I saw pt in my office earlier than scheduled today because of severe back spasms. These have been starting at 15:00 each night for the last several nights. They last for about 3-4 hours. He tried to take ibuprofen without much benefit. His skin has been healing well from the previous biopsies. He denies recurrent fever. He has had more energy and was able to return to work day for 1/2 a day. Assessment: Painful back spasm, may be related to underlying serum sickness or medication. We will follow-up with a CT scan to see what is going on. Serum sickness. I gave him a script to get the CT scan performed in addition to a mammogram. He will return in 1-2 weeks. Thank you for allowing me to follow this pt with you. I saw pt in my office for follow-up today. My findings were as follows: Recent hospitalization for hypersensitivity to oral typhoid vaccine. Recent serum sickness attributed to vaccines. Bilateral gynecomastia. For future vaccines, I would not give him Typhoid vaccine at this time. I think that it is safe to complete his course of Hep-A vaccine. His mammogram was unremarkable, however for the palpable nodule, I think he should be the doctor who he saw approximately 3 years ago. If there is any question, I would have the breast tissue removed. I will see him again as needed. His appetite has improved, he denies nausea or vomiting. His rash has improved. He is still somewhat weak. He will continue on prednisone and IV antibiotics until his next visit. For his congestion, I gave him oral trimethoprim sulfa methoxazole. He will take 1 tab twice daily for 1 week. I advised him that if he should have any rash, to discontinue this immediately and contact our office. We may repeat his CT scan, but not at this time. I told him that he can begin walking, but no other exercising at this time. I will see him again in 1 week in follow-up. I saw pt in my office for consultation today. My findings were as follows: Fever of undetermined origin for 2 1/2 weeks duration. The pt reports that he has had previous oral Typhoid vaccine several years ago when he traveled, but had no reaction. He reports that after the second pill, he began to have fever, chills, myalgia, nausea and vomiting. He had had significant night sweats, headache, excessive fatigue. This has persisted for the 2 1/2 weeks. He completed taking the entire course of oral Typhoid. He has developed recurrent breast lump. He has night sweats, particularly whenever he takes ibuprofen. He thinks he has last weight (4 or 5 pounds). He frequently gets boils on his back. There are some old, crusted lesions on his legs. Summary of problems: fever, arthralgias, recent macular papular rash and abdominal discomfort with diarrhea. This most likely represents an adverse reaction to vaccine, I would be most suspicious of oral Typhoid vaccine. He did have the oral Typhoid vaccine once previously in 11/1996. It was appropriate to readminister as you require full course treatment every 5 years. Must consider the possibility of whether this could be a reaction to combination Hep-A, Hep-B or Meningococcal vaccine, though this seems less likely.  7/31/06 Received medical records from hospital where patient admitted 2/3/06-2/11/06.  Final dx: recent fever of 3 weeks duration of undetermined origin attributed to serum-sickness-like reaction related to recent travel vaccination with dyphoid, HepA&B & Menactra.  Patient had PMH of gynecomastia w/persisten breast mass.  Patient is plant biologist who travels extensively for work.  Had fever, chills, N&V, night sweats & diarrhea.  5# weight loss & arthralgias.  Consults of ID, GI, pulmonary & rheumatology included with records.  Multiple labs & x-ray reports included. /ss