Patients Profile

Name: Riva Sanders

Address: North York, Toronto, Ontario
Age: 34 yrs. old
Sex: Female
Birth Date: December 25, 1980
Religion: Christian
Civil Status: Married
Physician: Dr. Annalyn Yu
Nurse on Duty: Edgar S., RN
Date and Time: September 1, 2014; 13:10
Chief Complaint: fever and flu like symptoms
Final Diagnosis: Lyme disease
Ethnicity: Hispanic
OHIP number : **** - *** - ***- DG

General Data: This is a case of Riva Sanders, 34 years old, female,
presently residing at North York, Toronto, Ontario. Client came to
doctors office at 13:10 complaining about flu like symptoms, stiff
neck and fever. Temperature at 38.83 C (101.9 F). Client stated
that she had recently gone in week long Camping and fishing trip
along with her husband Sebastian and their Three year old
daughter Coraline in Lake Erie on Norfolk County, Ontario on
August 24, 2014.

August 26, 2014, Both Riva and Coraline appears to have an
allergic reaction to typical bug bite, rashes were seen near the bug
bite. Riva also reckoned that a tick were spotted on her left
gastrocnemius muscle. At August 28, 2014 symptoms such as stiff
neck and chills were reported by the client. Bulls eye rash noted
on left gastrocnemius






History of Present Illness:

Fever
Fatigue
Chills
Headache
Stiff neck
Malaise/weakness

Past Medical History:

No past medical history


Family History:

(+) hypertension (father)
(+) rheumatoid arthritis (mother)
(+) Cancer (aunt)
(+) MND - Lou gerhigs disease (uncle)
(-) Diabetes meliitus


Personal and Social History:

(+) Alcohol drinker
(+) Smoker
Sexually active

Physical Assessment
General survey of the patient:

1. Appears stated age:

Appears her stated age

2. Level of consciousness:

Alert and oriented, attending to questions and responds accordingly



3. Skin Colour:

Light Tan skin

4. Nutritional Status:

Weight within normal range for height and body weight

5. Posture and position

When standing appears comfortably erect as appropriate for age,
Sitting comfortably in chair
No signs of scoliosis, kiphosis or lordosis

6. Obvious physical deformities

No obvious physical deformities

7. Mobility:

No involuntary movement
ROM of joints
No assistive devices
No signs of scoliosis, kiphosis or lordosis
Can easily rise from seated position

8. Facial Expression

Maintains eye contact
Expression changes appropriate to situation

9. Mood and Affect:

10. Speech:

Can articulate properly to questions
Oriented to time and place
Conveying ideas clearly
Word choice appropriate to culture and education

11. Hearing:

Can hear questions clearly answer appriopritely
Both ears can respond well to whispered voice test

12. Personal Hygiene:

Client appears well-kept clean and groomed appropriately
Hair is brushed and kept in a ponytail

GENERAL
Conscious
Coherent, not in distress
Oriented to time and place

SKIN
Skin is warm to touch
Hyperthemia on patient (38.83 C)
No jaundice
No active edema
Good skin turgor
erythematous papule on left lower leg 8 diameter, central punctum at
16cm

HEAD
Symmetric
Normocephalic
Negative Lesions
No tumor
Symmetrical facial movements

EYES
Eyebrow symmetrically aligned
Bilateral Clear Grey iris, no cloudiness on cornea
No glasses, no soft contact lens
Pupils are equal, round and reactive to light and Accommodation
(PERRLA)

NOSE
No Secretions, discharge
No tenderness or lesions
Symmetric and straight
Patent nostrils

EARS
No Secretions
Auricles dont have lesions or tumors
Auricles aligned with outer canthus of the eye
Symmetrical

MOUTH and THROAT
Buccal mucosa was pink
Dark pink lips
Ventral surface of tongue is smooth present with saliva
Dorsal surface of tongue is pink and rough with papillae
32 teeth are present with 16 teeth each row, no dentures
Teeth appears white and shiny enamel
Gag reflex present
NECK
Supple neck
Trachea was in the middle
Lymph nodes can be palpated

CHEST
Does not use accessory muscles when breathing
Thorax is symmetrical and in elliptical shape
Sternocleidomastoid muscle not visible
Breathing is automatic, relaxed, regular and even
No noise on inspiration and expiration

HEART
NRRR (Normal Rate Regular Rhythm)
(-) murmur

ABDOMEN
Abdomen is symmetrical bilaterally
Umbilicus is in midline and inverted; no signs of redness or crusts
Normal active bowel sounds
Soft
Flat
No tenderness
Spleen not palpable

UPPER and LOWER EXTREMITIES
No edema
Full pulses (popliteal, dorsalis pedis )
Erythematous papule on left lower leg 8 diameter; with central punctum of
16 cm
Fingers and Toes are symmetrical and pink
No signs of nail clubbing

Vital signs:
September 1, 2014
13: 50 vital signs are as follows:
Blood pressure : 110/80 mm/hg
Pulse rate: 80 beats per minute
Respiratory rate: 17 breaths per minute
Body temperature: 38.83 C (101.9 F).
O2 saturation : 99% on room air




Diagnostic examinations:
(enzyme-linked immunosorbent assay) ELISA : positive for Borrelia borgdorferi
antibodies
(protein immunoblot) Western blot : IgM and IgG positive
Prescription given:
Dr. Yu Ordered:
Amoxicillin (Amoxil)
500 mg PO q8h for 21 days

Pathophysiology