Lyme Disease
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”.
SUBJECTIVE:
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.
PMH/PSH: ▪ 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.
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”.
SUBJECTIVE:
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.
PMH/PSH: ▪ 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.
References: Bickley, L. S. (2009). Bates’ Guide to Physical Examination and History Taking (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Bratton. RL, et al. Mayo Clinic Proceedings. (2008). Diagnosis and Treatment of Lyme Disease. 83(5):566-571. Buttaro, T. M., et al. (2008). Primary Care: a Collaborative Practice (3rd ed). Philadelphia, PA: Mosby Elsevier. Centers for Disease Control and Prevention. (2011). Lyme Disease. Atlanta, GA. Retrieved from http://www.cdc.gov/lyme/. Goldman, L.,Schafer, A. (2011). Goldman’s Cecil Medicine. 24th ed. Chapter 329-Lyme Disease. Retrieved from http://www.mdconsult.com.libproxy2.umdnj.edu/php/290531072-6/homepage