case study

Patient’s 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 doctor’s office at 13:10 complaining about flu like symptoms, stiff neck and fever. Temperature at 38.83 ºC (101.9 ºF). 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. Bull’s 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 gerhig’s 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

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

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

* Symmetric
* Normocephalic
* Negative Lesions
* No tumor
* Symmetrical facial movements

* 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)

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

* No Secretions
* Auricles don’t have lesions or tumors
* Auricles aligned with outer canthus of the eye
* Symmetrical

* 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
* Supple neck
* Trachea was in the middle
* Lymph nodes can be palpated

* 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

* NRRR (Normal Rate Regular Rhythm)?
* (-) murmur

* 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

* 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 ºC (101.9 ºF).
O2 saturation : 99% on room air

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