Lyme Disease
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: NEUROLOGY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
L facial weakness and numbness
 
Major Surgical or Invasive Procedure:
___ line placement ___

 
History of Present Illness:
___ year-old right-handed male with no significant past medical 
history, presents for evaluation of left facial numbness.  The 
patient notes that he was in his usual state of good health 
until last ___ afternoon, when he noted some pain in his 
left ear.  He also noted that his left tongue did not seem to 
perceive taste as well.  His neck was somewhat stiff, though 
this improved over the weekend.  On ___, he noted some left 
cheek numbness and he presented to the ED for evaluation of 
these symptoms.  He was tested for Lyme disease, though results 
have not yet returned.  He was discharged and told to follow-up 
in Neurology urgent care clinic this week.  However, over the 
weekend, he noted that his left face was becoming subtly weak.  
Today, he noted that his left eye was a bit red.  This evening, 
his facial numbness gradually spread to involve his left 
forehead and left lips.  He was told to call if his symptoms 
worsened, and was directed to come in for further evaluation.    
  

Of note, the patient reports a recent camping trip in the third 
week of ___, when he was noted to have a tick on him.  There 
was no rash, nor rash since.
 
Review of Systems:
No F/C, N/V/D, CP, SOB, vision change or loss, hearing loss or 
tinnitus, dysphagia, weakness, N/T in the extremities, or 
incoordination. 

 
Past Medical History:
None
 
Social History:
___
Family History:
none noted
 
Physical Exam:
Vitals: T 97.3 F    BP 129/60   P 82    RR 18    SaO2 99 RA
General: NAD, well-nourished
HEENT: NC/AT, left sclera injected, MMM, no exudates in 
oropharynx, no vesicles in ear canals noted
Neck: supple, no nuchal rigidity
Lungs: clear to auscultation 
CV: regular rate and rhythm, no MMRG 
Abdomen:  soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
 
Neurologic Examination: 
Mental Status: 
Awake and alert, able to relay history, cooperative with exam, 
normal affect 
Oriented to person, place, time
Attention: can say days of week backward 
Language: fluent, non-dysarthric speech, no paraphasic errors, 
naming, comprehension intact; reading intact 
Fund of knowledge: normal 
Memory: registration: ___ items, recall ___ items at 3 minutes 
No evidence of apraxia or neglect 
 
Cranial Nerves: 
Optic disc margins sharp; Visual fields are full to 
confrontation.  ___ acuity bilaterally.  Pupils equally round 
and reactive to light, 3 to 2 mm bilaterally.  Extraocular 
movements intact, no nystagmus. Facial sensation reduced to 
light touch on left, V1-V3, but notices no significant 
difference on PP.  Left facial weakness involving eye and mouth, 
blink is slower on left.  Hearing intact to finger rub 
bilaterally. Palate elevates midline.  Tongue protrudes midline, 
no fasciculations.  Trapezii full strength bilaterally. 
 
Motor: 
Normal bulk and tone throughout. No pronator drift.  No tremor.
      D T B WE FiF ___ IP  Q  H  TA  ___  
Right ___ 5  5    ___  ___  5   5     
Left  ___ 5  5    ___  ___  5   5     
 
Sensation: No deficits to light touch, pin prick, temperature 
(cold), vibration, and proprioception throughout. 
 

Reflexes: B T Br Pa Pl 
Right     ___  2  2 
Left      ___  2  2  
Toes were withdrawal bilaterally. 
 
Coordination: No intention tremor, dysdiadochokinesia noted. No 
dysmetria on FNF or HKS bilaterally. Normal FFM.
 
Gait:  Good initiation. Narrow-based, normal stride and arm 
swing.  Able to walk on toes, heels, and in tandem without 
difficulty. Romberg absent.

 
Pertinent Results:
___ 10:49AM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 10:49AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 
LEUK-NEG
___ 06:10AM   GLUCOSE-98 UREA N-11 CREAT-1.0 SODIUM-140 
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
___ 06:10AM   CALCIUM-9.6 PHOSPHATE-4.7* MAGNESIUM-2.1
___ 06:10AM   CRP-1.1
___ 06:10AM   WBC-8.1 RBC-4.41* HGB-13.8* HCT-39.6* MCV-90 
MCH-31.2 MCHC-34.8 RDW-12.7
___ 06:10AM   PLT COUNT-219
___ 06:10AM   ___ PTT-32.2 ___
___ 06:10AM   SED RATE-1
___ 02:00AM CEREBROSPINAL FLUID (CSF)  PROTEIN-42 
GLUCOSE-62
___ 02:00AM CEREBROSPINAL FLUID (CSF)  WBC-56 RBC-1* 
POLYS-4 ___ MACROPHAG-7
___ 10:00PM   GLUCOSE-106* UREA N-10 CREAT-1.1 SODIUM-140 
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
___ 10:00PM   estGFR-Using this
___ 10:00PM   ALT(SGPT)-16 AST(SGOT)-19 LD(LDH)-162 ALK 
PHOS-83 TOT BILI-0.5
___ 10:00PM   ALBUMIN-5.0*
___ 10:00PM   WBC-6.5 RBC-4.51* HGB-14.1 HCT-40.5 MCV-90 
MCH-31.3 MCHC-34.8 RDW-12.7
___ 10:00PM   NEUTS-69.3 ___ MONOS-6.3 EOS-1.8 
BASOS-1.0
___ 10:00PM   PLT COUNT-236
 
Brief Hospital Course:
MRI with contrast showed enhancement of cranial nerves 5 and 7.  
CSF with 56 WBC, 1 RBC, glc 62, prot 42.  Initially started on 
ceftriaxone 2g IV Q24hrs and acyclovir.  Acyclovir d/c'd due to 
low clinical suspicion, HSV PCR pending.  Lyme serum western 
blot pending, CSF lyme pending.  Given high suspicion for lyme, 
planned for 21d course of ceftriaxone.  ___ line placed ___ 
and arranged for home IV infusion therapy.  

 
Medications on Admission:
none
 
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1) 
Drop Ophthalmic Q 8H (Every 8 Hours) as needed for for eye 
irritation.
Disp:*1 bottle* Refills:*0*
2. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig: 
Two (2) grams Intravenous Q24H (every 24 hours) for 19 days: 
starting ___.
Disp:*40 grams* Refills:*0*
3. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous once 
a day for 19 days: after medication infusion.
Disp:*50 mL* Refills:*0*
4. Saline Flush 0.9 % Syringe Sig: Twenty (20) mL Injection once 
a day for 19 days: 10 mL flush before and 10mL flush after each 
medication infusion and Q8hrs prn.
Disp:*QS * Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
L facial weakness and numbness, CSF pleocytosis and enhancement 
of cranial nerves, likely lyme disease

 
Discharge Condition:
stable

 
Discharge Instructions:
You likely have lyme disease causing your facial weakness and 
sensory changes.  You will need a total 21 day course of IV 
antibiotics (ceftriaxone).  We have arranged for infusions at 
your dormatory.  

Please call the the ___ (___) on 
___ and as to have Dr. ___ paged to get 
results of pending blood and spinal fluid studies including lyme 
disease results.

Please follow-up in neurology clinic as below.  
 
Followup Instructions:
___

{'pain in left ear': ['Lyme Disease'], 'left tongue does not perceive taste': ['Lyme Disease'], 'stiff neck': ['Lyme Disease'], 'left cheek numbness': ['Lyme Disease'], 'subtly weak left face': ['Lyme Disease'], 'left eye red': ['Lyme Disease'], 'facial numbness spread to involve left forehead and left lips': ['Lyme Disease']}