CHIEF COMPLAINT: Tick bites and body aches.
SUBJECTIVE: Starting about 3 weeks ago, the patient had exposure to 26 known tick bites. They are all deer ticks. He is a (XX) and has frequent exposure, but this is the first time that he had this many and all at once.
Multiple ones of them were embedded by the time he was able to get them out. During the last 5 to 7 days, he has had body aches in all of his joints and also feeling of chills all over his body.
His appetite is a little bit diminished. He has had no cough, no fever, no nasal discharge, no shortness of breath.
He is otherwise feeling well and has no other complaints today.
OBJECTIVE:
VITAL SIGNS: Reviewed and in the chart.
GENERAL: The patient is a (XX)-year-old male, in no acute distress.
HEENT: Normocephalic and atraumatic. Hearing and vision are grossly intact.
LUNGS: Even unlabored respirations.
EXTREMITIES: Bulk symmetry, moves all extremities, ambulating with a steady gait.
SKIN: Multiple, erythematous flat lesions with scattered distribution all over his body. No site is warm and no site is indurated. There are no open areas and no drainage. Possible erythema migrans to left lower arm.
ASSESSMENT AND PLAN: This is a (XX)-year-old male with complaints of multiple tick bites and body aches. The body aches are most likely secondary to Lyme disease, and we are going to treat him with 100 mg of doxycycline twice daily for the next 21 days.
Advised him on appropriate use and potential side effects of this medication, including photosensitivity.
Recommended that he try to go easy on himself for a few days until he is starting to feel better. He should expect to start feeling himself feeling back to baseline in the next 5 to 7 days.
He should take the medication to completion. I would like for the patient to come back for reevaluation in approximately 1 week to ensure that he is actually improving.
Also, it would be worth evaluating the sites of the tick bites again to ensure that they are improving.
