Identifying Data

Date: July 9, 2019

Sex: Female

Age: 29 years old

Location: Stat-Care Astoria, Queens

Source of Information: self

 

Chief complaint: “I have a spider bite on left leg” x 1 week

 

HPI:

29 y/o female with no PMHx presents complaining of unknown spider bite. Pt reported receiving a bite last week from unknown spider on left calf. Pt did not visualize the spider. Over the past week, the bite has developed into a target area of ecchymosis. Pt denies any pain or pruritis over area of ecchymosis. Pt reports feeling normal over the past week. Yesterday, 3 hours after massage therapy, pt experienced intense sweating, cramping, weakness and dizziness. The symptoms spontaneously resolved after 40 minutes. Pt states that she has been feeling nauseas after training today, but otherwise is feeling well. Pt denies current chills, fever, sob, CP, diaphoresis, cramping, weakness, headache, dizziness. No recent travel or exposure to wooded areas.

 

Past medical history: denies

Past hospitalizations: denies

Surgical history: denies

Immunizations: up to date

Medications: denies

Family history: non-contributory

 

Social History: 29-year-old single female, living with roommate, employed as yoga instructor

Habits: pt denies smoking cigarettes or illicit drug use. Pt admits to drinking a mixed drink 1-2x/2 weeks

Diet: pt eats a well balanced diet

Exercise: pt exercises daily

Safety measures: pt admits to wearing a seatbelt

Sleep: 6-7h/night

Sexual history: Pt is not currently sexually active. Denies history of STDs

 

Review of Systems

General: Admits to weakness, chills. Denies fatigue, fever, loss of appetites, fever, night sweats, recent weight loss or gain.

Skin, hair, and nails: Admits to area of ecchymosis. Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritis and changes in hair distribution.

Head: Denies headache, vertigo, head trauma, unconsciousness, coma, fracture.

Eyes: denies visual disturbances, fatigue, lacrimation, photophobia or pruritis.

Ears: denies deafness, pain, discharge, tinnitus, and hearing aids

Nose/sinuses: denies discharge, epistaxis, and obstruction

Mouth and Throat: Denies sore throat, SOB, bleeding gums, sore tongue, mouth ulcers, voice changes, or dentures.

Neck: denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary System: Denies dyspnea, SOB, orthopnea, PND cough, wheezing, hemoptysis and cyanosis.

Cardiovascular: Denies CP, HTN, edema, palpitations, irregular heartbeat, and syncope.

Gastrointestinal system: denies nausea, vomiting, decreased appetite, intolerance to foods, hemorrhoids, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, constipation, rectal bleeding, blood in stool, pain in flank

Nervous: Admits to weakness and dizziness, Denies headaches seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory.

Musculoskeletal system: Denies muscle/joint pain, deformity of swelling, redness or arthritis

Peripheral vascular system: Denies varicose veins, peripheral edema, intermittent claudication, coldness or trophic changes, or color change

Hematological system:  Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric: Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional

 

 

Objective:

General: A/Ox3, in no acute distress, well developed, well nourished, appears stated age.

 

Vitals: Temp 99.4, HR 67, BP 111/80, Ht 5’ 8”, weight 130 lb, BMI 19.48, RR 15, O2 100%

 

Skin: 5 cm circular area of ecchymosis with central clearing on left lower leg, above lateral malleolus. Warm and moist with good turgor.

Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear

Visual fields full OU. PERRLA, EOMs full with no nystagmus.

Ears: Symmetrical and normal size. No evidence of lesions/masses/trauma on external ears.
No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/intact with light reflex in normal position AU.

Nose: Symmetrical, no obvious masses/lesions/deformities/trauma/discharge.

 

Mouth: Mucosa pink, moist, no evidence of masses, edema or lesions. Injected oropharynx, no evidence of exudate or inflammation.

 

Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM.

Heart: PMI in the 5^th ICS in mid-clavicular line. RRR. S1 and S2 are present. No S3, S4, splitting of heart sounds or murmurs present.

 

Chest: symmetrical, no deformities, no evidence of trauma. Respirations rapid, but unlabored/no paradoxical respirations or use of accessory muscles notes. Non-tender to palpation.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No adventitious sounds.

 

Abdomen: Flat, symmetrical, no evidence of striae, caput medusae or abnormal pulsations, BS present in all four quadrants. Non-tender to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

 

Extremities: Full range of motion, no edema, erythema, or deformities. Pulses intact throughout. No clubbing or cyanosis. Capillary refill <2 seconds throughout.

 

Neurological: A/O x3

 

DDx:

• Unknown insect bite
• Lyme disease
• Contact wound

 

Assessment: 29 y/o female with no PMHx presents complaining of unknown spider bite and single episode of weakness, dizziness and diaphoresis. Presentation consistent with non-venomous insect bite, rule out Lyme disease.

 

Plan:

 

Non-venomous insect bite:

• Labs: CBC, CRP, ESR, Lyme, CMP
• Return to office for follow up in 1 week for lab results and rash assessment
• Pt instructed to return to office or go to ED if episode of dizziness and diaphoresis returns.

 

Lab Results:

• CRP, CMP, CBC, ESR: WNL
• Lyme: positive