chrisvoncsefalvay/vaers-narrative-generation huggingface dataset:
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Chronic left ventricular failure, Diabetes mellitus, Echocardiogram, Ejection fraction, Essential hypertension
Clinical narrative: Patient ID:  MRN:   Name:  Age: 89 y.o.  Birthday:   Admit Date: 8/17/2022 10:19 PM  Discharge Date: 8/23/2022  ?   Unit: 3A118/3A118A  Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Symptomatic bradycardia  Active Problems:    Diabetes mellitus    Persistent atrial fibrillation    Elevated d-dimer    Hypothyroid    Left ventricular systolic dysfunction    Essential hypertension  ckd3b           Hospital Course: Patient is a 89 y.o. male admitted with symptomatic bradycardia. Bb held. Cards assessed. ech owith ef of 40-45%, chronic systolic hf. Held lasix and given ivf for hypotension. PE, diagnosed on admission as well. Vq positive. Started on eliquis. Pulm rec 6 mo of oac. Chronic afib, but rate low. Covid 19 coincidentally diagnosed. Completed 5 days of remdesivir. Likely cause of PE, but no pneumonia or hypoxia. Dc with close f/u with cards / pcp     No new Assessment & Plan notes have been filed under this hospital service since the last note was generated.  Service: Hospitalist                 Physical Exam on the Date of Discharge:  Vitals: Blood pressure 120/73, pulse (!) 43, temperature 97.6 °F (36.4 °C), temperature source Oral, resp. rate 18, height 5' 6" (167.6 cm), weight 74.3 kg (163 lb 12.8 oz), SpO2 99 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard        @HOSPDCED@     Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO PULMONOLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  home     Discharge Condition:  fair
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Fibrin D dimer increased, Heart rate decreased, Hypotension, Hypothyroidism, Left ventricular dysfunction
Clinical narrative: Patient ID:  MRN:   Name:  Age: 89 y.o.  Birthday:   Admit Date: 8/17/2022 10:19 PM  Discharge Date: 8/23/2022  ?   Unit: 3A118/3A118A  Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Symptomatic bradycardia  Active Problems:    Diabetes mellitus    Persistent atrial fibrillation    Elevated d-dimer    Hypothyroid    Left ventricular systolic dysfunction    Essential hypertension  ckd3b           Hospital Course: Patient is a 89 y.o. male admitted with symptomatic bradycardia. Bb held. Cards assessed. ech owith ef of 40-45%, chronic systolic hf. Held lasix and given ivf for hypotension. PE, diagnosed on admission as well. Vq positive. Started on eliquis. Pulm rec 6 mo of oac. Chronic afib, but rate low. Covid 19 coincidentally diagnosed. Completed 5 days of remdesivir. Likely cause of PE, but no pneumonia or hypoxia. Dc with close f/u with cards / pcp     No new Assessment & Plan notes have been filed under this hospital service since the last note was generated.  Service: Hospitalist                 Physical Exam on the Date of Discharge:  Vitals: Blood pressure 120/73, pulse (!) 43, temperature 97.6 °F (36.4 °C), temperature source Oral, resp. rate 18, height 5' 6" (167.6 cm), weight 74.3 kg (163 lb 12.8 oz), SpO2 99 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard        @HOSPDCED@     Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO PULMONOLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  home     Discharge Condition:  fair
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Ventilation/perfusion scan
Clinical narrative: Patient ID:  MRN:   Name:  Age: 89 y.o.  Birthday:   Admit Date: 8/17/2022 10:19 PM  Discharge Date: 8/23/2022  ?   Unit: 3A118/3A118A  Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Symptomatic bradycardia  Active Problems:    Diabetes mellitus    Persistent atrial fibrillation    Elevated d-dimer    Hypothyroid    Left ventricular systolic dysfunction    Essential hypertension  ckd3b           Hospital Course: Patient is a 89 y.o. male admitted with symptomatic bradycardia. Bb held. Cards assessed. ech owith ef of 40-45%, chronic systolic hf. Held lasix and given ivf for hypotension. PE, diagnosed on admission as well. Vq positive. Started on eliquis. Pulm rec 6 mo of oac. Chronic afib, but rate low. Covid 19 coincidentally diagnosed. Completed 5 days of remdesivir. Likely cause of PE, but no pneumonia or hypoxia. Dc with close f/u with cards / pcp     No new Assessment & Plan notes have been filed under this hospital service since the last note was generated.  Service: Hospitalist                 Physical Exam on the Date of Discharge:  Vitals: Blood pressure 120/73, pulse (!) 43, temperature 97.6 °F (36.4 °C), temperature source Oral, resp. rate 18, height 5' 6" (167.6 cm), weight 74.3 kg (163 lb 12.8 oz), SpO2 99 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard        @HOSPDCED@     Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO PULMONOLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  home     Discharge Condition:  fair
Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: Admitted to hospital.
Age: 27.0
Sex: F
Vaccine: COVID19
Symptoms: Delivery, Maternal exposure before pregnancy, Postpartum haemorrhage, Pre-eclampsia, Pregnancy
Clinical narrative: Patient Name:    Patient MRN:    Patient DOB:       Date of Admission: 8/17/2022     Date of Discharge: 8/20/2022     Diagnosis: Vaginal Delivery     Hospital Course                      OB History    Gravida   Para   Term   Preterm   AB   Living    2   2   1   1       2    SAB   IAB   Ectopic   Multiple   Live Births                0   2         #   Outcome   Date   GA   Lbr Len/2nd   Weight   Sex   Delivery   Anes   PTL   Lv    2   Preterm   08/18/22   35w4d       3.162 kg (6 lb 15.5 oz)   M   Vag-Spont   EPI       LIV    1   Term   03/04/21   37w0d       2.829 kg (6 lb 3.8 oz)   F   Vag-Vacuum   EPI       LIV       Complications: Mild preeclampsia, Postpartum hemorrhage             The patient  underwent a Vaginal delivery during this hospitalization.  She is now 2 days postpartum.  She has not had complications since the delivery.  She has not been febrile.  She did not have a surgical sterilization at the time of her delivery.       At the time of discharge, the patient was afebrile and has been tolerating a regular diet.  She has been ambulating and voiding without difficulty.  Denies symptoms of orthostasis.      Plan     She has been given discharge instructions which include the following: No straining, No lifting over 15 pounds, No sex, No tampons, No douche and No tub baths.  Follow up for a postpartum exam in 6 weeks.  Call for any signs of fever, foul discharge, increased bleeding, wound redness or draining, or signs of postpartum depression.     Discharge Medications     Motrin 800 mg one every 8 hours #30        Signed:  MD  8/20/2022  9:36 AM
Age: 27.0
Sex: F
Vaccine: COVID19
Symptoms: Premature labour, Vacuum extractor delivery
Clinical narrative: Patient Name:    Patient MRN:    Patient DOB:       Date of Admission: 8/17/2022     Date of Discharge: 8/20/2022     Diagnosis: Vaginal Delivery     Hospital Course                      OB History    Gravida   Para   Term   Preterm   AB   Living    2   2   1   1       2    SAB   IAB   Ectopic   Multiple   Live Births                0   2         #   Outcome   Date   GA   Lbr Len/2nd   Weight   Sex   Delivery   Anes   PTL   Lv    2   Preterm   08/18/22   35w4d       3.162 kg (6 lb 15.5 oz)   M   Vag-Spont   EPI       LIV    1   Term   03/04/21   37w0d       2.829 kg (6 lb 3.8 oz)   F   Vag-Vacuum   EPI       LIV       Complications: Mild preeclampsia, Postpartum hemorrhage             The patient  underwent a Vaginal delivery during this hospitalization.  She is now 2 days postpartum.  She has not had complications since the delivery.  She has not been febrile.  She did not have a surgical sterilization at the time of her delivery.       At the time of discharge, the patient was afebrile and has been tolerating a regular diet.  She has been ambulating and voiding without difficulty.  Denies symptoms of orthostasis.      Plan     She has been given discharge instructions which include the following: No straining, No lifting over 15 pounds, No sex, No tampons, No douche and No tub baths.  Follow up for a postpartum exam in 6 weeks.  Call for any signs of fever, foul discharge, increased bleeding, wound redness or draining, or signs of postpartum depression.     Discharge Medications     Motrin 800 mg one every 8 hours #30        Signed:  MD  8/20/2022  9:36 AM
Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Extra dose administered
Clinical narrative: Admitted to hospital.
Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Atrial fibrillation, COVID-19, Cardiac telemetry normal, Computerised tomogram head normal, Depressed level of consciousness
Clinical narrative: Patient ID:  Age: 63 y.o.  Admit Date: 8/17/2022  2:43 PM  Discharge Date:  8/20/2022  Admitting Physician:   Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Syncope  Active Problems:    DM (diabetes mellitus)    A-fib    COVID-19 virus infection    Headache    Essential hypertension           HPI:       Patient is a 63 y.o. male who is seen at ED after an unresponsive episode.  Patient currently reports that he lives at SNF and he went to the nursing desk and that was the last think that he would remember.  It was reported that he did have a syncopal event at the facility.  He reports that he has not noted any palpitations, chest pain, or SOA.  Admits to hx of seizure. Pt was difficult to arouse in the ED and a stroke alert was called.       Hospital Course: No notes on file     . Was admitted to neurology floor. He was on telemetry and there was no evidence of arrhythmia to explain this symptom. Orthostatic vitals not obtain as patient has difficulty sitting up or standing up from bed. He was given IV fluid hydration he was seen by neurology. Impression was possible pseudoseizure versus CVA versus acute metabolic encephalopathy. He has Covid 19 infection. He has no evidence of nocturnal infection. MRI of the head can be done as he have a cardio mems and spinal stimulator. He has been complaining of headache and he was given a cocktail for migraine headache and currently is improved. His back to his baseline. He was on airborne isolation because of the Covid 19 infection. He will be discharged to nursing home today.           Physical Exam on the Date of Discharge:  Physical exam:   General Appearance: alert, NAD   Neck: no JVD, no LN enlargement   Lungs: clear, no wheezing    Heart: RRR, S1 S2 heard   Abdomen / GI: soft, non-tender, no ascites   Extremities / musculoskeletal:  edema, no synovitis    Skin: no rash, dry skin   Neuro: follows commands, moves extremities            Consults:    IP CONSULT TO SOCIAL WORK     Significant Diagnostic Studies:     CT head: No acute abnormality.        Disposition:  SNF     Discharge Condition:  good
Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Diabetes mellitus, Dysstasia, Essential hypertension, Headache, Migraine
Clinical narrative: Patient ID:  Age: 63 y.o.  Admit Date: 8/17/2022  2:43 PM  Discharge Date:  8/20/2022  Admitting Physician:   Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Syncope  Active Problems:    DM (diabetes mellitus)    A-fib    COVID-19 virus infection    Headache    Essential hypertension           HPI:       Patient is a 63 y.o. male who is seen at ED after an unresponsive episode.  Patient currently reports that he lives at SNF and he went to the nursing desk and that was the last think that he would remember.  It was reported that he did have a syncopal event at the facility.  He reports that he has not noted any palpitations, chest pain, or SOA.  Admits to hx of seizure. Pt was difficult to arouse in the ED and a stroke alert was called.       Hospital Course: No notes on file     . Was admitted to neurology floor. He was on telemetry and there was no evidence of arrhythmia to explain this symptom. Orthostatic vitals not obtain as patient has difficulty sitting up or standing up from bed. He was given IV fluid hydration he was seen by neurology. Impression was possible pseudoseizure versus CVA versus acute metabolic encephalopathy. He has Covid 19 infection. He has no evidence of nocturnal infection. MRI of the head can be done as he have a cardio mems and spinal stimulator. He has been complaining of headache and he was given a cocktail for migraine headache and currently is improved. His back to his baseline. He was on airborne isolation because of the Covid 19 infection. He will be discharged to nursing home today.           Physical Exam on the Date of Discharge:  Physical exam:   General Appearance: alert, NAD   Neck: no JVD, no LN enlargement   Lungs: clear, no wheezing    Heart: RRR, S1 S2 heard   Abdomen / GI: soft, non-tender, no ascites   Extremities / musculoskeletal:  edema, no synovitis    Skin: no rash, dry skin   Neuro: follows commands, moves extremities            Consults:    IP CONSULT TO SOCIAL WORK     Significant Diagnostic Studies:     CT head: No acute abnormality.        Disposition:  SNF     Discharge Condition:  good
Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Oedema, Seizure, Sitting disability, Syncope, Unresponsive to stimuli
Clinical narrative: Patient ID:  Age: 63 y.o.  Admit Date: 8/17/2022  2:43 PM  Discharge Date:  8/20/2022  Admitting Physician:   Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Syncope  Active Problems:    DM (diabetes mellitus)    A-fib    COVID-19 virus infection    Headache    Essential hypertension           HPI:       Patient is a 63 y.o. male who is seen at ED after an unresponsive episode.  Patient currently reports that he lives at SNF and he went to the nursing desk and that was the last think that he would remember.  It was reported that he did have a syncopal event at the facility.  He reports that he has not noted any palpitations, chest pain, or SOA.  Admits to hx of seizure. Pt was difficult to arouse in the ED and a stroke alert was called.       Hospital Course: No notes on file     . Was admitted to neurology floor. He was on telemetry and there was no evidence of arrhythmia to explain this symptom. Orthostatic vitals not obtain as patient has difficulty sitting up or standing up from bed. He was given IV fluid hydration he was seen by neurology. Impression was possible pseudoseizure versus CVA versus acute metabolic encephalopathy. He has Covid 19 infection. He has no evidence of nocturnal infection. MRI of the head can be done as he have a cardio mems and spinal stimulator. He has been complaining of headache and he was given a cocktail for migraine headache and currently is improved. His back to his baseline. He was on airborne isolation because of the Covid 19 infection. He will be discharged to nursing home today.           Physical Exam on the Date of Discharge:  Physical exam:   General Appearance: alert, NAD   Neck: no JVD, no LN enlargement   Lungs: clear, no wheezing    Heart: RRR, S1 S2 heard   Abdomen / GI: soft, non-tender, no ascites   Extremities / musculoskeletal:  edema, no synovitis    Skin: no rash, dry skin   Neuro: follows commands, moves extremities            Consults:    IP CONSULT TO SOCIAL WORK     Significant Diagnostic Studies:     CT head: No acute abnormality.        Disposition:  SNF     Discharge Condition:  good
Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Blood pressure abnormal, Hypertensive encephalopathy, Magnetic resonance imaging abnormal, Metabolic encephalopathy
Clinical narrative: Admit Date:  8/17/2022     Discharge Date: 8/20/22     Principal Dx/ Final Dx:  Acute metabolic encephalopathy     Relevant Inpt Dx:  Principal Problem:    Acute metabolic encephalopathy  Active Problems:    Rheumatoid arthritis involving both wrists with positive rheumatoid factor    Essential hypertension           HPI:     Hospital Course:    This 84 year old man was admitted with acute metabolic encephalopathy.  It was felt to be hypertensive encephalopathy.  His BP improved and he has been doing well.  He is alert and conversant and ambulating in hall.  MRI shows chronic changes but nothing acute                 Consults:    IP CONSULT TO NEUROLOGY  IP CONSULT TO SOCIAL WORK           Disposition:  home     Discharge Condition:  fair
Age: 61.0
Sex: M
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: Admitted to hospital.
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Acute myocardial infarction, Ammonia normal, Asthenia, Blood creatinine increased, Blood gases
Clinical narrative: Physician Discharge Summary     Patient ID:  Age: 78 y.o.  Admit Date: 8/17/2022 11:14 PM  Discharge Date: 8/23/2022     Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Acute on chronic diastolic congestive heart failure  Active Problems:    Type 2 diabetes mellitus with peripheral neuropathy    NSTEMI (non-ST elevated myocardial infarction)    COVID-19    Acute renal failure superimposed on stage 3a chronic kidney disease    Benign essential HTN              Hospital Course: Patient is a 78 y.o. male admitted with a/c diastolic hf. Also covid + on admission. Received 5 years remdesivir. Was still undergoing diuresis. See plan below. Rehab called and accepting pt mid treatment. Dc with close f/u      * Acute on chronic diastolic congestive heart failure  ?Acute on chronic diastolic heart failure. IV Lasix 40 mg twice a day. Continue to monitor and O's and daily weights. reconsult cards. Echocardiogram ordered showing normal ejection fraction.   ?Chest pain/non-ST elevation MI: seen by cards earlier in stay. Troponins borderline elevated at 0.13-0.15. Not acute coronary syndrome pattern however. Stress normal.    ?Non sustained V tach. Cardiology reconsulted, reviewed, and cleared .    ?Covid 19:  Remdesivir completed 5 days, supplements, daily labs ordered. Monitor   ?Transient confusion likely secondary to use of benzodiazepine. Resolved. Family report recent memory changes as well. DC benzodiazepine and switched to Seroquel p.m. for insomnia. CT of the head shows chronic changes with no acute intracranial abnormality. Serum ammonia level is unremarkable. ABGs are reviewed. UA shows no evidence of UTI.    ?ATN per nephro. Creat still 1.8. Consult nephrology to assist.   ?Hypertension: Chronic. Continue home regimen. When necessary IV hydralazine ordered. Monitor   ?Diabetes: Chronic. Hold by mouth medications. Sliding scale ordered. Monitor   ?Debility. Feels. Weak, would like to consider inpatient rehab. PT/OT ordered. FOR SNF placement. SW following.    ?Hypoxia. Does not use O2 at home. 3L today.                      Physical Exam on the Date of Discharge:  Vitals: Blood pressure 140/62, pulse 52, temperature 97.7 °F (36.5 °C), temperature source Oral, resp. rate 18, height 5' 10" (177.8 cm), weight 65.1 kg (143 lb 9.6 oz), SpO2 98 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard             Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO NEPHROLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  SNF     Discharge Condition:  fair
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Cardiac failure acute, Cardiac failure congestive, Chest pain, Computerised tomogram head abnormal
Clinical narrative: Physician Discharge Summary     Patient ID:  Age: 78 y.o.  Admit Date: 8/17/2022 11:14 PM  Discharge Date: 8/23/2022     Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Acute on chronic diastolic congestive heart failure  Active Problems:    Type 2 diabetes mellitus with peripheral neuropathy    NSTEMI (non-ST elevated myocardial infarction)    COVID-19    Acute renal failure superimposed on stage 3a chronic kidney disease    Benign essential HTN              Hospital Course: Patient is a 78 y.o. male admitted with a/c diastolic hf. Also covid + on admission. Received 5 years remdesivir. Was still undergoing diuresis. See plan below. Rehab called and accepting pt mid treatment. Dc with close f/u      * Acute on chronic diastolic congestive heart failure  ?Acute on chronic diastolic heart failure. IV Lasix 40 mg twice a day. Continue to monitor and O's and daily weights. reconsult cards. Echocardiogram ordered showing normal ejection fraction.   ?Chest pain/non-ST elevation MI: seen by cards earlier in stay. Troponins borderline elevated at 0.13-0.15. Not acute coronary syndrome pattern however. Stress normal.    ?Non sustained V tach. Cardiology reconsulted, reviewed, and cleared .    ?Covid 19:  Remdesivir completed 5 days, supplements, daily labs ordered. Monitor   ?Transient confusion likely secondary to use of benzodiazepine. Resolved. Family report recent memory changes as well. DC benzodiazepine and switched to Seroquel p.m. for insomnia. CT of the head shows chronic changes with no acute intracranial abnormality. Serum ammonia level is unremarkable. ABGs are reviewed. UA shows no evidence of UTI.    ?ATN per nephro. Creat still 1.8. Consult nephrology to assist.   ?Hypertension: Chronic. Continue home regimen. When necessary IV hydralazine ordered. Monitor   ?Diabetes: Chronic. Hold by mouth medications. Sliding scale ordered. Monitor   ?Debility. Feels. Weak, would like to consider inpatient rehab. PT/OT ordered. FOR SNF placement. SW following.    ?Hypoxia. Does not use O2 at home. 3L today.                      Physical Exam on the Date of Discharge:  Vitals: Blood pressure 140/62, pulse 52, temperature 97.7 °F (36.5 °C), temperature source Oral, resp. rate 18, height 5' 10" (177.8 cm), weight 65.1 kg (143 lb 9.6 oz), SpO2 98 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard             Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO NEPHROLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  SNF     Discharge Condition:  fair
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Confusional state, Diabetes mellitus, Echocardiogram normal, Ejection fraction normal
Clinical narrative: Physician Discharge Summary     Patient ID:  Age: 78 y.o.  Admit Date: 8/17/2022 11:14 PM  Discharge Date: 8/23/2022     Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Acute on chronic diastolic congestive heart failure  Active Problems:    Type 2 diabetes mellitus with peripheral neuropathy    NSTEMI (non-ST elevated myocardial infarction)    COVID-19    Acute renal failure superimposed on stage 3a chronic kidney disease    Benign essential HTN              Hospital Course: Patient is a 78 y.o. male admitted with a/c diastolic hf. Also covid + on admission. Received 5 years remdesivir. Was still undergoing diuresis. See plan below. Rehab called and accepting pt mid treatment. Dc with close f/u      * Acute on chronic diastolic congestive heart failure  ?Acute on chronic diastolic heart failure. IV Lasix 40 mg twice a day. Continue to monitor and O's and daily weights. reconsult cards. Echocardiogram ordered showing normal ejection fraction.   ?Chest pain/non-ST elevation MI: seen by cards earlier in stay. Troponins borderline elevated at 0.13-0.15. Not acute coronary syndrome pattern however. Stress normal.    ?Non sustained V tach. Cardiology reconsulted, reviewed, and cleared .    ?Covid 19:  Remdesivir completed 5 days, supplements, daily labs ordered. Monitor   ?Transient confusion likely secondary to use of benzodiazepine. Resolved. Family report recent memory changes as well. DC benzodiazepine and switched to Seroquel p.m. for insomnia. CT of the head shows chronic changes with no acute intracranial abnormality. Serum ammonia level is unremarkable. ABGs are reviewed. UA shows no evidence of UTI.    ?ATN per nephro. Creat still 1.8. Consult nephrology to assist.   ?Hypertension: Chronic. Continue home regimen. When necessary IV hydralazine ordered. Monitor   ?Diabetes: Chronic. Hold by mouth medications. Sliding scale ordered. Monitor   ?Debility. Feels. Weak, would like to consider inpatient rehab. PT/OT ordered. FOR SNF placement. SW following.    ?Hypoxia. Does not use O2 at home. 3L today.                      Physical Exam on the Date of Discharge:  Vitals: Blood pressure 140/62, pulse 52, temperature 97.7 °F (36.5 °C), temperature source Oral, resp. rate 18, height 5' 10" (177.8 cm), weight 65.1 kg (143 lb 9.6 oz), SpO2 98 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard             Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO NEPHROLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  SNF     Discharge Condition:  fair
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Hypertension, Hypoxia, Insomnia, Left ventricular failure, Memory impairment
Clinical narrative: Physician Discharge Summary     Patient ID:  Age: 78 y.o.  Admit Date: 8/17/2022 11:14 PM  Discharge Date: 8/23/2022     Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Acute on chronic diastolic congestive heart failure  Active Problems:    Type 2 diabetes mellitus with peripheral neuropathy    NSTEMI (non-ST elevated myocardial infarction)    COVID-19    Acute renal failure superimposed on stage 3a chronic kidney disease    Benign essential HTN              Hospital Course: Patient is a 78 y.o. male admitted with a/c diastolic hf. Also covid + on admission. Received 5 years remdesivir. Was still undergoing diuresis. See plan below. Rehab called and accepting pt mid treatment. Dc with close f/u      * Acute on chronic diastolic congestive heart failure  ?Acute on chronic diastolic heart failure. IV Lasix 40 mg twice a day. Continue to monitor and O's and daily weights. reconsult cards. Echocardiogram ordered showing normal ejection fraction.   ?Chest pain/non-ST elevation MI: seen by cards earlier in stay. Troponins borderline elevated at 0.13-0.15. Not acute coronary syndrome pattern however. Stress normal.    ?Non sustained V tach. Cardiology reconsulted, reviewed, and cleared .    ?Covid 19:  Remdesivir completed 5 days, supplements, daily labs ordered. Monitor   ?Transient confusion likely secondary to use of benzodiazepine. Resolved. Family report recent memory changes as well. DC benzodiazepine and switched to Seroquel p.m. for insomnia. CT of the head shows chronic changes with no acute intracranial abnormality. Serum ammonia level is unremarkable. ABGs are reviewed. UA shows no evidence of UTI.    ?ATN per nephro. Creat still 1.8. Consult nephrology to assist.   ?Hypertension: Chronic. Continue home regimen. When necessary IV hydralazine ordered. Monitor   ?Diabetes: Chronic. Hold by mouth medications. Sliding scale ordered. Monitor   ?Debility. Feels. Weak, would like to consider inpatient rehab. PT/OT ordered. FOR SNF placement. SW following.    ?Hypoxia. Does not use O2 at home. 3L today.                      Physical Exam on the Date of Discharge:  Vitals: Blood pressure 140/62, pulse 52, temperature 97.7 °F (36.5 °C), temperature source Oral, resp. rate 18, height 5' 10" (177.8 cm), weight 65.1 kg (143 lb 9.6 oz), SpO2 98 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard             Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO NEPHROLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  SNF     Discharge Condition:  fair
Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Polyuria, SARS-CoV-2 test positive, Troponin increased, Urine analysis normal, Ventricular tachycardia
Clinical narrative: Physician Discharge Summary     Patient ID:  Age: 78 y.o.  Admit Date: 8/17/2022 11:14 PM  Discharge Date: 8/23/2022     Admitting Physician:    Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Acute on chronic diastolic congestive heart failure  Active Problems:    Type 2 diabetes mellitus with peripheral neuropathy    NSTEMI (non-ST elevated myocardial infarction)    COVID-19    Acute renal failure superimposed on stage 3a chronic kidney disease    Benign essential HTN              Hospital Course: Patient is a 78 y.o. male admitted with a/c diastolic hf. Also covid + on admission. Received 5 years remdesivir. Was still undergoing diuresis. See plan below. Rehab called and accepting pt mid treatment. Dc with close f/u      * Acute on chronic diastolic congestive heart failure  ?Acute on chronic diastolic heart failure. IV Lasix 40 mg twice a day. Continue to monitor and O's and daily weights. reconsult cards. Echocardiogram ordered showing normal ejection fraction.   ?Chest pain/non-ST elevation MI: seen by cards earlier in stay. Troponins borderline elevated at 0.13-0.15. Not acute coronary syndrome pattern however. Stress normal.    ?Non sustained V tach. Cardiology reconsulted, reviewed, and cleared .    ?Covid 19:  Remdesivir completed 5 days, supplements, daily labs ordered. Monitor   ?Transient confusion likely secondary to use of benzodiazepine. Resolved. Family report recent memory changes as well. DC benzodiazepine and switched to Seroquel p.m. for insomnia. CT of the head shows chronic changes with no acute intracranial abnormality. Serum ammonia level is unremarkable. ABGs are reviewed. UA shows no evidence of UTI.    ?ATN per nephro. Creat still 1.8. Consult nephrology to assist.   ?Hypertension: Chronic. Continue home regimen. When necessary IV hydralazine ordered. Monitor   ?Diabetes: Chronic. Hold by mouth medications. Sliding scale ordered. Monitor   ?Debility. Feels. Weak, would like to consider inpatient rehab. PT/OT ordered. FOR SNF placement. SW following.    ?Hypoxia. Does not use O2 at home. 3L today.                      Physical Exam on the Date of Discharge:  Vitals: Blood pressure 140/62, pulse 52, temperature 97.7 °F (36.5 °C), temperature source Oral, resp. rate 18, height 5' 10" (177.8 cm), weight 65.1 kg (143 lb 9.6 oz), SpO2 98 %.   General Appearance: alert, NAD  Lungs:  normal effort  Heart: S1 S2 heard             Consults:    IP CONSULT TO CARDIOLOGY  IP CONSULT TO CARDIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO NEPHROLOGY  IP CONSULT TO CARDIAC ELECTROPHYSIOLOGY              Disposition:  SNF     Discharge Condition:  fair
Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Extra dose administered
Clinical narrative: Admitted to hospital.
Age: 28.0
Sex: M
Vaccine: COVID19-2
Symptoms: Hyperhidrosis, Loss of consciousness, Pallor
Clinical narrative: Patient lost consciousness about 30 seconds after the vaccine was administered.  He was very pale and sweaty.  He regained consciousness with stimulation from his mother (a nurse practitioner) and then passed out again.  After about a minute he regained consciousness.  We asked his mother if she wanted us to call 911 and she said yes.  Our technician spoke to the 911 representative and they sent a team which arrived about 30 minutes later.  Patient slowly felt better and regained color in his face over about 20 minutes.  During that time we applied ice packs to neck and wrists.  His blood pressure was 110/72.  After the EMT team evaluated him, he declined transport and treatment and left with his mother because he felt much better.
Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: Admitted to hospital.
Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Extra dose administered
Clinical narrative: Admitted to hospital.
Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: Admitted to hospital.
Age: 73.0
Sex: F
Vaccine: COVID19-2
Symptoms: Acupuncture, Ear pain, Musculoskeletal stiffness, Nerve compression, Occipital neuralgia
Clinical narrative: None stated.
Age: 75.0
Sex: M
Vaccine: PPV
Symptoms: Injection site erythema, Injection site pain, Injection site swelling, Injection site warmth
Clinical narrative: Patient called with concerns about his arm below the injection site.   It was swollen and red.  Hot to touch and sore.  Just above the elbow bend.  Not at the injection site.  Complained about it like that the following date from injection.  No other symptoms described.  Just alerting us because he knew we probably needed to report it.  He was instructed to monitor with ice, ibu, and possible HCZ cream if needed.  If got worse or no better, then seek medical help.  Follow up with patient on 9/10.  Pt stated that his arm was ok and swelling almost all gone.  The only thing he did was ice and took a little asa.  No problems and was not concernend.
Age: 77.0
Sex: F
Vaccine: PNC20
Symptoms: Injection site erythema, Injection site pruritus, Injection site swelling, Injection site warmth
Clinical narrative: Patient complains of redness, itching, swollen, and hot to the touch at the injection site. Instructed patient to take Benadryl, and put ice on the injection site. If patient develops fever, then they are to seek medical attention. Patient said the inject site started bothering her the day after the injection was given, and has gotten worse every day since.
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Computerised tomogram thorax abnormal, Haemoptysis, Pneumonia, Pneumonia bacterial
Clinical narrative: Patient ID:  87 y.o.      Admit Date:  8/30/2022     Discharge Date: 9/2/22     Principal Dx/ Final Dx:  Pneumonia of both lower lobes due to infectious organism     Relevant Inpt Dx:  Principal Problem:    Pneumonia of both lower lobes due to infectious organism  Active Problems:    Dementia    Essential hypertension    Stage 3a chronic kidney disease           HPI:     Hospital Course:    This elderly man was admitted with pneumonia.  It was felt to be bacterial.  He was treated with antibiotics and nebs and is improved.  Today his lungs are without wheezes.  He will complete antibiotics orally and will also complete steroids.  He did test positive for covid but was not given remdesivir for this.  I feel his pneumonia is bacterial, not viral.  He did have hemoptysis; CT showed no mass and this is improved.        He does have htn and his BP medications were adjusted.             Consults:    IP CONSULT TO SOCIAL WORK           Disposition:  home     Discharge Condition:  fair
Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive
Clinical narrative: Patient ID:  87 y.o.      Admit Date:  8/30/2022     Discharge Date: 9/2/22     Principal Dx/ Final Dx:  Pneumonia of both lower lobes due to infectious organism     Relevant Inpt Dx:  Principal Problem:    Pneumonia of both lower lobes due to infectious organism  Active Problems:    Dementia    Essential hypertension    Stage 3a chronic kidney disease           HPI:     Hospital Course:    This elderly man was admitted with pneumonia.  It was felt to be bacterial.  He was treated with antibiotics and nebs and is improved.  Today his lungs are without wheezes.  He will complete antibiotics orally and will also complete steroids.  He did test positive for covid but was not given remdesivir for this.  I feel his pneumonia is bacterial, not viral.  He did have hemoptysis; CT showed no mass and this is improved.        He does have htn and his BP medications were adjusted.             Consults:    IP CONSULT TO SOCIAL WORK           Disposition:  home     Discharge Condition:  fair
Age: 74.0
Sex: F
Vaccine: COVID19-2
Symptoms: Bone pain, Chills, Fatigue, Injection site erythema, Injection site pain
Clinical narrative: Fever 101 degrees, chills, bones ached, body pain, fatigue 2 days, swollen itchy red and sore left arm still going on
Age: 74.0
Sex: F
Vaccine: COVID19-2
Symptoms: Injection site swelling, Pyrexia
Clinical narrative: Fever 101 degrees, chills, bones ached, body pain, fatigue 2 days, swollen itchy red and sore left arm still going on
Age: 66.0
Sex: F
Vaccine: TDAP, VARZOS
Symptoms: Erythema, Musculoskeletal stiffness, Pain, Skin warm
Clinical narrative: Redness, stiffness, warm and painful to the touch. No fevers or aches other than to the local area.
Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: Unevaluable event
Clinical narrative: Admitted to hospital.
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, COVID-19, Chronic kidney disease, Chronic obstructive pulmonary disease, Condition aggravated
Clinical narrative: tient ID:   82 y.o.       Admit Date:  8/30/2022     Discharge Date: 9/1/22     Principal Dx/ Final Dx:  COVID     Relevant Inpt Dx:  Principal Problem:    COVID  Active Problems:    Chronic obstructive pulmonary disease with acute exacerbation    Type 2 diabetes mellitus with diabetic polyneuropathy, without long-term current use of insulin    HTN (hypertension)    Tobacco abuse    Chronic kidney disease, stage III (moderate)ckd3a    Acute hypoxic respiratory failure        HPI:     Hospital Course:    This 82 year old man was admitted with covid and copd exacerbation.  He was hypoxic and required oxygen on admission.  He has improved.  Today he has no wheezing and his oxygen saturation is 92% on room air.  Follow up with pcp.  Complete steroids orally.                  Consults:    IP CONSULT TO SEPSIS NURSE NAVIGATOR  IP CONSULT TO SOCIAL WORK           Disposition:  home     Discharge Condition:  fair
Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Diabetic neuropathy, Hypertension, Tobacco abuse, Type 2 diabetes mellitus
Clinical narrative: tient ID:   82 y.o.       Admit Date:  8/30/2022     Discharge Date: 9/1/22     Principal Dx/ Final Dx:  COVID     Relevant Inpt Dx:  Principal Problem:    COVID  Active Problems:    Chronic obstructive pulmonary disease with acute exacerbation    Type 2 diabetes mellitus with diabetic polyneuropathy, without long-term current use of insulin    HTN (hypertension)    Tobacco abuse    Chronic kidney disease, stage III (moderate)ckd3a    Acute hypoxic respiratory failure        HPI:     Hospital Course:    This 82 year old man was admitted with covid and copd exacerbation.  He was hypoxic and required oxygen on admission.  He has improved.  Today he has no wheezing and his oxygen saturation is 92% on room air.  Follow up with pcp.  Complete steroids orally.                  Consults:    IP CONSULT TO SEPSIS NURSE NAVIGATOR  IP CONSULT TO SOCIAL WORK           Disposition:  home     Discharge Condition:  fair
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Angiogram, COVID-19, Catheter placement, Chronic obstructive pulmonary disease, Computerised tomogram abdomen abnormal
Clinical narrative: 60 y.o.       Admit Date:  8/30/2022     Discharge Date:   9/6/2022     Discharge Diagnosis:  Principal Problem:    Perinephric abscess, left  Active Problems:    COVID-19 virus infection    COPD with acute exacerbation    Failure of outpatient treatment    Essential hypertension    Uncontrolled type 2 diabetes mellitus with hyperglycemia    Hypomagnesemia        Hospital Course:  60 year old female was admitted with left perinephric abscess. She also required treatment for Covid-19 infection. She was septic from the abscess. She had placement of drain by IR on 8/31. Fluid culture and urin culture grew E coli. ID was involved and she has been on Merrem therapy. The drain was removed on 9/5 by urology. She has improved significantly. ID recommendation is for the patient to be continued on Ertapenem for 2 weeks from drain removal. She had mid line placed. She will be discharged home today with HH for continued therapy. Patient educated on appropriate level of care post-discharge. Follow up with urology and ID. Total discharge time >30 minutes.     Physical Exam on the day of discharge:  Last Recorded Vital Signs: Temp: 97.9 °F (36.6 °C)  Heart Rate (Monitor): 82  Pulse: 76  BP: 103/79  Respirations: 16  SpO2: 100 %  O2 Flow Rate (l/min): 0 l/min  General Appearance: no distress   Eyes: PERRLA  ENT: moist mucus membranes, no adenopathy  Lungs: clear to auscultation bilaterally   Heart: regular rate and rhythm  Abdomen: soft, non-tender   Skin: No rashes or lesions   Extremities: full ROM  Neuro: alert, normal strength and tone      Consults:  IP CONSULT TO UROLOGY  IP CONSULT TO INFECTIOUS DISEASES  IP CONSULT TO INTERVENTIONAL RADIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO IV THERAPY     Significant Diagnostic Studies:   CT abdomen and pelvis, CTA chest     Operations: Placement of 12 Fr percutaneous drain at left pararenal abscess under CT guidance        Disposition:  Home with HH
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Culture positive, Culture urine positive, Diabetes mellitus inadequate control, Drain placement, Drain removal
Clinical narrative: 60 y.o.       Admit Date:  8/30/2022     Discharge Date:   9/6/2022     Discharge Diagnosis:  Principal Problem:    Perinephric abscess, left  Active Problems:    COVID-19 virus infection    COPD with acute exacerbation    Failure of outpatient treatment    Essential hypertension    Uncontrolled type 2 diabetes mellitus with hyperglycemia    Hypomagnesemia        Hospital Course:  60 year old female was admitted with left perinephric abscess. She also required treatment for Covid-19 infection. She was septic from the abscess. She had placement of drain by IR on 8/31. Fluid culture and urin culture grew E coli. ID was involved and she has been on Merrem therapy. The drain was removed on 9/5 by urology. She has improved significantly. ID recommendation is for the patient to be continued on Ertapenem for 2 weeks from drain removal. She had mid line placed. She will be discharged home today with HH for continued therapy. Patient educated on appropriate level of care post-discharge. Follow up with urology and ID. Total discharge time >30 minutes.     Physical Exam on the day of discharge:  Last Recorded Vital Signs: Temp: 97.9 °F (36.6 °C)  Heart Rate (Monitor): 82  Pulse: 76  BP: 103/79  Respirations: 16  SpO2: 100 %  O2 Flow Rate (l/min): 0 l/min  General Appearance: no distress   Eyes: PERRLA  ENT: moist mucus membranes, no adenopathy  Lungs: clear to auscultation bilaterally   Heart: regular rate and rhythm  Abdomen: soft, non-tender   Skin: No rashes or lesions   Extremities: full ROM  Neuro: alert, normal strength and tone      Consults:  IP CONSULT TO UROLOGY  IP CONSULT TO INFECTIOUS DISEASES  IP CONSULT TO INTERVENTIONAL RADIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO IV THERAPY     Significant Diagnostic Studies:   CT abdomen and pelvis, CTA chest     Operations: Placement of 12 Fr percutaneous drain at left pararenal abscess under CT guidance        Disposition:  Home with HH
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Escherichia test positive, Essential hypertension, Hyperglycaemia, Hypomagnesaemia, Perinephric abscess
Clinical narrative: 60 y.o.       Admit Date:  8/30/2022     Discharge Date:   9/6/2022     Discharge Diagnosis:  Principal Problem:    Perinephric abscess, left  Active Problems:    COVID-19 virus infection    COPD with acute exacerbation    Failure of outpatient treatment    Essential hypertension    Uncontrolled type 2 diabetes mellitus with hyperglycemia    Hypomagnesemia        Hospital Course:  60 year old female was admitted with left perinephric abscess. She also required treatment for Covid-19 infection. She was septic from the abscess. She had placement of drain by IR on 8/31. Fluid culture and urin culture grew E coli. ID was involved and she has been on Merrem therapy. The drain was removed on 9/5 by urology. She has improved significantly. ID recommendation is for the patient to be continued on Ertapenem for 2 weeks from drain removal. She had mid line placed. She will be discharged home today with HH for continued therapy. Patient educated on appropriate level of care post-discharge. Follow up with urology and ID. Total discharge time >30 minutes.     Physical Exam on the day of discharge:  Last Recorded Vital Signs: Temp: 97.9 °F (36.6 °C)  Heart Rate (Monitor): 82  Pulse: 76  BP: 103/79  Respirations: 16  SpO2: 100 %  O2 Flow Rate (l/min): 0 l/min  General Appearance: no distress   Eyes: PERRLA  ENT: moist mucus membranes, no adenopathy  Lungs: clear to auscultation bilaterally   Heart: regular rate and rhythm  Abdomen: soft, non-tender   Skin: No rashes or lesions   Extremities: full ROM  Neuro: alert, normal strength and tone      Consults:  IP CONSULT TO UROLOGY  IP CONSULT TO INFECTIOUS DISEASES  IP CONSULT TO INTERVENTIONAL RADIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO IV THERAPY     Significant Diagnostic Studies:   CT abdomen and pelvis, CTA chest     Operations: Placement of 12 Fr percutaneous drain at left pararenal abscess under CT guidance        Disposition:  Home with HH
Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Sepsis, Treatment failure, Type 2 diabetes mellitus
Clinical narrative: 60 y.o.       Admit Date:  8/30/2022     Discharge Date:   9/6/2022     Discharge Diagnosis:  Principal Problem:    Perinephric abscess, left  Active Problems:    COVID-19 virus infection    COPD with acute exacerbation    Failure of outpatient treatment    Essential hypertension    Uncontrolled type 2 diabetes mellitus with hyperglycemia    Hypomagnesemia        Hospital Course:  60 year old female was admitted with left perinephric abscess. She also required treatment for Covid-19 infection. She was septic from the abscess. She had placement of drain by IR on 8/31. Fluid culture and urin culture grew E coli. ID was involved and she has been on Merrem therapy. The drain was removed on 9/5 by urology. She has improved significantly. ID recommendation is for the patient to be continued on Ertapenem for 2 weeks from drain removal. She had mid line placed. She will be discharged home today with HH for continued therapy. Patient educated on appropriate level of care post-discharge. Follow up with urology and ID. Total discharge time >30 minutes.     Physical Exam on the day of discharge:  Last Recorded Vital Signs: Temp: 97.9 °F (36.6 °C)  Heart Rate (Monitor): 82  Pulse: 76  BP: 103/79  Respirations: 16  SpO2: 100 %  O2 Flow Rate (l/min): 0 l/min  General Appearance: no distress   Eyes: PERRLA  ENT: moist mucus membranes, no adenopathy  Lungs: clear to auscultation bilaterally   Heart: regular rate and rhythm  Abdomen: soft, non-tender   Skin: No rashes or lesions   Extremities: full ROM  Neuro: alert, normal strength and tone      Consults:  IP CONSULT TO UROLOGY  IP CONSULT TO INFECTIOUS DISEASES  IP CONSULT TO INTERVENTIONAL RADIOLOGY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO SOCIAL WORK  IP CONSULT TO IV THERAPY     Significant Diagnostic Studies:   CT abdomen and pelvis, CTA chest     Operations: Placement of 12 Fr percutaneous drain at left pararenal abscess under CT guidance        Disposition:  Home with HH
Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Colonoscopy abnormal, Diverticulum, Gastrointestinal haemorrhage, Haemoglobin decreased, Heart rate increased
Clinical narrative: Patient ID:   Admit Date:  8/30/2022   Discharge Date: 9/2/22   Principal Dx/ Final Dx: BRBPR (bright red blood per rectum)   Relevant Inpt Dx: Principal Problem:   BRBPR (bright red blood per rectum) Active Problems:   COVID-19 virus infection   Essential hypertension   Atrial fibrillation       HPI:   Hospital Course:   This 71 year old man was admitted with GI bleeding.  He was seen by GI and his xarelto was held.  Bleeding felt to be lower GI bleeding.  Colonoscopy showed extensive diverticulosis and one polyp.   Source of bleeding felt diverticular . He has been cleared by GI to resume his xarelto.     He has a fib and did have some rapid rate due to missed medications.  He is back on home meds now.     hgb today is 10.8.  Repeat cbc next week.     @HOSPDCED@   Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK     Disposition:  home   Discharge Condition:  fair