You are working in a prison in New England. It is August.
subjective
Ms. Russell is a 38-year-old woman who presents to the clinic after dropping a Health Service Request for muscle and joint pain that began a few days ago. She is on the outside work detail at the local national park, and works in the forest Monday through Friday. When she arrives in Nurse Sick Call, she complains of feeling “super tired,” and having headache, generalized muscle pain, joint pain, neck stiffness, and poor appetite.
She denies fever, chills, nausea, vomiting, anorexia, constipation, abdominal pain, cough, runny nose, sore throat, ear pain, nasal congestion, rash, dysuria, urinary symptoms, shortness of breath and chest pain. She denies having a tick bite, although one of her co-workers said that she saw a tick on her arm while working a few days ago. She stated that she did have a rash that looked like the “ringworm” that her daughter used to get from their dog, but it is gone now.
Her health history includes hypothyroidism (diagnosed age 33 while incarcerated), benign hypertension (diagnosed age 35 while incarcerated), hypercholesteremia (diagnosed age 35 while incarcerated), for which she is being treated and followed in Chronic Disease Clinic. She is also obese. She had two Cesarean sections. She has had no other surgery. She has been incarcerated for the last 15 months and is due to be released in 9 months. Prior to incarceration, she was a smoker and social drinker. She denies substance use. Her family history includes diabetes, MI and CAD (father) and breast cancer, hypothyroidism, and diabetes (mother). Her family history is negative for autoimmune disease.
objective
Allergies
No known drug allergies; no known food allergies.
Current Medication
Levothyroxine 50 mcg daily;
Hydrochlorothiazide/lisinopril 12.5 mg/10 mg daily;
Atorvastatin 20 mg daily.
Patient also reports that she took some Tylenol for the pain prior to dropping the Sick Call Request.
Physical Assessment
Vitals: T 97.8°F; P 78; R 18; BP 130/86; HT 5’4”, WT 163 lbs, BMI 28.
No acute distress, communicates well, afebrile.
Psychiatric: Appropriate mood and affect.
Skin, Hair, and Nails: No skin rash or lesion appreciated. No abnormal findings with hair or nails.
Eyes: Conjunctiva and sclera clear, no injection or exudate.
ENT/Mouth: Ear canals clear, TMs pearly gray, intact with normal light reflex. No nasal deformity, pharynx without erythema or exudate.
Lungs: Clear to auscultation without adventitious sounds; good air movement throughout.
Heart: S1, S2, RRR, no murmurs, rubs or gallops auscultated; radial and femoral pulses strong and equal.
Abdomen: Soft, non-tender to palpation, + bowel sounds all quadrants; not distended.
Lymphatic: Bilaterally palpable lymph nodes – cervical, axillary, and inguinal.
Musculoskeletal: Muscle strength appropriate and equal bilaterally, full range of active and passive motion; muscle tenderness noted with movement and palpation – generalized.
Neurologic: A&O×4, cranial nerves II to XII intact.
Correctional Nurse Actions
Note the abnormal indications in Ms. Russell’s presentation, including muscle and joint weakness, and swollen lymph nodes, and the history of her working outside, in New England, with the possibility of a tick bite. A provider should be called, even though her vital signs are stable.
Provider Actions
Differential Diagnoses for Ms. Russell
•Fibromyalgia should be considered, but this patient’s duration of symptoms is short. In general, pain for longer than three months and in multiple sites are classic findings for Fibromyalgia. Duration in this case is much shorter. In addition, Fibromyalgia is a diagnosis of exclusion, so other causes must be examined.
•Systemic Lupus Erythematosus is also a possible diagnosis. A patient with muscle and joint pain may be considered for Systemic Lupus Erythematosus. In Ms. Russell’s case, her generalized lymphadenopathy is not consistent with Systemic Lupus Erythematosus, and her family history is not positive for any autoimmune condition.
•Osteoarthritis is often considered when a patient presents with joint pain. Ms. Russell’s acute symptoms including flu-like symptoms and generalized lymph nodes suggest her condition is probably something else.
•Influenza is certainly on the Differential Diagnosis list. The patient presented with influenza-like symptoms. However, in the northern hemisphere, influenza cases are typically most active between October and April and often present with fever higher than 99°F. Ms. Russell is presenting in August.
•Rocky Mountain Spotted Fever should be included as well. Although Rocky Mountain Spotted Fever may happen in any state, it is more commonly seen in six states (North Carolina, Oklahoma, Arkansas, Tennessee, Missouri, and Arizona). Rash is a typical sign in people with Rocky Mountain Spotted Fever. The rash usually develops 2 to 4 days after the fever begins. Ms. Russell has no fever or rash, making this a less likely diagnosis.
•Lyme disease is highly likely. The patient presents with muscle pain, joint pain, fatigue, headache, neck stiffness, and lack of appetite. She has recently been working in the woods in a region where Lyme disease is commonly seen. Her coworker said that she saw a tick on Ms. Russell while they were working outside. The diagnosis of Lyme’s Disease is also supported by her palpable lymph nodes. While Ms. Russell did not present with the usual erythema migrans (“Bull’s Eye”) lesion that is seen in approximately 80% of Lyme disease cases, the remainder of her history and presentation is highly suggestive of Lyme disease.
Diagnostic Tests/Imaging
Urine pregnancy test was done in the clinic to rule out pregnancy. Although she has been incarcerated for approximately 15 months, it is prudent to check for pregnancy so that the most effective antibiotic can be prescribed. Her pregnancy test was negative.
Blood testing is neither required nor recommended in Ms. Russell’s case. This is early-stage Lyme disease; she presents with constitutional symptoms after potentially having a tick bite. Therefore, serology would likely be negative and unnecessary.
PLAN
Ms. Russell is prescribed doxycycline 100 mg BID for 14 days.
Patient education regarding the suspected diagnosis (Lyme disease) and the use of Doxycycline and its potential side effects, including diarrhea and stomach pain if not taken with food was given. Ms. Russell’s questions were addressed and she verbalized an understanding of all teachings.
Ms. Russell was scheduled for a Provider Sick Call follow-up in one week, and instructed to contact healthcare staff immediately for any worsening of symptoms.
OUTCOME
Ms. Russell returned for her follow-up appointment in one week, and stated that she was doing better. Two months later, when she came for her Chronic Disease Clinic appointment for her hypothyroidism, hypertension, and hypercholesteremia, she was completely free of signs and symptoms.
Critical Thoughts
Screening Labs, Diagnosis Criteria, and Treatment Plan
For Lyme disease, if serology testing is performed too early (within 4 weeks of symptom onset), a patient may not have developed antibodies, resulting in a false-negative result. Therefore, negative results do not exclude active Lyme disease.
During the first few days after onset, Lyme disease often mimics flu-like symptoms and/or constitutional symptoms. There is no consistent distinctive pattern of symptoms to this diagnosis. Therefore, it is challenging for clinicians to make a confident, definitive diagnosis.
The oral antibiotic doxycycline is an appropriate treatment for early-stage Lyme disease and is a relatively benign treatment. Because of the challenges associated with the diagnosis, empiric oral antibiotic is an appropriate next step during early-stage disease even if there is some uncertainty about the diagnosis, given that rapid treatment is important to prevent long-term morbidity.
It is extremely important as Providers that we are good stewards of antibiotic therapy, only prescribing them when necessary, and educating our patients about antibiotic resistance. However, there are circumstances that present, like Ms. Russell and her Lyme disease signs and symptoms, when prescribing an antibiotic is appropriate even if you do not have the evidence to confirm the diagnosis. With Lyme disease, IgM antibodies appear within one to two weeks. Therefore, it is important to treat right away without ordering or waiting for labs.
In this case, Lyme disease was high on the differential diagnoses list, and so a number of questions were asked about tick bites, as well as questions about her symptoms. The patient history, if obtained properly and thoroughly, is the best way to develop your differential diagnoses for any patient presenting to you in the clinic.
References
Bockenstedt LK, Wormser GP. Review: unraveling Lyme disease. Arthritis Rheumatol. 2014;66(9):2313–2323. doi:10.1002/art
Cairns V. Lyme disease: implications for general practice. Br J Gen Pract. 2020;70(692):106–107. doi:10.3399/bjgp20X708341
Centers for Disease Control and Prevention. Lyme disease maps: most recent year. 2019. https://www.cdc.gov/lyme/datasurveillance/maps-recent.html
Nichols C, Windemuth B. Lyme disease: from early localized disease to post-Lyme disease syndrome. J Nurse Pract. 2013;9(6):362–367. doi:10.1016/j.nurpra.2013.04.017
Wijesinghe, Sampath. (2021). 101 Primary Care Case Studies: A workbook for clincal and bedside skills. Springer Publishing Company. Kindle edition.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
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