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]

Appearance of the patient Patients are usually well appearing in early stages but may appear fatigued Vital signs Fever and/or chills Skin Erythema migrans (target-like lesions): usually single, present at the site of tick bite Regional lymphadenopathy: around site of tick bite Some patients may have: Multiple annular lesions Malar rash Evanescent skin lesions Urticarial rash HEENT Headache Pain on neck flexion Some patients may have: Pharyngitis Conjunctivitis Fewer patients may have: Periorbital edema Photophobia Ear pain Neck Neck stiffness

• A small number of patients may have:
  • Chest pain

• Some patients may have:
  • Hepatomegaly
  • Splenomegaly
  • Right upper quadrant pain
• Fewer patients may have:
  • Generalized tenderness

• Some patients may have:
  • Dysesthesia
  • Dizziness

• Migratory arthralgias
• Myalgia
• Back ache
• Some patients may have:
  • Frank arthritis
• Fewer patients may have:
  • Muscle tenderness
  • Hand stiffness

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

• Slow or irregular pulse

Skin Erythema migrans (target-like lesions): usually multiple lesions are secondary to dissemination, not to be confused with multiple tick bites Borrelial lymphocytoma: cutaneous B-cell pseudolymphoma Malar rash Diffuse erythema or urticaria Regional or generalized lymphadenopathy HEENT Facial deviation Dry eyes Drooling of saliva Blurred vision

• Neck stiffness
• Neck pain
• Cannon A waves in patients with complete heart block

• Tachycardia
• Palpitations
• Cardiac rub
• Dyspnea
• S3 and/or S4 may also be present

• Splenomegaly

• Dizziness
• Numbness and tingling in extermities
• Ataxia
• Chorea

• Migratory arthralgia

• Patients appear ill and fatigued

• Acrodermatitis chronica atrophicans
• Localized scleroderma-like lesions

• Severe headache
• Sore throat
• Vision changes
• Odynophagia
• Otalgia
• Tinnitus
• Hearing loss
• Vertigo
• Temporomandibular joint pain
• Dysgeusia

• Tender neck flexion
• Neck pain

• Fasciculations
• Spastic paraparesis
• Ataxia
• Neuropsychiatric findings, including dementia, anxiety, depression, schizophrenia-like psychosis, bipolar disorder

• Arthralgias: commonly involving knee, may be migratory
• Joint tenderness
• Joint swelling
• Joint effusion
• Enthesitis
• Periostitis or joint subluxations below acrodermatitis

• 
  Common bullseye rash pattern associated with Lyme Disease – Source: WIKICOMMONS
• 
  Characteristic “bulls-eye”-like rash caused by Lyme disease – Source: WIKICOMMONS
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  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. – Source: Public Health Image Library (PHIL).
• 
  Left lateral buttock of a patient who’d presented with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease. – Source: Public Health Image Library (PHIL).
• 
  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. – Source: Public Health Image Library (PHIL).
• 
  Posterior knee with the erythema migrans (EM) rash characteristic of what was diagnosed as Lyme disease, caused by the bacterium Borrelia burgdorferi. – Source: Public Health Image Library (PHIL).
• 
  Medial aspect of the right calf of a patient who’d presented with what was diagnosed as Lyme disease. – Source: Public Health Image Library (PHIL).
• 
  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. – Source: Public Health Image Library (PHIL).
• 
  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. – Source: Public Health Image Library (PHIL).
• 
  Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. – Source: Public Health Image Library (PHIL).
• 
  Pathognomonic erythematous rash in the pattern of a “bull’s-eye”. Patient subsequently contracted Lyme disease. – Source: Public Health Image Library (PHIL).
• 
  Facial palsy caused by an infection by the bacterial spirochete Borrelia burgdorferi. Patient was subsequently diagnosed with Lyme disease. – Source: Public Health Image Library (PHIL).
• 
  Erythema chronicum migrans. – Source: Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

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