An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?

1. A

   A decreased urinary output and flank pain

2. B

   A fever of over 103°F occurring over the last 2-3 weeks

3. C

   Rashes covering the palms of the hands and the soles of the feet

4. D

   Headaches, malaise, or sore throat

Appeared in: NORCET -4 , 2023

Explanation

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• The child's symptoms of knee swelling and pain are characteristic of Stage 3 (Late Disseminated) Lyme disease, also known as Lyme arthritis.
• This late stage occurs weeks to months after the initial infection by the spirochete Borrelia burgdorferi.
• To confirm a diagnosis of a progressive disease presenting in a late stage, it is essential to ask about symptoms of the earlier stages.
• Headaches, malaise, and sore throat are common constitutional 'flu-like' symptoms that appear in the early stages (Stage 1 and 2) of Lyme disease.

Why Other Options Were Wrong

• Option A: These symptoms (decreased urinary output, flank pain) are indicative of renal or urinary tract problems, which are not associated with the clinical progression of Lyme disease.
• Option B: A persistent, high-grade fever (over 103°F) is not typical for Lyme disease, which usually presents with low-grade fever in its early stages. Additionally, Lyme arthritis develops months after the initial infection, making a 2-3 week timeline inconsistent.
• Option C: A rash on the palms and soles is a classic sign of other diseases, notably Rocky Mountain spotted fever and secondary syphilis. The characteristic rash of Lyme disease is erythema migrans, an expanding 'bull's-eye' rash that occurs elsewhere on the body.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Clinical presentation and diagnostic history for Lyme disease to guide bedside assessment, documentation, and the next nursing action.
• A thorough patient history is a primary diagnostic tool for Lyme disease, as early symptoms like the erythema migrans rash may be missed, absent, or forgotten.
• Early diagnosis and treatment with antibiotics (e.g., doxycycline or amoxicillin) are crucial to prevent the progression to late-stage complications like chronic arthritis, carditis, and neurological problems.
• Nurses play a key role in educating patients and families about tick-bite prevention, including wearing protective clothing, using insect repellent, and performing tick checks after being outdoors.

How to Approach the Question

• First, identify the key information in the clinical scenario: an 8-year-old child with knee swelling/pain and a suspected diagnosis of Lyme disease.
• Recall the pathophysiology and staging of Lyme disease. Recognize that joint involvement (arthritis) is a manifestation of late-stage (Stage 3) disease.
• Understand that the purpose of taking a history in this context is to find evidence of earlier stages of the disease to confirm the diagnosis.
• Evaluate each option to determine which one describes symptoms of early-stage (Stage 1 or 2) Lyme disease.
• Eliminate options that are inconsistent with the typical symptoms or timeline of Lyme disease, or are more characteristic of other conditions.

Concept Tested & Keywords

• Concept Tested: Clinical presentation and diagnostic history for Lyme disease.
• Stem keywords: 8-year-old child, swelling and pain in the knees, Lyme disease, initial history
• Lead-in keywords: important to include
• Clinical cues: Knee swelling and pain in a child suggests late-stage Lyme arthritis, prompting questions about earlier symptoms.

Question ID

QinLggcb9phsxbIl1cm1yF

Copy ID

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 pp. 1888-1890, 1886-1888