chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Bacterial test positive, Blood culture negative, Blood glucose, Bronchitis, COVID-19
Clinical narrative: Patient currently inpatient at (8) days starting from 11/18/2021. Patient is a 90 y.o. female who presents today with shortness of breath.  History is limited from the patient, however patient's son provides additional history as possible.  Patient's son states that she was hospitalized a couple weeks ago for suspected urinary tract infection.  He states following hospitalization she had significant weakness and she was discharged to assisted living for ongoing care.  While at assisted living the patient was noted to have significant respiratory distress and fevers, for which reason the patient was sent to the ER for further evaluation.  Patient was noted to be COVID positive.  She reports being vaccinated.  Patient is somewhat immunocompromised with her CLL.  On presentation, the patient was requiring high-flow nasal cannula to maintain appropriate saturations.  Patient does report that she uses 2-3 L of oxygen at night while sleeping, however she is unsure of any specific associated pulmonary diagnosis.  Anticipated care plan was discussed with the patient and her son.  Both report should patient's respiratory status worsen intubation is not desired.  Questions have been answered to patient and son satisfaction.  ASSESSMENT/PLAN: Acute on chronic respiratory failure with hypoxia  Assessment & Plan Patient reports baseline oxygen needs of 2-3 L at night Patient was requiring high-flow nasal cannula on admission secondary to pneumonia   Continue weaning oxygen as tolerated otherwise treatment as outlined under pneumonia   * Pneumonia Assessment & Plan Patient with noted positive COVID test in the emergency department (11/18/2012) Unclear whether pneumonia is bacterial in nature or related to COVID-19.   Will continue to cover with IV Rocephin and azithromycin for potential bacterial pneumonia Additionally will start patient on 6 mg of Decadron for possible COVID pneumonia Routine monitoring of vitals Will monitor blood culture results Patient's home Eliquis should be adequate anticoagulation for patient's positive COVID status   Type 2 diabetes mellitus, without long-term current use of insulin  Assessment & Plan Very low-dose mealtime and corrective scale coverage while admitted Will continue trending patient's bedside glucose for further titration   CLL (chronic lymphocytic leukemia)  Assessment & Plan Likely cause of patient's noted leukocytosis Will continue monitoring complete blood count throughout admission   Atrial fibrillation  Assessment & Plan Continue Eliquis for anticoagulation and metoprolol for rate control   Atrophic kidney Assessment & Plan Patient's son reports a history of an atrophic kidney he states his chronically infected.  He notes patient recently underwent a 10 day antibiotic course.  UA in kidney function reviewed.  No further indication of ongoing urinary infection is noted and patient has appropriate kidney function
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiac failure congestive, Cardiomegaly, Chest X-ray normal, Culture urine positive, Dyspnoea
Clinical narrative: Patient currently inpatient at (8) days starting from 11/18/2021. Patient is a 90 y.o. female who presents today with shortness of breath.  History is limited from the patient, however patient's son provides additional history as possible.  Patient's son states that she was hospitalized a couple weeks ago for suspected urinary tract infection.  He states following hospitalization she had significant weakness and she was discharged to assisted living for ongoing care.  While at assisted living the patient was noted to have significant respiratory distress and fevers, for which reason the patient was sent to the ER for further evaluation.  Patient was noted to be COVID positive.  She reports being vaccinated.  Patient is somewhat immunocompromised with her CLL.  On presentation, the patient was requiring high-flow nasal cannula to maintain appropriate saturations.  Patient does report that she uses 2-3 L of oxygen at night while sleeping, however she is unsure of any specific associated pulmonary diagnosis.  Anticipated care plan was discussed with the patient and her son.  Both report should patient's respiratory status worsen intubation is not desired.  Questions have been answered to patient and son satisfaction.  ASSESSMENT/PLAN: Acute on chronic respiratory failure with hypoxia  Assessment & Plan Patient reports baseline oxygen needs of 2-3 L at night Patient was requiring high-flow nasal cannula on admission secondary to pneumonia   Continue weaning oxygen as tolerated otherwise treatment as outlined under pneumonia   * Pneumonia Assessment & Plan Patient with noted positive COVID test in the emergency department (11/18/2012) Unclear whether pneumonia is bacterial in nature or related to COVID-19.   Will continue to cover with IV Rocephin and azithromycin for potential bacterial pneumonia Additionally will start patient on 6 mg of Decadron for possible COVID pneumonia Routine monitoring of vitals Will monitor blood culture results Patient's home Eliquis should be adequate anticoagulation for patient's positive COVID status   Type 2 diabetes mellitus, without long-term current use of insulin  Assessment & Plan Very low-dose mealtime and corrective scale coverage while admitted Will continue trending patient's bedside glucose for further titration   CLL (chronic lymphocytic leukemia)  Assessment & Plan Likely cause of patient's noted leukocytosis Will continue monitoring complete blood count throughout admission   Atrial fibrillation  Assessment & Plan Continue Eliquis for anticoagulation and metoprolol for rate control   Atrophic kidney Assessment & Plan Patient's son reports a history of an atrophic kidney he states his chronically infected.  He notes patient recently underwent a 10 day antibiotic course.  UA in kidney function reviewed.  No further indication of ongoing urinary infection is noted and patient has appropriate kidney function
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Enterococcus test positive, Full blood count, Gram stain, Hypoxia, Leukocytosis
Clinical narrative: Patient currently inpatient at (8) days starting from 11/18/2021. Patient is a 90 y.o. female who presents today with shortness of breath.  History is limited from the patient, however patient's son provides additional history as possible.  Patient's son states that she was hospitalized a couple weeks ago for suspected urinary tract infection.  He states following hospitalization she had significant weakness and she was discharged to assisted living for ongoing care.  While at assisted living the patient was noted to have significant respiratory distress and fevers, for which reason the patient was sent to the ER for further evaluation.  Patient was noted to be COVID positive.  She reports being vaccinated.  Patient is somewhat immunocompromised with her CLL.  On presentation, the patient was requiring high-flow nasal cannula to maintain appropriate saturations.  Patient does report that she uses 2-3 L of oxygen at night while sleeping, however she is unsure of any specific associated pulmonary diagnosis.  Anticipated care plan was discussed with the patient and her son.  Both report should patient's respiratory status worsen intubation is not desired.  Questions have been answered to patient and son satisfaction.  ASSESSMENT/PLAN: Acute on chronic respiratory failure with hypoxia  Assessment & Plan Patient reports baseline oxygen needs of 2-3 L at night Patient was requiring high-flow nasal cannula on admission secondary to pneumonia   Continue weaning oxygen as tolerated otherwise treatment as outlined under pneumonia   * Pneumonia Assessment & Plan Patient with noted positive COVID test in the emergency department (11/18/2012) Unclear whether pneumonia is bacterial in nature or related to COVID-19.   Will continue to cover with IV Rocephin and azithromycin for potential bacterial pneumonia Additionally will start patient on 6 mg of Decadron for possible COVID pneumonia Routine monitoring of vitals Will monitor blood culture results Patient's home Eliquis should be adequate anticoagulation for patient's positive COVID status   Type 2 diabetes mellitus, without long-term current use of insulin  Assessment & Plan Very low-dose mealtime and corrective scale coverage while admitted Will continue trending patient's bedside glucose for further titration   CLL (chronic lymphocytic leukemia)  Assessment & Plan Likely cause of patient's noted leukocytosis Will continue monitoring complete blood count throughout admission   Atrial fibrillation  Assessment & Plan Continue Eliquis for anticoagulation and metoprolol for rate control   Atrophic kidney Assessment & Plan Patient's son reports a history of an atrophic kidney he states his chronically infected.  He notes patient recently underwent a 10 day antibiotic course.  UA in kidney function reviewed.  No further indication of ongoing urinary infection is noted and patient has appropriate kidney function
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Lung opacity, Pleural effusion, Pneumonia, Pulmonary congestion, Pyrexia
Clinical narrative: Patient currently inpatient at (8) days starting from 11/18/2021. Patient is a 90 y.o. female who presents today with shortness of breath.  History is limited from the patient, however patient's son provides additional history as possible.  Patient's son states that she was hospitalized a couple weeks ago for suspected urinary tract infection.  He states following hospitalization she had significant weakness and she was discharged to assisted living for ongoing care.  While at assisted living the patient was noted to have significant respiratory distress and fevers, for which reason the patient was sent to the ER for further evaluation.  Patient was noted to be COVID positive.  She reports being vaccinated.  Patient is somewhat immunocompromised with her CLL.  On presentation, the patient was requiring high-flow nasal cannula to maintain appropriate saturations.  Patient does report that she uses 2-3 L of oxygen at night while sleeping, however she is unsure of any specific associated pulmonary diagnosis.  Anticipated care plan was discussed with the patient and her son.  Both report should patient's respiratory status worsen intubation is not desired.  Questions have been answered to patient and son satisfaction.  ASSESSMENT/PLAN: Acute on chronic respiratory failure with hypoxia  Assessment & Plan Patient reports baseline oxygen needs of 2-3 L at night Patient was requiring high-flow nasal cannula on admission secondary to pneumonia   Continue weaning oxygen as tolerated otherwise treatment as outlined under pneumonia   * Pneumonia Assessment & Plan Patient with noted positive COVID test in the emergency department (11/18/2012) Unclear whether pneumonia is bacterial in nature or related to COVID-19.   Will continue to cover with IV Rocephin and azithromycin for potential bacterial pneumonia Additionally will start patient on 6 mg of Decadron for possible COVID pneumonia Routine monitoring of vitals Will monitor blood culture results Patient's home Eliquis should be adequate anticoagulation for patient's positive COVID status   Type 2 diabetes mellitus, without long-term current use of insulin  Assessment & Plan Very low-dose mealtime and corrective scale coverage while admitted Will continue trending patient's bedside glucose for further titration   CLL (chronic lymphocytic leukemia)  Assessment & Plan Likely cause of patient's noted leukocytosis Will continue monitoring complete blood count throughout admission   Atrial fibrillation  Assessment & Plan Continue Eliquis for anticoagulation and metoprolol for rate control   Atrophic kidney Assessment & Plan Patient's son reports a history of an atrophic kidney he states his chronically infected.  He notes patient recently underwent a 10 day antibiotic course.  UA in kidney function reviewed.  No further indication of ongoing urinary infection is noted and patient has appropriate kidney function
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Renal function test normal, Respiratory distress, SARS-CoV-2 test positive, Shoulder arthroplasty, Sputum culture
Clinical narrative: Patient currently inpatient at (8) days starting from 11/18/2021. Patient is a 90 y.o. female who presents today with shortness of breath.  History is limited from the patient, however patient's son provides additional history as possible.  Patient's son states that she was hospitalized a couple weeks ago for suspected urinary tract infection.  He states following hospitalization she had significant weakness and she was discharged to assisted living for ongoing care.  While at assisted living the patient was noted to have significant respiratory distress and fevers, for which reason the patient was sent to the ER for further evaluation.  Patient was noted to be COVID positive.  She reports being vaccinated.  Patient is somewhat immunocompromised with her CLL.  On presentation, the patient was requiring high-flow nasal cannula to maintain appropriate saturations.  Patient does report that she uses 2-3 L of oxygen at night while sleeping, however she is unsure of any specific associated pulmonary diagnosis.  Anticipated care plan was discussed with the patient and her son.  Both report should patient's respiratory status worsen intubation is not desired.  Questions have been answered to patient and son satisfaction.  ASSESSMENT/PLAN: Acute on chronic respiratory failure with hypoxia  Assessment & Plan Patient reports baseline oxygen needs of 2-3 L at night Patient was requiring high-flow nasal cannula on admission secondary to pneumonia   Continue weaning oxygen as tolerated otherwise treatment as outlined under pneumonia   * Pneumonia Assessment & Plan Patient with noted positive COVID test in the emergency department (11/18/2012) Unclear whether pneumonia is bacterial in nature or related to COVID-19.   Will continue to cover with IV Rocephin and azithromycin for potential bacterial pneumonia Additionally will start patient on 6 mg of Decadron for possible COVID pneumonia Routine monitoring of vitals Will monitor blood culture results Patient's home Eliquis should be adequate anticoagulation for patient's positive COVID status   Type 2 diabetes mellitus, without long-term current use of insulin  Assessment & Plan Very low-dose mealtime and corrective scale coverage while admitted Will continue trending patient's bedside glucose for further titration   CLL (chronic lymphocytic leukemia)  Assessment & Plan Likely cause of patient's noted leukocytosis Will continue monitoring complete blood count throughout admission   Atrial fibrillation  Assessment & Plan Continue Eliquis for anticoagulation and metoprolol for rate control   Atrophic kidney Assessment & Plan Patient's son reports a history of an atrophic kidney he states his chronically infected.  He notes patient recently underwent a 10 day antibiotic course.  UA in kidney function reviewed.  No further indication of ongoing urinary infection is noted and patient has appropriate kidney function
Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Staphylococcus test positive, Urinary tract infection, Urine analysis normal, White blood cell count
Clinical narrative: Patient currently inpatient at (8) days starting from 11/18/2021. Patient is a 90 y.o. female who presents today with shortness of breath.  History is limited from the patient, however patient's son provides additional history as possible.  Patient's son states that she was hospitalized a couple weeks ago for suspected urinary tract infection.  He states following hospitalization she had significant weakness and she was discharged to assisted living for ongoing care.  While at assisted living the patient was noted to have significant respiratory distress and fevers, for which reason the patient was sent to the ER for further evaluation.  Patient was noted to be COVID positive.  She reports being vaccinated.  Patient is somewhat immunocompromised with her CLL.  On presentation, the patient was requiring high-flow nasal cannula to maintain appropriate saturations.  Patient does report that she uses 2-3 L of oxygen at night while sleeping, however she is unsure of any specific associated pulmonary diagnosis.  Anticipated care plan was discussed with the patient and her son.  Both report should patient's respiratory status worsen intubation is not desired.  Questions have been answered to patient and son satisfaction.  ASSESSMENT/PLAN: Acute on chronic respiratory failure with hypoxia  Assessment & Plan Patient reports baseline oxygen needs of 2-3 L at night Patient was requiring high-flow nasal cannula on admission secondary to pneumonia   Continue weaning oxygen as tolerated otherwise treatment as outlined under pneumonia   * Pneumonia Assessment & Plan Patient with noted positive COVID test in the emergency department (11/18/2012) Unclear whether pneumonia is bacterial in nature or related to COVID-19.   Will continue to cover with IV Rocephin and azithromycin for potential bacterial pneumonia Additionally will start patient on 6 mg of Decadron for possible COVID pneumonia Routine monitoring of vitals Will monitor blood culture results Patient's home Eliquis should be adequate anticoagulation for patient's positive COVID status   Type 2 diabetes mellitus, without long-term current use of insulin  Assessment & Plan Very low-dose mealtime and corrective scale coverage while admitted Will continue trending patient's bedside glucose for further titration   CLL (chronic lymphocytic leukemia)  Assessment & Plan Likely cause of patient's noted leukocytosis Will continue monitoring complete blood count throughout admission   Atrial fibrillation  Assessment & Plan Continue Eliquis for anticoagulation and metoprolol for rate control   Atrophic kidney Assessment & Plan Patient's son reports a history of an atrophic kidney he states his chronically infected.  He notes patient recently underwent a 10 day antibiotic course.  UA in kidney function reviewed.  No further indication of ongoing urinary infection is noted and patient has appropriate kidney function
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, Benign prostatic hyperplasia, Bipolar disorder, Blood culture negative, COVID-19
Clinical narrative: Patient currently admitted inpatient stay at (6) days starting 11/20/2021  Patient is a 69 y.o. male who presents today with weakness. He has been in his usual state of health, (which is difficult to define, pt scattered historian; has hospital bed because can't breathe laying down, though has normal echo from April 2021, gets around by walking slowly) till today when felt so weak, he couldn't get out of bed. Does have HH to help with needs. PMH of diabetes mellitus, BPH, bipolar, hypertension.    In the ED, he was stable, with slight tachycardia 90-100 and fever 101F, CXR showed infiltrate left lower lobe, He was given fluids and tylenol, as well as decadron since he tested (+) for Covid. He is vaccinated. He requires admission for sepsis due to pneumonia.   ASSESSMENT / PLAN: Pneumonia due to infectious organism Assessment & Plan -Left sided -Pt is a community dweller, no recent hospitalizations  -Low index of suspicion for MRSA, pseudomonas -Not having productive cough -Maintaining sats on room air -Tx for CAP--azithromycin, rocephin     * Sepsis without acute organ dysfunction  Assessment & Plan -Pneumonia most likely source  -Blood cultures pending -Pt has received 2L of fluid, start LR at 200 as still appears dry, HR 90's     COVID Assessment & Plan -Tested positive, but is vaccinated -Has no hypoxia; eating/drinking well -Cause of sepsis seems to be a bacterial pneumonia -Will give BID lovenox, but hold off on steroids, antivirals for now     Type 2 diabetes mellitus with diabetic autonomic neuropathy, without long-term current use of insulin Assessment & Plan -On multiple antihyperglycemics, not insulin -Lantus 10 HS and SSI   Bipolar disorder in full remission Assessment & Plan -Latuda not in formulary, pt cannot get meds from home -Sub geodon, continue Zyprexa   Benign prostatic hyperplasia with urinary frequency Assessment & Plan -Continue finasteride, tamsulosin   Hypertension, benign Assessment & Plan -Continue losartan, hold spironolactone/Lasix
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19 pneumonia, Chest X-ray abnormal, Condition aggravated, Diabetic autonomic neuropathy, Dyspnoea
Clinical narrative: Patient currently admitted inpatient stay at (6) days starting 11/20/2021  Patient is a 69 y.o. male who presents today with weakness. He has been in his usual state of health, (which is difficult to define, pt scattered historian; has hospital bed because can't breathe laying down, though has normal echo from April 2021, gets around by walking slowly) till today when felt so weak, he couldn't get out of bed. Does have HH to help with needs. PMH of diabetes mellitus, BPH, bipolar, hypertension.    In the ED, he was stable, with slight tachycardia 90-100 and fever 101F, CXR showed infiltrate left lower lobe, He was given fluids and tylenol, as well as decadron since he tested (+) for Covid. He is vaccinated. He requires admission for sepsis due to pneumonia.   ASSESSMENT / PLAN: Pneumonia due to infectious organism Assessment & Plan -Left sided -Pt is a community dweller, no recent hospitalizations  -Low index of suspicion for MRSA, pseudomonas -Not having productive cough -Maintaining sats on room air -Tx for CAP--azithromycin, rocephin     * Sepsis without acute organ dysfunction  Assessment & Plan -Pneumonia most likely source  -Blood cultures pending -Pt has received 2L of fluid, start LR at 200 as still appears dry, HR 90's     COVID Assessment & Plan -Tested positive, but is vaccinated -Has no hypoxia; eating/drinking well -Cause of sepsis seems to be a bacterial pneumonia -Will give BID lovenox, but hold off on steroids, antivirals for now     Type 2 diabetes mellitus with diabetic autonomic neuropathy, without long-term current use of insulin Assessment & Plan -On multiple antihyperglycemics, not insulin -Lantus 10 HS and SSI   Bipolar disorder in full remission Assessment & Plan -Latuda not in formulary, pt cannot get meds from home -Sub geodon, continue Zyprexa   Benign prostatic hyperplasia with urinary frequency Assessment & Plan -Continue finasteride, tamsulosin   Hypertension, benign Assessment & Plan -Continue losartan, hold spironolactone/Lasix
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Hypertension, Lung infiltration, Lung opacity, Mobility decreased, Pneumonia
Clinical narrative: Patient currently admitted inpatient stay at (6) days starting 11/20/2021  Patient is a 69 y.o. male who presents today with weakness. He has been in his usual state of health, (which is difficult to define, pt scattered historian; has hospital bed because can't breathe laying down, though has normal echo from April 2021, gets around by walking slowly) till today when felt so weak, he couldn't get out of bed. Does have HH to help with needs. PMH of diabetes mellitus, BPH, bipolar, hypertension.    In the ED, he was stable, with slight tachycardia 90-100 and fever 101F, CXR showed infiltrate left lower lobe, He was given fluids and tylenol, as well as decadron since he tested (+) for Covid. He is vaccinated. He requires admission for sepsis due to pneumonia.   ASSESSMENT / PLAN: Pneumonia due to infectious organism Assessment & Plan -Left sided -Pt is a community dweller, no recent hospitalizations  -Low index of suspicion for MRSA, pseudomonas -Not having productive cough -Maintaining sats on room air -Tx for CAP--azithromycin, rocephin     * Sepsis without acute organ dysfunction  Assessment & Plan -Pneumonia most likely source  -Blood cultures pending -Pt has received 2L of fluid, start LR at 200 as still appears dry, HR 90's     COVID Assessment & Plan -Tested positive, but is vaccinated -Has no hypoxia; eating/drinking well -Cause of sepsis seems to be a bacterial pneumonia -Will give BID lovenox, but hold off on steroids, antivirals for now     Type 2 diabetes mellitus with diabetic autonomic neuropathy, without long-term current use of insulin Assessment & Plan -On multiple antihyperglycemics, not insulin -Lantus 10 HS and SSI   Bipolar disorder in full remission Assessment & Plan -Latuda not in formulary, pt cannot get meds from home -Sub geodon, continue Zyprexa   Benign prostatic hyperplasia with urinary frequency Assessment & Plan -Continue finasteride, tamsulosin   Hypertension, benign Assessment & Plan -Continue losartan, hold spironolactone/Lasix
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Pneumonia bacterial, Pollakiuria, Pyrexia, SARS-CoV-2 test positive, Sepsis
Clinical narrative: Patient currently admitted inpatient stay at (6) days starting 11/20/2021  Patient is a 69 y.o. male who presents today with weakness. He has been in his usual state of health, (which is difficult to define, pt scattered historian; has hospital bed because can't breathe laying down, though has normal echo from April 2021, gets around by walking slowly) till today when felt so weak, he couldn't get out of bed. Does have HH to help with needs. PMH of diabetes mellitus, BPH, bipolar, hypertension.    In the ED, he was stable, with slight tachycardia 90-100 and fever 101F, CXR showed infiltrate left lower lobe, He was given fluids and tylenol, as well as decadron since he tested (+) for Covid. He is vaccinated. He requires admission for sepsis due to pneumonia.   ASSESSMENT / PLAN: Pneumonia due to infectious organism Assessment & Plan -Left sided -Pt is a community dweller, no recent hospitalizations  -Low index of suspicion for MRSA, pseudomonas -Not having productive cough -Maintaining sats on room air -Tx for CAP--azithromycin, rocephin     * Sepsis without acute organ dysfunction  Assessment & Plan -Pneumonia most likely source  -Blood cultures pending -Pt has received 2L of fluid, start LR at 200 as still appears dry, HR 90's     COVID Assessment & Plan -Tested positive, but is vaccinated -Has no hypoxia; eating/drinking well -Cause of sepsis seems to be a bacterial pneumonia -Will give BID lovenox, but hold off on steroids, antivirals for now     Type 2 diabetes mellitus with diabetic autonomic neuropathy, without long-term current use of insulin Assessment & Plan -On multiple antihyperglycemics, not insulin -Lantus 10 HS and SSI   Bipolar disorder in full remission Assessment & Plan -Latuda not in formulary, pt cannot get meds from home -Sub geodon, continue Zyprexa   Benign prostatic hyperplasia with urinary frequency Assessment & Plan -Continue finasteride, tamsulosin   Hypertension, benign Assessment & Plan -Continue losartan, hold spironolactone/Lasix
Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Tachycardia, Type 2 diabetes mellitus
Clinical narrative: Patient currently admitted inpatient stay at (6) days starting 11/20/2021  Patient is a 69 y.o. male who presents today with weakness. He has been in his usual state of health, (which is difficult to define, pt scattered historian; has hospital bed because can't breathe laying down, though has normal echo from April 2021, gets around by walking slowly) till today when felt so weak, he couldn't get out of bed. Does have HH to help with needs. PMH of diabetes mellitus, BPH, bipolar, hypertension.    In the ED, he was stable, with slight tachycardia 90-100 and fever 101F, CXR showed infiltrate left lower lobe, He was given fluids and tylenol, as well as decadron since he tested (+) for Covid. He is vaccinated. He requires admission for sepsis due to pneumonia.   ASSESSMENT / PLAN: Pneumonia due to infectious organism Assessment & Plan -Left sided -Pt is a community dweller, no recent hospitalizations  -Low index of suspicion for MRSA, pseudomonas -Not having productive cough -Maintaining sats on room air -Tx for CAP--azithromycin, rocephin     * Sepsis without acute organ dysfunction  Assessment & Plan -Pneumonia most likely source  -Blood cultures pending -Pt has received 2L of fluid, start LR at 200 as still appears dry, HR 90's     COVID Assessment & Plan -Tested positive, but is vaccinated -Has no hypoxia; eating/drinking well -Cause of sepsis seems to be a bacterial pneumonia -Will give BID lovenox, but hold off on steroids, antivirals for now     Type 2 diabetes mellitus with diabetic autonomic neuropathy, without long-term current use of insulin Assessment & Plan -On multiple antihyperglycemics, not insulin -Lantus 10 HS and SSI   Bipolar disorder in full remission Assessment & Plan -Latuda not in formulary, pt cannot get meds from home -Sub geodon, continue Zyprexa   Benign prostatic hyperplasia with urinary frequency Assessment & Plan -Continue finasteride, tamsulosin   Hypertension, benign Assessment & Plan -Continue losartan, hold spironolactone/Lasix
Age: 42.0
Sex: F
Vaccine: COVID19
Symptoms: Thrombosis, Vaginal haemorrhage
Clinical narrative: 11/14/2021  Noticed I was passing clumps into the toilet. 11/15/2021 to 11/17/2021  Light vaginal bleeding; bright red. I have not had a period in over 2 years. I stopped having periods early 2019. 11/18/2021  Passed clots.
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Abdominal pain, Acquired diaphragmatic eventration, Acute kidney injury, Acute respiratory failure, Asthenia
Clinical narrative: Patient currently admitted at (5) days inpatient starting on 11/21/2021. Patient is a 79 y.o. male who presents today with weakness and diarrhea. The patient has a history of renal transplant, diabetes, CKD 3, HTN, HLD, COPD. The patient speaks another language and his son at bedside assists with translation. The patient is fully vaccinated for COVID and he was getting his booster shot on 11/18. Later that day he developed symptoms of fatigue and weakness. He then developed diarrhea and abdominal pain, fever and cough. He has some shortness of breath with activity. He came to the ER for evaluation.    In the ER the patient was COVID positive. He was found to be hypoxic requiring 2L NC. His CXR was negative for any acute abnormalities. He had labs showing AKI and hypokalemia. He was given decadron and potassium supplement. The hospitalist team was contacted for admission and further management.   ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure Assessment & Plan Secondary to COVID, no infiltrates noted on CXR at this time Symptom onset: 11/18 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 12/8 due to immune compromised status  Vaccination Status: Fully vaccinated, got his booster shot on the day of symptom onset  Continue supplemental O2, Titrate/wean to maintain SpO2>92% Continue Dexamethasone 1/10 Continue Remdesivir 1/5 Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: Full      AKI (acute kidney injury) Assessment & Plan Likely due to dehydration with poor PO intake and diarrhea  History of renal transplant Monitor renal function closely  Hold home lasix and lisinopril    COVID-19 virus infection Assessment & Plan Tested positive 11/21 Fully vaccinated, got booster the same day as symptom onset See plan above    COPD (chronic obstructive pulmonary disease) Assessment & Plan Continue inhalers  No wheezing on exam   Chronic kidney disease (CKD), stage III (moderate) Assessment & Plan Now with AKI Continue to monitor renal function closely    Dyslipidemia Assessment & Plan Continue statin    HTN (hypertension) Assessment & Plan BP stable Continue home metoprolol and hydralazine, hold home lisinopril and lasix with AKI   History of renal transplant Assessment & Plan Continue home tacrolimus, mycophenolate  Renal function worse than baseline, monitor closely    Type 2 diabetes mellitus  Assessment & Plan Last A1c 7.2, repeat pending Transition home levemir to lantus  Monitor blood sugars and adjust insulin as needed, anticipate hyperglycemia with steroid use
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Blood creatinine, Blood culture negative, C-reactive protein, COVID-19, Cardiomegaly
Clinical narrative: Patient currently admitted at (5) days inpatient starting on 11/21/2021. Patient is a 79 y.o. male who presents today with weakness and diarrhea. The patient has a history of renal transplant, diabetes, CKD 3, HTN, HLD, COPD. The patient speaks another language and his son at bedside assists with translation. The patient is fully vaccinated for COVID and he was getting his booster shot on 11/18. Later that day he developed symptoms of fatigue and weakness. He then developed diarrhea and abdominal pain, fever and cough. He has some shortness of breath with activity. He came to the ER for evaluation.    In the ER the patient was COVID positive. He was found to be hypoxic requiring 2L NC. His CXR was negative for any acute abnormalities. He had labs showing AKI and hypokalemia. He was given decadron and potassium supplement. The hospitalist team was contacted for admission and further management.   ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure Assessment & Plan Secondary to COVID, no infiltrates noted on CXR at this time Symptom onset: 11/18 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 12/8 due to immune compromised status  Vaccination Status: Fully vaccinated, got his booster shot on the day of symptom onset  Continue supplemental O2, Titrate/wean to maintain SpO2>92% Continue Dexamethasone 1/10 Continue Remdesivir 1/5 Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: Full      AKI (acute kidney injury) Assessment & Plan Likely due to dehydration with poor PO intake and diarrhea  History of renal transplant Monitor renal function closely  Hold home lasix and lisinopril    COVID-19 virus infection Assessment & Plan Tested positive 11/21 Fully vaccinated, got booster the same day as symptom onset See plan above    COPD (chronic obstructive pulmonary disease) Assessment & Plan Continue inhalers  No wheezing on exam   Chronic kidney disease (CKD), stage III (moderate) Assessment & Plan Now with AKI Continue to monitor renal function closely    Dyslipidemia Assessment & Plan Continue statin    HTN (hypertension) Assessment & Plan BP stable Continue home metoprolol and hydralazine, hold home lisinopril and lasix with AKI   History of renal transplant Assessment & Plan Continue home tacrolimus, mycophenolate  Renal function worse than baseline, monitor closely    Type 2 diabetes mellitus  Assessment & Plan Last A1c 7.2, repeat pending Transition home levemir to lantus  Monitor blood sugars and adjust insulin as needed, anticipate hyperglycemia with steroid use
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Central venous catheterisation, Chest X-ray abnormal, Cholecystectomy, Chronic kidney disease, Computerised tomogram head normal
Clinical narrative: Patient currently admitted at (5) days inpatient starting on 11/21/2021. Patient is a 79 y.o. male who presents today with weakness and diarrhea. The patient has a history of renal transplant, diabetes, CKD 3, HTN, HLD, COPD. The patient speaks another language and his son at bedside assists with translation. The patient is fully vaccinated for COVID and he was getting his booster shot on 11/18. Later that day he developed symptoms of fatigue and weakness. He then developed diarrhea and abdominal pain, fever and cough. He has some shortness of breath with activity. He came to the ER for evaluation.    In the ER the patient was COVID positive. He was found to be hypoxic requiring 2L NC. His CXR was negative for any acute abnormalities. He had labs showing AKI and hypokalemia. He was given decadron and potassium supplement. The hospitalist team was contacted for admission and further management.   ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure Assessment & Plan Secondary to COVID, no infiltrates noted on CXR at this time Symptom onset: 11/18 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 12/8 due to immune compromised status  Vaccination Status: Fully vaccinated, got his booster shot on the day of symptom onset  Continue supplemental O2, Titrate/wean to maintain SpO2>92% Continue Dexamethasone 1/10 Continue Remdesivir 1/5 Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: Full      AKI (acute kidney injury) Assessment & Plan Likely due to dehydration with poor PO intake and diarrhea  History of renal transplant Monitor renal function closely  Hold home lasix and lisinopril    COVID-19 virus infection Assessment & Plan Tested positive 11/21 Fully vaccinated, got booster the same day as symptom onset See plan above    COPD (chronic obstructive pulmonary disease) Assessment & Plan Continue inhalers  No wheezing on exam   Chronic kidney disease (CKD), stage III (moderate) Assessment & Plan Now with AKI Continue to monitor renal function closely    Dyslipidemia Assessment & Plan Continue statin    HTN (hypertension) Assessment & Plan BP stable Continue home metoprolol and hydralazine, hold home lisinopril and lasix with AKI   History of renal transplant Assessment & Plan Continue home tacrolimus, mycophenolate  Renal function worse than baseline, monitor closely    Type 2 diabetes mellitus  Assessment & Plan Last A1c 7.2, repeat pending Transition home levemir to lantus  Monitor blood sugars and adjust insulin as needed, anticipate hyperglycemia with steroid use
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Cough, Dehydration, Diarrhoea, Dyslipidaemia
Clinical narrative: Patient currently admitted at (5) days inpatient starting on 11/21/2021. Patient is a 79 y.o. male who presents today with weakness and diarrhea. The patient has a history of renal transplant, diabetes, CKD 3, HTN, HLD, COPD. The patient speaks another language and his son at bedside assists with translation. The patient is fully vaccinated for COVID and he was getting his booster shot on 11/18. Later that day he developed symptoms of fatigue and weakness. He then developed diarrhea and abdominal pain, fever and cough. He has some shortness of breath with activity. He came to the ER for evaluation.    In the ER the patient was COVID positive. He was found to be hypoxic requiring 2L NC. His CXR was negative for any acute abnormalities. He had labs showing AKI and hypokalemia. He was given decadron and potassium supplement. The hospitalist team was contacted for admission and further management.   ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure Assessment & Plan Secondary to COVID, no infiltrates noted on CXR at this time Symptom onset: 11/18 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 12/8 due to immune compromised status  Vaccination Status: Fully vaccinated, got his booster shot on the day of symptom onset  Continue supplemental O2, Titrate/wean to maintain SpO2>92% Continue Dexamethasone 1/10 Continue Remdesivir 1/5 Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: Full      AKI (acute kidney injury) Assessment & Plan Likely due to dehydration with poor PO intake and diarrhea  History of renal transplant Monitor renal function closely  Hold home lasix and lisinopril    COVID-19 virus infection Assessment & Plan Tested positive 11/21 Fully vaccinated, got booster the same day as symptom onset See plan above    COPD (chronic obstructive pulmonary disease) Assessment & Plan Continue inhalers  No wheezing on exam   Chronic kidney disease (CKD), stage III (moderate) Assessment & Plan Now with AKI Continue to monitor renal function closely    Dyslipidemia Assessment & Plan Continue statin    HTN (hypertension) Assessment & Plan BP stable Continue home metoprolol and hydralazine, hold home lisinopril and lasix with AKI   History of renal transplant Assessment & Plan Continue home tacrolimus, mycophenolate  Renal function worse than baseline, monitor closely    Type 2 diabetes mellitus  Assessment & Plan Last A1c 7.2, repeat pending Transition home levemir to lantus  Monitor blood sugars and adjust insulin as needed, anticipate hyperglycemia with steroid use
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea exertional, Endotracheal intubation, Fatigue, Fibrin D dimer, Full blood count
Clinical narrative: Patient currently admitted at (5) days inpatient starting on 11/21/2021. Patient is a 79 y.o. male who presents today with weakness and diarrhea. The patient has a history of renal transplant, diabetes, CKD 3, HTN, HLD, COPD. The patient speaks another language and his son at bedside assists with translation. The patient is fully vaccinated for COVID and he was getting his booster shot on 11/18. Later that day he developed symptoms of fatigue and weakness. He then developed diarrhea and abdominal pain, fever and cough. He has some shortness of breath with activity. He came to the ER for evaluation.    In the ER the patient was COVID positive. He was found to be hypoxic requiring 2L NC. His CXR was negative for any acute abnormalities. He had labs showing AKI and hypokalemia. He was given decadron and potassium supplement. The hospitalist team was contacted for admission and further management.   ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure Assessment & Plan Secondary to COVID, no infiltrates noted on CXR at this time Symptom onset: 11/18 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 12/8 due to immune compromised status  Vaccination Status: Fully vaccinated, got his booster shot on the day of symptom onset  Continue supplemental O2, Titrate/wean to maintain SpO2>92% Continue Dexamethasone 1/10 Continue Remdesivir 1/5 Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: Full      AKI (acute kidney injury) Assessment & Plan Likely due to dehydration with poor PO intake and diarrhea  History of renal transplant Monitor renal function closely  Hold home lasix and lisinopril    COVID-19 virus infection Assessment & Plan Tested positive 11/21 Fully vaccinated, got booster the same day as symptom onset See plan above    COPD (chronic obstructive pulmonary disease) Assessment & Plan Continue inhalers  No wheezing on exam   Chronic kidney disease (CKD), stage III (moderate) Assessment & Plan Now with AKI Continue to monitor renal function closely    Dyslipidemia Assessment & Plan Continue statin    HTN (hypertension) Assessment & Plan BP stable Continue home metoprolol and hydralazine, hold home lisinopril and lasix with AKI   History of renal transplant Assessment & Plan Continue home tacrolimus, mycophenolate  Renal function worse than baseline, monitor closely    Type 2 diabetes mellitus  Assessment & Plan Last A1c 7.2, repeat pending Transition home levemir to lantus  Monitor blood sugars and adjust insulin as needed, anticipate hyperglycemia with steroid use
Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Gastrointestinal tube insertion, Glycosylated haemoglobin increased, Hypertension, Hypokalaemia, Hypophagia
Clinical narrative: Patient currently admitted at (5) days inpatient starting on 11/21/2021. Patient is a 79 y.o. male who presents today with weakness and diarrhea. The patient has a history of renal transplant, diabetes, CKD 3, HTN, HLD, COPD. The patient speaks another language and his son at bedside assists with translation. The patient is fully vaccinated for COVID and he was getting his booster shot on 11/18. Later that day he developed symptoms of fatigue and weakness. He then developed diarrhea and abdominal pain, fever and cough. He has some shortness of breath with activity. He came to the ER for evaluation.    In the ER the patient was COVID positive. He was found to be hypoxic requiring 2L NC. His CXR was negative for any acute abnormalities. He had labs showing AKI and hypokalemia. He was given decadron and potassium supplement. The hospitalist team was contacted for admission and further management.   ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure Assessment & Plan Secondary to COVID, no infiltrates noted on CXR at this time Symptom onset: 11/18 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 12/8 due to immune compromised status  Vaccination Status: Fully vaccinated, got his booster shot on the day of symptom onset  Continue supplemental O2, Titrate/wean to maintain SpO2>92% Continue Dexamethasone 1/10 Continue Remdesivir 1/5 Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: Full      AKI (acute kidney injury) Assessment & Plan Likely due to dehydration with poor PO intake and diarrhea  History of renal transplant Monitor renal function closely  Hold home lasix and lisinopril    COVID-19 virus infection Assessment & Plan Tested positive 11/21 Fully vaccinated, got booster the same day as symptom onset See plan above    COPD (chronic obstructive pulmonary disease) Assessment & Plan Continue inhalers  No wheezing on exam   Chronic kidney disease (CKD), stage III (moderate) Assessment & Plan Now with AKI Continue to monitor renal function closely    Dyslipidemia Assessment & Plan Continue statin    HTN (hypertension) Assessment & Plan BP stable Continue home metoprolol and hydralazine, hold home lisinopril and lasix with AKI   History of renal transplant Assessment & Plan Continue home tacrolimus, mycophenolate  Renal function worse than baseline, monitor closely    Type 2 diabetes mellitus  Assessment & Plan Last A1c 7.2, repeat pending Transition home levemir to lantus  Monitor blood sugars and adjust insulin as needed, anticipate hyperglycemia with steroid use