Lyme disease physical examination: Difference between revisions

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__NOTOC__
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{{Lyme disease}}
{{Lyme disease}}
{{CMG}} {{AE}}{{Anmol}}
{{CMG}};{{AE}}{{Anmol}}


==Overview==
==Overview==
The physical examination of [[Lyme disease]] is necessary for the diagnosis. Erythema migrans and [[fever]] are commonly seen on physical examination in early disease. [[Disseminated disease]] is characterized by multiple erythema migrans, [[Neurology|neurological]], [[musculoskeletal]], and [[cardiac]] symptoms.<ref name="Steere1989">{{cite journal|last1=Steere|first1=Allen C.|title=Lyme Disease|journal=New England Journal of Medicine|volume=321|issue=9|year=1989|pages=586–596|issn=0028-4793|doi=10.1056/NEJM198908313210906}}</ref>
The physical examination of [[Lyme disease]] is necessary for diagnosis. [[Erythema migrans]] and [[fever]] are commonly seen on physical examination in early disease.<ref name="pmid68597262">{{cite journal|author=Steere AC, Bartenhagen NH, Craft JE, Hutchinson GJ, Newman JH, Rahn DW et al.|title=The early clinical manifestations of Lyme disease.|journal=Ann Intern Med|year=1983|volume=99|issue=1|pages=76-82|pmid=6859726|doi=|pmc=|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6859726}}</ref> [[Disseminated disease]] is characterized by multiple [[erythema migrans]], [[Neurology|neurological]], [[musculoskeletal]], and [[cardiac]] symptoms.<ref name="Steere1989">{{cite journal|last1=Steere|first1=Allen C.|title=Lyme Disease|journal=New England Journal of Medicine|volume=321|issue=9|year=1989|pages=586–596|issn=0028-4793|doi=10.1056/NEJM198908313210906}}</ref>


==Physical Examination in Stage 1 - Early localized disease==
==Physical Examination in Stage 1 - Early localized disease==
{|
|
===Appearance of the patient===


===Appearance of the patient===
*Patients are usually well appearing in early stages but may appear [[fatigue|fatigued]]
*Patients are usually well appearing in early stages; may appear [[fatigue]].


===Vital signs===
===Vital signs===
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=== Skin ===
=== Skin ===
*Erythema migrans (target like lesions) - Usually single, present at the site of [[tick]] bite.
*[[Erythema migrans]] (target-like [[lesions]]): usually single, present at the site of [[tick]] bite
*Regional [[Lymphadenopathy]] - Around site of [[tick]] bite.
*Regional [[lymphadenopathy]]: around site of [[tick]] bite
*Some patients may have:
**Multiple annular [[lesions]]
**[[Malar rash]]
**Evanescent [[skin]] [[lesions]]
**[[Urticaria|Urticarial]] [[rash]]


===HEENT===
===HEENT===
*[[Headache]]
*[[Headache]]
*Pain on [[neck]] flexion
*Some patients may have:
**[[Pharyngitis]]
**[[Conjunctivitis]]
*Fewer patients may have:
**[[Periorbital edema]]
**[[Photophobia]]
**[[Ear pain]]


===Neck===
===Neck===
*[[Neck stiffness]]
*[[Neck stiffness]]
|
[[Image:Classic Lyme disease rash.jpg|thumb|250px| Classic Lyme disease rash - [https://www.cdc.gov/lyme/signs_symptoms/rashes.html Source: CDC.gov ]]]
[[Image:Lyme disease Expanding rash with central crust.jpg|thumb|250px|Lyme disease, expamding rash with central clearing - [https://www.cdc.gov/lyme/signs_symptoms/rashes.html Source: CDC.gov]]]
|}
=== Cardiovascular ===
* A small number of patients may have:
** [[Chest pain]]
=== Abdomen ===
* Some patients may have:
** [[Hepatomegaly]]
** [[Splenomegaly]]
** [[Right upper quadrant pain]]
* Fewer patients may have:
** Generalized [[Abdominal tenderness|tenderness]]
=== Neurological ===
* Some patients may have:
** [[Dysesthesia]]
** [[Dizziness]]


=== Muscukoskeletal ===
=== Muscukoskeletal ===
*[[Arthralgias]]
*Migratory [[arthralgias]]
*[[Myalgia]]
*[[Myalgia]]
*[[Back pain|Back ache]]
*Some patients may have:
**Frank [[arthritis]]
*Fewer patients may have:
**[[Muscle]] [[tenderness]]
**[[Hand]] [[stiffness]]
==Physical Examination in Stage 2 - Early disseminated disease==
==Physical Examination in Stage 2 - Early disseminated disease==


===Appearance of the patient===
===Appearance of the patient===
*As the disease progresses patient may appear ill. Patient has severe [[malaise]] and [[fatigue]].
*As the disease progresses, the patient may appear ill. The patient has severe [[malaise]] and [[fatigue]].


===Vital signs===
===Vital signs===
*Slow or [[irregular pulse]]
*Slow or [[irregular pulse]]
 
{|
|
=== Skin ===
=== Skin ===
*Erythema migrans (target like lesions) - Usually multiple, multiple lesion are secondary to [[Disseminated disease|dissemination]]; not to be confused with multiple [[tick]] bite
*[[Erythema migrans]] (target-like [[lesions]]): usually multiple [[lesions]] are secondary to [[Disseminated disease|dissemination]], not to be confused with multiple [[tick]] bites
*Borrelial lymphocytoma - [[Cutaneous]] [[B-cell]] [[pseudolymphoma]]
*Borrelial lymphocytoma: [[cutaneous]] [[B-cell]] [[pseudolymphoma]]
*[[Malar rash]]
*[[Malar rash]]
*Diffuse [[erythema]] or [[urticaria]]
*Diffuse [[erythema]] or [[urticaria]]
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*[[Facial]] deviation
*[[Facial]] deviation
*[[Dry eyes]]
*[[Dry eyes]]
*Drooling of saliva
*Drooling of [[saliva]]
*Blurred vision
*Blurred vision
|
[[Image:LymeMultiple rash, disseminated infection.jpg|thumb|250px|right|Disseminated Lyme disease, multiple rash - [https://www.cdc.gov/lyme/signs_symptoms/rashes.html Source: CDC.gov]]]
|}


===Neck===
===Neck===
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*[[Numbness]] and [[tingling]] in extermities
*[[Numbness]] and [[tingling]] in extermities
*[[Ataxia]]
*[[Ataxia]]
*[[chorea]]
*[[Chorea]]


===Muscuoskeletal===
===Muscuoskeletal===
Line 75: Line 121:


===Appearance of the patient===
===Appearance of the patient===
*Patients appear ill and [[fatigue]].
*Patients appear ill and [[fatigue|fatigued]]


===Skin===
===Skin===
*[[Acrodermatitis chronica atrophicans]]
*[[Acrodermatitis chronica atrophicans]]
*Localized [[scleroderma]]-like lesions
*Localized [[scleroderma]]-like [[lesions]]


===HEENT===
===HEENT===
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*[[Spastic]] [[paraparesis]]
*[[Spastic]] [[paraparesis]]
*[[Ataxia]]
*[[Ataxia]]
*[[Neuropsychiatric]] findings includes [[dementia]], [[anxiety]], [[depression]], [[schizophrenia]]-like [[psychosis]], [[bipolar disorder]]  
*[[Neuropsychiatric]] findings, including [[dementia]], [[anxiety]], [[depression]], [[schizophrenia]]-like [[psychosis]], [[bipolar disorder]]  


=== Muscukoskeletal ===
=== Muscukoskeletal ===
*[[Arthralgias]] - Commonly involving [[knee]], may be migratory
*[[Arthralgias]]: commonly involving [[knee]], may be migratory
*[[Joint]] [[tenderness]]
*[[Joint]] [[tenderness]]
*[[Joint swelling]]
*[[Joint swelling]]
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'''Images'''
==Image gallery==
<gallery>
<gallery>
Image:BullseyeLymeDiseaseRash.jpg|Common bullseye rash pattern associated with Lyme Disease.
Image:BullseyeLymeDiseaseRash.jpg|Common bullseye rash pattern associated with Lyme Disease - <SMALL><SMALL>''[https://commons.wikimedia.org/wiki/File:Bullseye_Lyme_Disease_Rash.jpg Source: WIKICOMMONS]''</SMALL></SMALL>
Image:lymebite.png|Characteristic "bulls-eye"-like rash caused by Lyme disease.
Image:erythema chronicum migrans (Lyme Disease).jpg|Erythema Chronicum Migrans
</gallery>


<gallery>
Image:lymebite.png|Characteristic "bulls-eye"-like rash caused by Lyme disease - <SMALL><SMALL>''[https://commons.wikimedia.org/wiki/File:Lymebite.png Source: WIKICOMMONS]''</SMALL></SMALL>


Image: Borrelia07.jpeg| Right posterior shoulder region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by Borrelia burgdorferi. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia07.jpeg| Right posterior shoulder region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by ''Borrelia burgdorferi''. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image: Borrelia08.jpeg| Left lateral buttock of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia08.jpeg| Left lateral buttock of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).]</SMALL></SMALL>


Image: Borrelia10.jpeg| Right hip and waist region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia10.jpeg| Right hip and waist region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).]</SMALL></SMALL>


Image: Borrelia11.jpeg| Posterior knee with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by the bacterium, Borrelia burgdorferi. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia11.jpeg| Posterior knee with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by the bacterium ''Borrelia burgdorferi''. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image: Borrelia14.jpeg| Medial aspect of the right calf of a patient who’d presented with what was diagnosed as Lyme disease. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia14.jpeg| Medial aspect of the right calf of a patient who’d presented with what was diagnosed as Lyme disease. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image: Borrelia15.jpeg | Posterior right shoulder region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by Borrelia burgdorferi. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia15.jpeg | Posterior right shoulder region of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by ''Borrelia burgdorferi''. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image: Borrelia17.jpeg | This Lyme disease patient presented with the signs and symptoms indicative of arthritic changes to his right knee due to a Borrelia burgdorferi bacterial infection. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia17.jpeg | This Lyme disease patient presented with the signs and symptoms indicative of arthritic changes to his right knee due to a ''Borrelia burgdorferi'' bacterial infection. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image: Borrelia31.jpeg | Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia31.jpeg | Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image: Borrelia32.jpeg | Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia32.jpeg | Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image: Borrelia36.png|Facial palsy caused by an infection by the bacterial spirochete Borrelia burgdorferi. Patient was subsequently diagnosed with Lyme disease. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Borrelia36.png|Facial palsy caused by an infection by the bacterial spirochete ''Borrelia burgdorferi''. Patient was subsequently diagnosed with Lyme disease. - <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp Source: Public Health Image Library (PHIL).] </SMALL></SMALL>


Image:Erythema chronicum migrans 001.jpg|Erythema chronicum migrans. - <SMALL><SMALL>[http://www.peir.net Source: Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]</SMALL></SMALL>
</gallery>
</gallery>


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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Latest revision as of 22:35, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

The physical examination of Lyme disease is necessary for diagnosis. Erythema migrans and fever are commonly seen on physical examination in early disease.[1] Disseminated disease is characterized by multiple erythema migrans, neurological, musculoskeletal, and cardiac symptoms.[2]

Physical Examination in Stage 1 - Early localized disease

Appearance of the patient

  • Patients are usually well appearing in early stages but may appear fatigued

Vital signs

Skin

HEENT

Neck
Classic Lyme disease rash - Source: CDC.gov
Lyme disease, expamding rash with central clearing - Source: CDC.gov

Cardiovascular

Abdomen

Neurological

Muscukoskeletal

Physical Examination in Stage 2 - Early disseminated disease

Appearance of the patient

  • As the disease progresses, the patient may appear ill. The patient has severe malaise and fatigue.

Vital signs

Skin

HEENT
Disseminated Lyme disease, multiple rash - Source: CDC.gov

Neck

Cardiovascular

Abdomen

Neurological

Muscuoskeletal

Physical Examination in Stage 3 - Late disseminated disease

Appearance of the patient

Skin

HEENT

Neck

Neurological

Muscukoskeletal


Image gallery

References

  1. ↑ Steere AC, Bartenhagen NH, Craft JE, Hutchinson GJ, Newman JH, Rahn DW; et al. (1983). "The early clinical manifestations of Lyme disease". Ann Intern Med. 99 (1): 76–82. PMID 6859726.
  2. ↑ Steere, Allen C. (1989). "Lyme Disease". New England Journal of Medicine. 321 (9): 586–596. doi:10.1056/NEJM198908313210906. ISSN 0028-4793.


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