Lyme Disease

Topics: Lyme disease, Tick, Ixodes scapularis Pages: 6 (1613 words) Published: February 6, 2012
Lyme Disease

Chief Complaint: Parents report that their son has been febrile for a few days and “he has been rubbing his right ear off and on”.


HPI: A six-year-old male patient was brought into the clinic accompanied by both parents (mother and father). They said there son was feverish over the last few days reporting the highest fever of a 100.1. Parents noticed him recently touching his right ear as if he had an ear infection. The mother treated her son with Children’s Tylenol that temporarily decreased his temperature and provided a slight improvement. Parents have noticed their son lying around a little more than usual and more “sleepy”. Patient denies having a headache and loss of appetite. Patient denies urinary frequency, urgency or excessive thirst. Patient denies N/V/D. Patient denies joint pain, or muscle pain. Upon further questioning and based on my subsequent physical exam (see below), parents said they had removed a tick from his head over two weeks ago. They did not “notice” a rash. They were outdoors having a picnic in the park during one of the last sunny days of fall and think he may have gotten the tick that day.

Note: Clinician/patient exchange may have been slightly compromised as a result of a language barrier.Their primary language is Spanish and clinician have intermediate Spanish speaking level.

▪ Mother removed a tick with a tweezers two weeks ago. ▪ The tick was above the ear auricle, near the hairline and below the temporal bone. ▪ No other past medical history or past surgical procedures. Allergies: NKDA

Health Maintenance:
▪ Patient’s parents report that the States recommended immunizations (for persons ages 1-6) are up to date. ▪ 2011-2012 Seasonal Influenza vaccine administered prior to this visit. Medications: None Reported

Social History:
▪ Patient not exposed to household smoke.
▪ Patient is the youngest of 4 children.
▪ Patient is in Kindergarten.
▪ Patient lives with Parents and three other siblings: ➢ Brother 7 years
➢ Sister 9 years
➢ Brother 10 years
Family Medical History:
• Mother age 28 with no medical problems.
• Father age 32 with no medical problems.
• Patient’s three siblings report no medical problems. • Grandparents have no known medical problems.


Physical Exam:
5-year-old Mexican American male, properly groomed, dressed appropriately for the weather, with a quiet and friendly demeanor. Patient politely follows commands. Vitals include:
BP 100/60
HR 82
Resp 18
SpO2 97%
Temp 100.1 oral.
Ht 46 inches/3 ft 10’
Wt 80lbs/36.25kg
BMI 26.58
Head: “Bull’s-eye” rash (see integument) observed between right temporal bone and right ear auricle. This area is tender based on palpation. No scars, lumps, lesions or hair loss noted. No facial asymmetry, involuntary movements or deformities. No flaking, dryness, scaling or lice noticed. Eyes: Pupils are equal, round, reactive to light and accommodation. Extra ocular movements in tact. Vision is grossly in tact. 20/20 OD, 20/30 OU. Orbits, eyelids, conjunctiva and sclera normal and clear with no discharge. Ears: Right and left tympanic membranes clear and in tact. No erythema, no discharge. Canals are clear. Hearing in tact with whisper test. Nose: No evidence of trauma, infection or inflammation. Moist and pink mucous membranes. Throat: The oral cavity is clear. The tongue is clear with no lesions noted. Neck: Neck is supple with no palpable masses. Bilateral Anterior lymphadenopathy. The thyroid gland is not palpable. The trachea is in midline. Integument: Erythema Migrans (EM) rash presenting above right ear near the temporal lobe receding into the hairline. The rash is 5cm in diameter, circular with a central red spot, surrounded by clear skin that is ringed by an expanding red rash. The rash area is warm to touch and non-tender to...
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