malaise, Rhinorrhoea
Clinical narrative: About a week later I started having a runny nose and I was sick with flu-like symptoms and now i have a continuous headache now with the runny nose still. I have taken Tylenol Cold.
Age: 53.0
Sex: F
Vaccine: VARZOS
Symptoms: Rash, Rash erythematous, Rash pruritic
Clinical narrative: Patient got a itchy red rash on neck, face, arms, and legs.
Age: 50.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Pyrexia
Clinical narrative: Fatigue & High Fever for 48 hours. Day-1: 103deg Day-2: 102deg
Age: 91.0
Sex: F
Vaccine: RSV
Symptoms: Dyspnoea exertional, Metabolic function test, N-terminal prohormone brain natriuretic peptide, Peripheral swelling
Clinical narrative: Patient describes dyspnea on exertion and bilateral lower extremity swelling.
Age: 93.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Acute kidney injury, Asthenia, Balance disorder, Blood creatinine, Blood potassium decreased
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 9/11/2023 Discharge Date: 9/14/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Generalized weakness [R53.1] COVID-19 [U07.1]   Admission H&P: Patient is a 94 y.o. female with prior medical history of AFib, CHF, GERD, hyperlipidemia, hypothyroidism and who presents today with weakness, fatigue and cough.  The patient reports falling at home on Friday when she was getting up to take her morning dose of Synthroid she suddenly fell to the ground.  She does not recall hitting her head or losing consciousness.  She reports possible lightheadedness prior to falling and notes that she has been feeling unsteady since the fall.  Denies any headache prior to fall.  She does have a remote history of seizures but denies any recent seizure activity.  Denies chest pain, or shortness a breath.  She does have a nonproductive cough which started around Friday as well.  She reports significant fatigue and weakness.  She lives at home alone and typically independent with ADLs.  She reports minimal orally intake over the past 3 days.  Denies any fevers but does endorse chills.  Has mild discomfort in her back and left side of the chest but has not required anything for pain .   In the emergency department several scans were completed including CT cervical and thoracic spine which were both negative for acute process.  CT thorax no evidence of trauma and unchanged small pericardial effusion.  CT of the head was negative for acute process.  Labs revealed a mild worsening of creatinine of 1.51 and potassium of 3.0.  Potassium was replaced in the emergency department she was also found to be COVID-19 positive.  An order for orthostatic vital signs and ambulatory pulse ox was placed however the patient was too weak to ambulate.  Admit to hospitalist service for physical therapy occupational therapy and IV fluid resuscitation.   HOSPITAL COURSE:  94 years old woman presented after a fall due to generalized muscle weakness. She was found to have COVID positive and acute kidney injury. AKI resolved with IV fluids and HCTZ 12.5 mg was discontinued on discharge since it worsened her kidney function. Her BP remained controlled on amlodipine 2.5 mg BID, so BP needs to be managed outpatient per PCP. PT and OT recommended discharge to home with home health care services. For COVID 19, no remdesivir was given was because of her AKI and reduced creatinine clearance. No paxlovid was given on discharge either due to low creatinine clearance per pharmacy. Patient was not requiring oxygen inpatient. Patient was discharged in hemodynamically and clinically stable state. For GERD, pantoprazole 20 mg daily was continued but famotidine dosing was adjusted to 20 mg every other day due to renal adjustment per pharmacy.
Age: 93.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: COVID-19, Chest discomfort, Chills, Computerised tomogram head normal, Computerised tomogram normal
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 9/11/2023 Discharge Date: 9/14/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Generalized weakness [R53.1] COVID-19 [U07.1]   Admission H&P: Patient is a 94 y.o. female with prior medical history of AFib, CHF, GERD, hyperlipidemia, hypothyroidism and who presents today with weakness, fatigue and cough.  The patient reports falling at home on Friday when she was getting up to take her morning dose of Synthroid she suddenly fell to the ground.  She does not recall hitting her head or losing consciousness.  She reports possible lightheadedness prior to falling and notes that she has been feeling unsteady since the fall.  Denies any headache prior to fall.  She does have a remote history of seizures but denies any recent seizure activity.  Denies chest pain, or shortness a breath.  She does have a nonproductive cough which started around Friday as well.  She reports significant fatigue and weakness.  She lives at home alone and typically independent with ADLs.  She reports minimal orally intake over the past 3 days.  Denies any fevers but does endorse chills.  Has mild discomfort in her back and left side of the chest but has not required anything for pain .   In the emergency department several scans were completed including CT cervical and thoracic spine which were both negative for acute process.  CT thorax no evidence of trauma and unchanged small pericardial effusion.  CT of the head was negative for acute process.  Labs revealed a mild worsening of creatinine of 1.51 and potassium of 3.0.  Potassium was replaced in the emergency department she was also found to be COVID-19 positive.  An order for orthostatic vital signs and ambulatory pulse ox was placed however the patient was too weak to ambulate.  Admit to hospitalist service for physical therapy occupational therapy and IV fluid resuscitation.   HOSPITAL COURSE:  94 years old woman presented after a fall due to generalized muscle weakness. She was found to have COVID positive and acute kidney injury. AKI resolved with IV fluids and HCTZ 12.5 mg was discontinued on discharge since it worsened her kidney function. Her BP remained controlled on amlodipine 2.5 mg BID, so BP needs to be managed outpatient per PCP. PT and OT recommended discharge to home with home health care services. For COVID 19, no remdesivir was given was because of her AKI and reduced creatinine clearance. No paxlovid was given on discharge either due to low creatinine clearance per pharmacy. Patient was not requiring oxygen inpatient. Patient was discharged in hemodynamically and clinically stable state. For GERD, pantoprazole 20 mg daily was continued but famotidine dosing was adjusted to 20 mg every other day due to renal adjustment per pharmacy.
Age: 93.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Computerised tomogram spine, Computerised tomogram thorax abnormal, Cough, Creatinine renal clearance decreased, Electrolyte substitution therapy
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 9/11/2023 Discharge Date: 9/14/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Generalized weakness [R53.1] COVID-19 [U07.1]   Admission H&P: Patient is a 94 y.o. female with prior medical history of AFib, CHF, GERD, hyperlipidemia, hypothyroidism and who presents today with weakness, fatigue and cough.  The patient reports falling at home on Friday when she was getting up to take her morning dose of Synthroid she suddenly fell to the ground.  She does not recall hitting her head or losing consciousness.  She reports possible lightheadedness prior to falling and notes that she has been feeling unsteady since the fall.  Denies any headache prior to fall.  She does have a remote history of seizures but denies any recent seizure activity.  Denies chest pain, or shortness a breath.  She does have a nonproductive cough which started around Friday as well.  She reports significant fatigue and weakness.  She lives at home alone and typically independent with ADLs.  She reports minimal orally intake over the past 3 days.  Denies any fevers but does endorse chills.  Has mild discomfort in her back and left side of the chest but has not required anything for pain .   In the emergency department several scans were completed including CT cervical and thoracic spine which were both negative for acute process.  CT thorax no evidence of trauma and unchanged small pericardial effusion.  CT of the head was negative for acute process.  Labs revealed a mild worsening of creatinine of 1.51 and potassium of 3.0.  Potassium was replaced in the emergency department she was also found to be COVID-19 positive.  An order for orthostatic vital signs and ambulatory pulse ox was placed however the patient was too weak to ambulate.  Admit to hospitalist service for physical therapy occupational therapy and IV fluid resuscitation.   HOSPITAL COURSE:  94 years old woman presented after a fall due to generalized muscle weakness. She was found to have COVID positive and acute kidney injury. AKI resolved with IV fluids and HCTZ 12.5 mg was discontinued on discharge since it worsened her kidney function. Her BP remained controlled on amlodipine 2.5 mg BID, so BP needs to be managed outpatient per PCP. PT and OT recommended discharge to home with home health care services. For COVID 19, no remdesivir was given was because of her AKI and reduced creatinine clearance. No paxlovid was given on discharge either due to low creatinine clearance per pharmacy. Patient was not requiring oxygen inpatient. Patient was discharged in hemodynamically and clinically stable state. For GERD, pantoprazole 20 mg daily was continued but famotidine dosing was adjusted to 20 mg every other day due to renal adjustment per pharmacy.
Age: 93.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Fall, Fatigue, Gait inability, Hypokalaemia, Hypophagia
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 9/11/2023 Discharge Date: 9/14/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Generalized weakness [R53.1] COVID-19 [U07.1]   Admission H&P: Patient is a 94 y.o. female with prior medical history of AFib, CHF, GERD, hyperlipidemia, hypothyroidism and who presents today with weakness, fatigue and cough.  The patient reports falling at home on Friday when she was getting up to take her morning dose of Synthroid she suddenly fell to the ground.  She does not recall hitting her head or losing consciousness.  She reports possible lightheadedness prior to falling and notes that she has been feeling unsteady since the fall.  Denies any headache prior to fall.  She does have a remote history of seizures but denies any recent seizure activity.  Denies chest pain, or shortness a breath.  She does have a nonproductive cough which started around Friday as well.  She reports significant fatigue and weakness.  She lives at home alone and typically independent with ADLs.  She reports minimal orally intake over the past 3 days.  Denies any fevers but does endorse chills.  Has mild discomfort in her back and left side of the chest but has not required anything for pain .   In the emergency department several scans were completed including CT cervical and thoracic spine which were both negative for acute process.  CT thorax no evidence of trauma and unchanged small pericardial effusion.  CT of the head was negative for acute process.  Labs revealed a mild worsening of creatinine of 1.51 and potassium of 3.0.  Potassium was replaced in the emergency department she was also found to be COVID-19 positive.  An order for orthostatic vital signs and ambulatory pulse ox was placed however the patient was too weak to ambulate.  Admit to hospitalist service for physical therapy occupational therapy and IV fluid resuscitation.   HOSPITAL COURSE:  94 years old woman presented after a fall due to generalized muscle weakness. She was found to have COVID positive and acute kidney injury. AKI resolved with IV fluids and HCTZ 12.5 mg was discontinued on discharge since it worsened her kidney function. Her BP remained controlled on amlodipine 2.5 mg BID, so BP needs to be managed outpatient per PCP. PT and OT recommended discharge to home with home health care services. For COVID 19, no remdesivir was given was because of her AKI and reduced creatinine clearance. No paxlovid was given on discharge either due to low creatinine clearance per pharmacy. Patient was not requiring oxygen inpatient. Patient was discharged in hemodynamically and clinically stable state. For GERD, pantoprazole 20 mg daily was continued but famotidine dosing was adjusted to 20 mg every other day due to renal adjustment per pharmacy.
Age: 93.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Muscular weakness, Musculoskeletal discomfort, Pericardial effusion, Renal impairment, SARS-CoV-2 test positive
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 9/11/2023 Discharge Date: 9/14/2023  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Generalized weakness [R53.1] COVID-19 [U07.1]   Admission H&P: Patient is a 94 y.o. female with prior medical history of AFib, CHF, GERD, hyperlipidemia, hypothyroidism and who presents today with weakness, fatigue and cough.  The patient reports falling at home on Friday when she was getting up to take her morning dose of Synthroid she suddenly fell to the ground.  She does not recall hitting her head or losing consciousness.  She reports possible lightheadedness prior to falling and notes that she has been feeling unsteady since the fall.  Denies any headache prior to fall.  She does have a remote history of seizures but denies any recent seizure activity.  Denies chest pain, or shortness a breath.  She does have a nonproductive cough which started around Friday as well.  She reports significant fatigue and weakness.  She lives at home alone and typically independent with ADLs.  She reports minimal orally intake over the past 3 days.  Denies any fevers but does endorse chills.  Has mild discomfort in her back and left side of the chest but has not required anything for pain .   In the emergency department several scans were completed including CT cervical and thoracic spine which were both negative for acute process.  CT thorax no evidence of trauma and unchanged small pericardial effusion.  CT of the head was negative for acute process.  Labs revealed a mild worsening of creatinine of 1.51 and potassium of 3.0.  Potassium was replaced in the emergency department she was also found to be COVID-19 positive.  An order for orthostatic vital signs and ambulatory pulse ox was placed however the patient was too weak to ambulate.  Admit to hospitalist service for physical therapy occupational therapy and IV fluid resuscitation.   HOSPITAL COURSE:  94 years old woman presented after a fall due to generalized muscle weakness. She was found to have COVID positive and acute kidney injury. AKI resolved with IV fluids and HCTZ 12.5 mg was discontinued on discharge since it worsened her kidney function. Her BP remained controlled on amlodipine 2.5 mg BID, so BP needs to be managed outpatient per PCP. PT and OT recommended discharge to home with home health care services. For COVID 19, no remdesivir was given was because of her AKI and reduced creatinine clearance. No paxlovid was given on discharge either due to low creatinine clearance per pharmacy. Patient was not requiring oxygen inpatient. Patient was discharged in hemodynamically and clinically stable state. For GERD, pantoprazole 20 mg daily was continued but famotidine dosing was adjusted to 20 mg every other day due to renal adjustment per pharmacy.
Age: 78.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Affect lability, Asthenia, COVID-19, Computerised tomogram head normal, Condition aggravated
Clinical narrative: BRIEF OVERVIEW: Admission Date: 9/10/2023 Discharge Date: Sep 22, 2023 Discharge Disposition:  skilled nursing facility        ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Asthenia [R53.1] Generalized weakness [R53.1] Acute cough [R05.1]   HOSPITAL COURSE: The patient is a 79-year-old lady was presented to the hospital from assisted living due to generalized weakness and fatigue, cough and shortness of breath.  Her past medical is significant for lewy body dementia. Symptoms had been present and worsening for a few days prior to admission.   Initial workup revealed that she was positive for COVID 19. She did not require oxygen. She was seen by PT / OT who recommended sar. She had some confusion and emotional lability worse from baseline dementia. She had CTH which was unremarkable. MRI brain was also unremarkable.  Unfortunately, the patient had to wait until she was out of COVID precautions before being able to be discharged to SAR.  Eventually, she was cleared on 09/22 and was discharged to SAR in medically stable condition.
Age: 78.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Confusional state, Cough, Dementia, Dyspnoea, Fatigue
Clinical narrative: BRIEF OVERVIEW: Admission Date: 9/10/2023 Discharge Date: Sep 22, 2023 Discharge Disposition:  skilled nursing facility        ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Asthenia [R53.1] Generalized weakness [R53.1] Acute cough [R05.1]   HOSPITAL COURSE: The patient is a 79-year-old lady was presented to the hospital from assisted living due to generalized weakness and fatigue, cough and shortness of breath.  Her past medical is significant for lewy body dementia. Symptoms had been present and worsening for a few days prior to admission.   Initial workup revealed that she was positive for COVID 19. She did not require oxygen. She was seen by PT / OT who recommended sar. She had some confusion and emotional lability worse from baseline dementia. She had CTH which was unremarkable. MRI brain was also unremarkable.  Unfortunately, the patient had to wait until she was out of COVID precautions before being able to be discharged to SAR.  Eventually, she was cleared on 09/22 and was discharged to SAR in medically stable condition.
Age: 78.0
Sex: F
Vaccine: COVID19-2, FLU4
Symptoms: Magnetic resonance imaging head normal, Pollakiuria, SARS-CoV-2 test positive
Clinical narrative: BRIEF OVERVIEW: Admission Date: 9/10/2023 Discharge Date: Sep 22, 2023 Discharge Disposition:  skilled nursing facility        ?  No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Asthenia [R53.1] Generalized weakness [R53.1] Acute cough [R05.1]   HOSPITAL COURSE: The patient is a 79-year-old lady was presented to the hospital from assisted living due to generalized weakness and fatigue, cough and shortness of breath.  Her past medical is significant for lewy body dementia. Symptoms had been present and worsening for a few days prior to admission.   Initial workup revealed that she was positive for COVID 19. She did not require oxygen. She was seen by PT / OT who recommended sar. She had some confusion and emotional lability worse from baseline dementia. She had CTH which was unremarkable. MRI brain was also unremarkable.  Unfortunately, the patient had to wait until she was out of COVID precautions before being able to be discharged to SAR.  Eventually, she was cleared on 09/22 and was discharged to SAR in medically stable condition.
Age: 62.0
Sex: M
Vaccine: COVID19-2
Symptoms: Alcohol withdrawal syndrome, Confusional state, Cough, Dehydration, Encephalopathy
Clinical narrative: Hospitalized 9/28/22-10/2/22 confusion, fatigue, malaise, tachycardia, HTN, alcohol withdrawal, encephalopathy, dehydration, cough, thrombocytopenia, hyponatremia,
Age: 62.0
Sex: M
Vaccine: COVID19-2
Symptoms: Fatigue, Hypertension, Hyponatraemia, Malaise, Tachycardia
Clinical narrative: Hospitalized 9/28/22-10/2/22 confusion, fatigue, malaise, tachycardia, HTN, alcohol withdrawal, encephalopathy, dehydration, cough, thrombocytopenia, hyponatremia,
Age: 62.0
Sex: M
Vaccine: COVID19-2
Symptoms: Thrombocytopenia
Clinical narrative: Hospitalized 9/28/22-10/2/22 confusion, fatigue, malaise, tachycardia, HTN, alcohol withdrawal, encephalopathy, dehydration, cough, thrombocytopenia, hyponatremia,
Age: 0.5
Sex: F
Vaccine: COVID19, DTAPHEPBIP, PNC13
Symptoms: Incorrect dose administered
Clinical narrative: Baby was given a whole vial (undiluted) of the Pfizer Covid 6 mos to 4 year dose
Age: 11.0
Sex: M
Vaccine: UNK
Symptoms: Vaccination site erythema, Vaccination site pain, Vaccination site pruritus, Vaccination site warmth
Clinical narrative: Large local reaction at vaccine site involving pain/erythema/warmth/pruritus, approx 4i inches in diameter, without associated systemic symptoms.
Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Asthenia, COVID-19, Cardiac telemetry normal, Fall
Clinical narrative: BRIEF OVERVIEW: Admission Date: 9/10/2023 Discharge Date: Sep 11, 2023 Discharge Disposition:  home or self care      Active Issues Requiring Follow-up: None No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Weakness generalized [R53.1] AKI (acute kidney injury) (HCC) [N17.9] Syncope, unspecified syncope type [R55] COVID-19 [U07.1]   HOSPITAL COURSE: Patient was admitted for observation and evaluation for her falls.  On telemetry there was no a arrhythmias noted.  PT was not performed, but OT saw patient and found her to be strong enough to go home.  Her diet was improved while she was here in the hospital.  IV fluids were again not required.  No symptomatic treatments were necessary for COVID as she had no pulmonary or GI symptoms.   This patient was medically stable at discharge to go home.  She will have a tenuous course of caution with mobilization and daughter will be with.  Would consider her contagious for a 7 day.  Which is nearly up at this time.
Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Syncope
Clinical narrative: BRIEF OVERVIEW: Admission Date: 9/10/2023 Discharge Date: Sep 11, 2023 Discharge Disposition:  home or self care      Active Issues Requiring Follow-up: None No future appointments.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Weakness generalized [R53.1] AKI (acute kidney injury) (HCC) [N17.9] Syncope, unspecified syncope type [R55] COVID-19 [U07.1]   HOSPITAL COURSE: Patient was admitted for observation and evaluation for her falls.  On telemetry there was no a arrhythmias noted.  PT was not performed, but OT saw patient and found her to be strong enough to go home.  Her diet was improved while she was here in the hospital.  IV fluids were again not required.  No symptomatic treatments were necessary for COVID as she had no pulmonary or GI symptoms.   This patient was medically stable at discharge to go home.  She will have a tenuous course of caution with mobilization and daughter will be with.  Would consider her contagious for a 7 day.  Which is nearly up at this time.
Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Oral pain, Pyrexia, Respiratory symptom
Clinical narrative: Mouth sore, febrile, exhaustion, resp. symptoms that never completely go,
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Differential white blood cell count normal, Dyspnoea, Dyspnoea exertional, Electrocardiogram normal
Clinical narrative: Patient experienced new onset Shortness of breath and palpitations on the day of vaccinations. She noted experiencing body aches and pain . She also notes getting heart palpitations that come and go. She reports new Shortness of breath with climbing stairs. She reports overall feeling exhausted and having a dry cough.
Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Fibrin D dimer increased, Full blood count, Pain, Palpitations
Clinical narrative: Patient experienced new onset Shortness of breath and palpitations on the day of vaccinations. She noted experiencing body aches and pain . She also notes getting heart palpitations that come and go. She reports new Shortness of breath with climbing stairs. She reports overall feeling exhausted and having a dry cough.
Age: 2.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect dose administered, Product preparation error
Clinical narrative: Child was given the full (undiluted) vial of the Covid 23/24 6 mos to 4 year vaccine
Age: 14.0
Sex: F
Vaccine: MNQ
Symptoms: Inappropriate schedule of product administration
Clinical narrative: Vaccination given early
Age: 19.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Immediate post-injection reaction, Syncope
Clinical narrative: Vasovagal syncope immediately prior to second vaccination administration
Age: 69.0
Sex: F
Vaccine: RSV
Symptoms: Injection site erythema, Injection site pruritus
Clinical narrative: Patient received vaccine on Monday and reports feeling fine until Friday when she noticed redness around the injection site and itching.
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Back pain, Chills, Dysstasia, Fatigue, Headache
Clinical narrative: profound vertigo and nausea, I was literally falling into the walls. Treated with meclazine which has decreased the vertigo but not alleviated it. On 11/11/23 I was unable to stand without risking falling and stayed in bed until 11/12/23. Also experienced, generalized muscles aches and fatigue, chills, hot flashes. Pain noted in lumbar area and R kidney area on day 4 post injection. Also more fatigue than with any previous vaccine, slept for 9+ hrs (I usually sleep 4-5 hrs) after spending the entire day in bed. Very severe frontal headache x 3 days , now headache is mild. I was part of the Moderna covid study and never had side effects like this for any of the other vaccines.,
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Hot flush, Mobility decreased, Myalgia, Nausea, Renal pain
Clinical narrative: profound vertigo and nausea, I was literally falling into the walls. Treated with meclazine which has decreased the vertigo but not alleviated it. On 11/11/23 I was unable to stand without risking falling and stayed in bed until 11/12/23. Also experienced, generalized muscles aches and fatigue, chills, hot flashes. Pain noted in lumbar area and R kidney area on day 4 post injection. Also more fatigue than with any previous vaccine, slept for 9+ hrs (I usually sleep 4-5 hrs) after spending the entire day in bed. Very severe frontal headache x 3 days , now headache is mild. I was part of the Moderna covid study and never had side effects like this for any of the other vaccines.,
Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Vertigo
Clinical narrative: profound vertigo and nausea, I was literally falling into the walls. Treated with meclazine which has decreased the vertigo but not alleviated it. On 11/11/23 I was unable to stand without risking falling and stayed in bed until 11/12/23. Also experienced, generalized muscles aches and fatigue, chills, hot flashes. Pain noted in lumbar area and R kidney area on day 4 post injection. Also more fatigue than with any previous vaccine, slept for 9+ hrs (I usually sleep 4-5 hrs) after spending the entire day in bed. Very severe frontal headache x 3 days , now headache is mild. I was part of the Moderna covid study and never had side effects like this for any of the other vaccines.,
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Computerised tomogram abdomen, Computerised tomogram head, Dizziness, Endoscopy
Clinical narrative: Constant nausea  Weakness Fatigue  Lightheadedness
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Nausea
Clinical narrative: Constant nausea  Weakness Fatigue  Lightheadedness
Age: 77.0
Sex: F
Vaccine: FLU4
Symptoms: Abdominal pain upper, Headache, Pain, Pain in extremity, Vision blurred
Clinical narrative: headache, body ache, stomach ache, pain in arm, vision blurry
Age: 2.0
Sex: M
Vaccine: COVID19, FLUC4
Symptoms: Incorrect dose administered, Product preparation error
Clinical narrative: Child was accidently given the whole undiluted vial of Covid Pfizer vaccine age 6 mos to 4 years
Age: 4.0
Sex: M
Vaccine: COVID19
Symptoms: Product administered to patient of inappropriate age, Product preparation error
Clinical narrative: Child was accidently administer the whole undiluted vial of Covid Pfizer 6 mos to 4 year vaccine dose.
Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Chest X-ray normal, Computerised tomogram head, Cough, Echocardiogram abnormal, Electrocardiogram T wave abnormal
Clinical narrative: Syncope episode while driving, patient went to Emergency department- arrived there at 1646.
Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Electrocardiogram ambulatory, Fibrin D dimer normal, Impaired driving ability, Syncope, Troponin
Clinical narrative: Syncope episode while driving, patient went to Emergency department- arrived there at 1646.
Age: 2.0
Sex: M
Vaccine: COVID19
Symptoms: Incorrect dose administered, Product preparation error
Clinical narrative: Child was accidently administered the whole undiluted vial of the Pfizer Covid 6 mos to 4 year dose
Age: 61.0
Sex: F
Vaccine: FLUC4
Symptoms: Extra dose administered, Wrong product administered
Clinical narrative: Patient receive Flu shot in September 2023 - reported for RSV vaccine and received second Flu shot on 11/13.
Age: 27.0
Sex: F
Vaccine: COVID19-2
Symptoms: Chest pain, Dyspnoea
Clinical narrative: "Chest pain and trouble breathing. Need to sit up or else it will feel worse. It comes on and off for the next few days. Took ibuprofen to manage the pain."
Age: 74.0
Sex: F
Vaccine: RSV
Symptoms: Decreased appetite, Fatigue, Headache, Injection site pruritus, Injection site swelling
Clinical narrative: No unusual pain at injection site, but increased swelling after 10 hours.  Woke at 2:00 a.m. with severe vomiting and headache.  Headache fatigue all the next day. No hunger at meal times. Constant thirst. Itching at injection site
Age: 74.0
Sex: F
Vaccine: RSV
Symptoms: Thirst, Vomiting
Clinical narrative: No unusual pain at injection site, but increased swelling after 10 hours.  Woke at 2:00 a.m. with severe vomiting and headache.  Headache fatigue all the next day. No hunger at meal times. Constant thirst. Itching at injection site
Age: 54.0
Sex: F
Vaccine: VARZOS
Symptoms: Angiogram cerebral normal, Angiogram normal, Balance disorder, Cervical spinal stenosis, Coordination abnormal
Clinical narrative: Left-sided muscle weakness. Weakness in the left arm and left leg with associated left foot drop/drag.  Double vision out left eye,  Balance and coordination concerns with waddling gait . Seeing neurologist, rheumatologist and has PT/OT and vision therapy weekly.
Age: 54.0
Sex: F
Vaccine: VARZOS
Symptoms: Diplopia, Electromyogram normal, Gait disturbance, Hemiparesis, Magnetic resonance imaging head normal
Clinical narrative: Left-sided muscle weakness. Weakness in the left arm and left leg with associated left foot drop/drag.  Double vision out left eye,  Balance and coordination concerns with waddling gait . Seeing neurologist, rheumatologist and has PT/OT and vision therapy weekly.
Age: 54.0
Sex: F
Vaccine: VARZOS
Symptoms: Magnetic resonance imaging spinal abnormal, Muscular weakness, Peroneal nerve palsy
Clinical narrative: Left-sided muscle weakness. Weakness in the left arm and left leg with associated left foot drop/drag.  Double vision out left eye,  Balance and coordination concerns with waddling gait . Seeing neurologist, rheumatologist and has PT/OT and vision therapy weekly.
Age: 87.0
Sex: M
Vaccine: RSV
Symptoms: Pain in extremity, Tenderness
Clinical narrative: is 11/01/2023  Patient said that his arm still hurt and tender to the touch, but no redness or swelling at the injection site for the AREXVY vaccine that he got on 09/05/2023. He is not taking any medication for pain. I counseled and advised him to reach out to his PCP. 11/04/2023  Patient is feeling better and able to do yard works but still hurting. His PCP is not available until next week. 11/07/2023  Patient is feeling much better more than 50%. He did not see his PCP in person, only communicate through phone. He is using ice pack to help with the pain.
Age: 80.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoaesthesia, Nerve conduction studies, Neuralgia, Pain in extremity
Clinical narrative: Bilateral hand numbness and night pain--medial nerve sx  saw orth and primary MD  symptoms persist
Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Chills, Headache, Pyrexia
Clinical narrative: Headache, chills, fever
Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: Ageusia, Anosmia, Asthenia, Cough, Decreased appetite
Clinical narrative: Hospitalized 9/28/22-10/4/22 decreased appetite, loss of taste and smell,  weakness, fatigue, fall, debility, hypoxia, altered mental status, cough, PNA, fluid overload,
Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: Fall, Fatigue, Hypervolaemia, Hypoxia, Mental status changes
Clinical narrative: Hospitalized 9/28/22-10/4/22 decreased appetite, loss of taste and smell,  weakness, fatigue, fall, debility, hypoxia, altered mental status, cough, PNA, fluid overload,
Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: Pneumonia
Clinical narrative: Hospitalized 9/28/22-10/4/22 decreased appetite, loss of taste and smell,  weakness, fatigue, fall, debility, hypoxia, altered mental status, cough, PNA, fluid overload,
Sex: M
Vaccine: HEP
Symptoms: Extra dose administered
Clinical narrative: Baby was inadvertently given 2 doses of Hep B while in ICU, one on 10/5/23 and one on 10/14/23.  Baby did not display any signs of reaction to second vaccine.  Doctor counseled parents on event and had them follow up with pediatrician about when to get next vaccine in series now that baby had received a second too early.