Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Follow-up for Lyme disease / New or worsening symptoms concerning Lyme disease (specify)
History of Present Illness:
For follow-up visits, inquire about any new or worsening symptoms since the last encounter (e.g., fatigue, muscle aches, joint pain, headaches, cognitive difficulties).
Describe the character, duration, and severity of new symptoms.
Mention any recent tick bites or exposure to tick-infested areas.
Briefly describe any changes in medications or adherence to treatment regimen.
Past Medical History:
Include the date of Lyme disease diagnosis and the stage of infection at diagnosis (early localized – erythema migrans rash, early disseminated – with symptoms beyond the initial rash location, late disseminated – involving nervous system, joints, or heart).
Mention any relevant past medical history, including:
Previous tick-borne illnesses
Underlying medical conditions
Medications:
List all current medications, including those specifically used for Lyme disease treatment (e.g., antibiotics – amoxicillin, doxycycline, cefuroxime axetil).
Social History:
Inquire about outdoor activities and potential tick exposure.
Family History:
Inquire about a family history of Lyme disease (not typically relevant but can be included if pertinent).
Physical Exam:
Vital signs: Include temperature (may be elevated with active infection).
General observation: Assess for signs of fatigue, joint swelling or tenderness.
Neurological exam: Evaluate for cognitive impairment, memory problems, or neurological deficits (e.g., facial palsy, numbness, weakness).
Musculoskeletal exam: Assess for joint pain, tenderness, or swelling.
Laboratory Tests (if performed):
ELISA and Western Blot tests: These blood tests are used to confirm Lyme disease diagnosis, but interpretation can be complex, and confirmatory testing with a different method may be required.
Complete blood count (CBC): May reveal elevated white blood cells if there is active infection.
Additional Testing (if indicated):
Lumbar puncture: To assess for Lyme meningitis (neurological involvement).
Electrocardiogram (ECG): To assess for Lyme carditis (heart involvement).
Joint aspiration: To analyze joint fluid for evidence of Lyme arthritis.
Assessment:
Lyme disease status: State whether Lyme disease is currently active, in remission, or if post-treatment Lyme disease syndrome (PTLDS) is suspected.
Severity of symptoms: Briefly describe the perceived severity of symptoms based on the patient’s report and physical examination findings.
Neurological involvement (if present): Describe any evidence of nervous system involvement.
Joint involvement (if present): Describe any joint pain, swelling, or limitations.
Plan:
Treatment:
Outline the treatment plan based on the stage of infection and the presence of ongoing symptoms. This may include:
Antibiotics: If active Lyme disease is confirmed, a course of antibiotics will be prescribed based on the specific bacteria identified and the stage of infection.
Anti-inflammatory medications: May be used to manage pain and inflammation associated with PTLDS.
Physical therapy: Can help improve mobility and function in patients with joint pain or weakness.
Monitoring: Schedule follow-up visits to monitor symptom improvement and address any potential complications.
Referral to a specialist: Consider referral to an infectious disease specialist for complex cases or suspected neurological or cardiac involvement.
Education:
Educate the patient about Lyme disease, transmission, symptoms, treatment options, and prevention strategies (avoiding tick bites, using insect repellent).
Discuss the possibility of PTLDS and the importance of reporting any persistent symptoms following antibiotic treatment.
Follow-up:
Schedule follow-up visits based on the severity of symptoms and the need for monitoring.
Advise the patient to return sooner if they experience worsening symptoms or develop new concerning symptoms suggestive of neurological or cardiac involvement.