Pick ‘n’ Mix Week 2 February 2023

Estimated Reading Time: 6 minutes

We are really grateful to Trudie Pestell for sharing this fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department for a while.

Each week we will bring you some clinical pearls to add in to your knowledge and understanding with links to other resources as well as an OSCE of the week. This week has an abdominal theme.


A zoonotic infection caused by a spirochete of genus Borrelia, a gram negative, anaerobic bacteria, which is transmitted to humans by ixodes ticks. Animals are the primary reservoir, with ticks becoming infected by feeding on an infected animal.

Clinical Features

Erythema migrans is the pathognomnic rash, which usually develops within 1-4 weeks of the bite.

Other features include

  • Headache, fever, malaise,
  • MSK: arthralgia, arthritis
  • CVS: myocarditis,
  • Neuro: meningitis, encephalitis, radiculopathy, facial nerve palsy, hearing loss

Risk Factors

  • Outdoor activities- recreational, occupational, residential in an area known to have Lyme
  • Tick bite duration >= 48 hours


  • Over 9yrs: -Doxycycline or amoxicillin for 21 days
  • Under 9yrs: -Amoxicillin (21 days) or azithromycin (17 days)

A history of a tick bite AND no symptoms?

Antibiotic prophylaxis is NOT routinely recommended

‘Enjoy the outdoors but be tick aware’

Jarisch-Herxheimer reaction – a side effect of treatment

Potential complication of antimicrobial treatment for any spirochete infection

  • Usually occurs in the first 24 hours of treatment
  • A cytokine mediated systemic reaction in reponse to dead spirochetes
  • Systemic upset: fever, chills, myalgia, headaches
  • Self-limiting and usually resolves within 24–48 hours, but it is important to counsel patients on this side effect, as it may mean people discontinue treatment.

The case of traumatic shortness of breath

The beginning:

A 29year old female of no fixed abode presents with shortness of breath & left sided chest pain. She reports that two days previously she was involved in an altercation in which she was stabbed in the left side of the chest. She didn’t initially seek attention as she was afraid of the police becoming involved.

Her observations are:

  • Resp Rate – 31/min,
  • Oxygen saturations on room air 93% RA,
  • Heart Rate 103/minute,
  • Blood pressure 111/71.

A chest xray is performed…

The penetrating injury has caused both bleeding and a leak of air into the pleural space.

Use this to practise your abdominal examination. Remember there are resources for lots more system examinations here.



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