Age: 70.0
Sex: F
Vaccine: HEPA, MEN, TYP, YF
Symptoms: Renal impairment, Swollen tongue
Clinical narrative: 01/26/2017 Called patient today to see how her trip was. She states she did not get to go on trip because she ended back up in hospital. She states on the day she was discharged the first time, she had a fever and was given "2 ASA prior to discharge and told to take ASA every 6 hrs if she needed once she was home". She states she stayed home with a fever for 13 days, and realizes now she should have returned to MD sooner. She then went back to MD and they sent her back to hospital for 2-3 days, telling her she had a (?) "viral infection", and sent her home with antibiotics. I asked if she meant "bacterial" and she said she wasn't sure, but she completed antibiotics and feels much better now. She has regained her strength and is back to driving, shopping etc independently and is planning on going on trip  in  February. She stated she feels like the yellow fever vaccine is what may have caused her initial problems. 12/21/2016 Received call from nurse, stating patient did not show for appt yesterday. 12/21/2016 Spoke to nurse. She confirmed patient has appt today. We discussed PPH appt and vaccines received and recent hospitalization and symptoms. She explained hospitalization notes and treatment given. She explained patient's "problem list" from past visits with Dr and this hospitalization. Patient had told me she was put on "steroids" which made her react negatively and want to leave hospital. She states she became very agitated to "heart monitor and IV tubing and just wanted to go home. I was unclear if she left hospital or was discharged. She states she apologized to MD and he states many pts respond like that to steroids. She states she was told the tongue and throat swelling was from Ramipril she was taking and steroids were to treat swelling. She listed this as routine/regular med on PPH intake, but nurse states hospital notes indicate she told "them" she had just recently "started taking it again", so it was suspected she was experiencing acute angioedema and told not to take Ramipril ever again. Nurse listed other issues from patient's chart (problem list): essential HTN, Diabetes Type 2, hyperlipidemia, chronic Hep B disease, goiter, sickle cell trait, anemia (unspecified) benign neoplasm of colon, hx of elevated CRP, rheumatoid and osteo arthritis. Hospital notes also mentioned "acute renal failure superimposed on stage 3". Nurse could not find any other detailed history regarding kidney issues except creatinine was slightly elevated according to lab results from 4/16. Nurse she states either she or Dr will call and give me update after her appt. I also made contact with Dr today and will keep him updated as needed. 12/19/2016 Patient called office stating she has  experience medical issues since receiving vaccines on 11.21.16. She states she was "fine for 8 days after appt" and then began experiencing irregular heart beat, heart palpitations, fever (increased temps) and kidneys started to malfunction along with   [Due to memory limitations, the remainder of this text could not be compared.]   ng with throat and tongue swelling. Message I received was she went to ER this "past Wednesday (12/14/16) and "was there until Saturday 12/17/16. She states she showed "MD what shots she received and was told her "high BP meds are what caused swelling of throat and tongue", but other symptoms were from "shots". I called patient 12/19 to inquire about her status, she states she was put on steroids for swelling and she had "kidney malfunction" and irregular heart rate etc. She states she was "going crazy with the heart monitor and IV fluids and them getting all tangles in her gowns etc and having to get up so frequently to go to bathroom that she decided she needed to just go home. She doesn't remember if MD discharged her of if he "just knew she needed to go home so she was "discharged". She states she has a hard time eating much. She admitted she does not check her blood sugar at home due to expense of "blood sugar pads", but does take Metformin as directed. She states her BS was elevated during hospitalization. I recommended she follow up with PCP and make sure she is ok and able to travel. She states she has apt 12/20 with Dr, her PCP and will not travel if not healthy. 11/21/2016 Patient is traveling for pleasure. Reviewed CDC/PPH recommendations. She has history of Hep B infection. She states she got it when she was younger from a blood transfusion. She declined polio boost and is current with Tdap. Discussed importance of using insect repellant with 20-50% DEET and permethrin options. Discussed food and water precautions and risk of rabies. MALARONE 250/100mg #23 called to pharmacy. Message left on pharmacy VM. 11/21/2016 - Patient medical history reviewed/discussed. Patient advised of recommended immunizations/side effects for age and destination. Patient received itinerary. Current Vaccine Information Statements Available. Immunizations Recorded in Official Booklet. Counseled     01/26/2017 Called patient today to see how her trip was. She states she did not get to go on trip because she ended back up in hospital. She states on the day she was discharged the first time, she had a fever and was given "2 ASA prior to discharge and told to take ASA every 6 hrs if she needed once she was home". She states she stayed home with a fever for 13 days, and realizes now she should have returned to MD sooner. She then went back to MD and they sent her back to hospital for 2-3 days, telling her she had a (?) "viral infection", and sent her home with antibiotics. I asked if she meant "bacterial" and she said she wasn't sure, but she completed antibiotics and feels much better now. She has regained her strength and is back to driving, shopping etc independently and is planning on going on trip  in  February. She stated she feels like the yellow fever vaccine is what may have caused her initial problems. 12/21/2016 Received call from nurse, stating patient did not show for appt yesterday. 12/20/2016 Spoke to nurse. She confirmed patient has appt today. We discussed PPH appt and vaccines received and recent hospitalization and symptoms. She explained hospitalization notes and treatment given. She explained patient's "problem list" from past visits with Dr and this hospitalization. Patient had told me she was put on "steroids" which made her react negatively and want to leave hospital. She states she became very agitated to "heart monitor and IV tubing and just wanted to go home. I was unclear if she left hospital or was discharged. She states she apologized to MD and he states many pts respond like that to steroids. She states she was told the tongue and throat swelling was from Ramipril she was taking and steroids were to treat swelling. She listed this as routine/regular med on PPH intake, but nurse states hospital notes indicate she told "them" she had just recently "started taking it again", so it was suspected she was experiencing acute angioedema and told not to take Ramipril ever again. Nurse listed other issues from patient's chart (problem list): essential HTN, Diabetes Type 2, hyperlipidemia, chronic Hep B disease, goiter, sickle cell trait, anemia (unspecified) benign neoplasm of colon, hx of elevated CRP, rheumatoid and osteo arthritis. Hospital notes also mentioned "acute renal failure superimposed on stage 3". Nurse could not find any other detailed history regarding kidney issues except creatinine was slightly elevated according to lab results from 4/16. Nurse she states either she or Dr will call and give me update after her appt. I also made contact with Dr today and will keep him updated as needed. 12/19/2016 Patient called office stating she has  experience medical issues since receiving vaccines on 11.21.16. She states she was "fine for 8 days after appt" and then began experiencing irregular heart beat, heart palpitations, fever (increased temps) and kidneys started to malfunction along with [Due to memory limitations, the remainder of this text could not be compared.]   ng with throat and tongue swelling. Message I received was she went to ER this "past Wednesday (12/14/16) and "was there until Saturday 12/17/16. She states she showed "MD what shots she received and was told her "high BP meds are what caused swelling of throat and tongue", but other symptoms were from "shots". I called patient 12/19 to inquire about her status, she states she was put on steroids for swelling and she had "kidney malfunction" and irregular heart rate etc. She states she was "going crazy with the heart monitor and IV fluids and them getting all tangles in her gowns etc and having to get up so frequently to go to bathroom that she decided she needed to just go home. She doesn't remember if MD discharged her of if he "just knew she needed to go home so she was "discharged". She states she has a hard time eating much. She admitted she does not check her blood sugar at home due to expense of "blood sugar pads", but does take Metformin as directed. She states her BS was elevated during hospitalization. I recommended she follow up with PCP and make sure she is ok and able to travel. She states she has apt 12/20 with Dr, her PCP and will not travel if not healthy. 11/21/2016 Patient is traveling for pleasure. Reviewed CDC/PPH recommendations. She has history of Hep B infection. She states she got it when she was younger from a blood transfusion. She declined polio boost and is current with Tdap. Discussed importance of using insect repellant with 20-50% DEET and permethrin options. Discussed food and water precautions and risk of rabies. MALARONE 250/100mg #23 called to pharmacy. Message left on pharmacy VM. 11/21/2016 - Patient medical history reviewed/discussed. Patient advised of recommended immunizations/side effects for age and destination. Patient received itinerary. Current Vaccine Information Statements Available. Immunizations Recorded in Official Booklet. Counseled