Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s reason for visit, such as:
Tick bite (describe location, date of attachment if known)
Erythema migrans rash (expanding red, circular rash) – if present
Systemic symptoms (fever, fatigue, headache, muscle aches) – if present
History of Present Illness:
Onset, duration, and location of the tick bite (if known).
Removal of the tick (describe method of removal if known).
Development of any rash at the bite site or elsewhere on the body.
Presence of any systemic symptoms like fever, fatigue, headache, muscle aches, or swollen lymph nodes.
Recent outdoor activities in tick-infested areas.
Past Medical History:
Known allergies (including medication allergies).
History of tick-borne illnesses (e’t., Lyme disease, Rocky Mountain spotted fever).
Immunocompromised status (if applicable).
Social History:
Recent travel history, especially to areas endemic for tick-borne diseases.
Occupation or hobbies that increase exposure to ticks (e.g., outdoor workers, hikers).
Pet ownership (dogs and cats can bring ticks indoors).
Physical Exam:
Vital signs (may be normal or show fever in some tick-borne illnesses).
Skin examination:
Assess the tick bite site for redness, swelling, or formation of an erythema migrans rash (expanding red, circular rash with a clear center).
Examine for any other rashes suggestive of tick-borne illnesses.
Lymph node examination (look for swollen lymph nodes).
Diagnostic Tests (as indicated):
Tick identification (if available): Helpful for determining potential risk of specific tick-borne diseases based on the tick species.
Blood tests:
Complete blood count (CBC) – may show non-specific findings like leukocytosis (elevated white blood cell count) in some infections.
Serologic testing for tick-borne illnesses: Timing is crucial as antibodies may take weeks to develop. Tests may include those for Lyme disease, Rocky Mountain spotted fever, ehrlichiosis, anaplasmosis, depending on suspicion based on geographic location and clinical presentation.
Assessment:
Tick bite confirmed (based on history or physical exam).
Presence or absence of erythema migrans rash.
Clinical suspicion of a specific tick-borne illness based on symptoms, geographic location, and potential tick exposure.
Consideration of alternative diagnoses (e.g., insect bite reaction, cellulitis).
Plan:
Prophylactic Antibiotics (consideration):
Doxycycline may be prescribed as a single dose for certain tick bites, especially in high-risk areas for Lyme disease, to prevent infection.
Decision depends on factors like geographic location, tick species (if identified), and presence of erythema migrans rash.
Antibiotic Treatment (if indicated):
If a specific tick-borne illness is diagnosed or highly suspected based on clinical presentation and serology testing, specific antibiotic regimens will be initiated based on the identified illness.
Observation: In some cases, observation with close follow-up may be recommended, especially if the tick bite is isolated and there are no concerning symptoms.
Referral: Consider referral to an infectious disease specialist for complex cases or those with diagnostic uncertainty.
Patient Education:
Educate the patient about tick-borne illnesses, their symptoms, and potential complications.
Provide information on tick bite prevention (e.g., using insect repellent, checking for ticks after outdoor activities).
Instruct the patient on recognizing signs and symptoms of tick-borne illnesses and to seek prompt medical attention if they develop.
Discuss the rationale for chosen management approach (prophylaxis, treatment, or observation).
Provide follow-up instructions (e.g., returning for a re-check, completing antibiotic course).
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. The diagnosis and management of tick bites and potential tick-borne illnesses require careful consideration of various factors and consultation with a healthcare professional familiar with local tick-borne diseases