Dermatology · Model history

An expanding ring-shaped rash after hiking: a model dermatology history

Setting
Outpatient primary care clinic
Patient
Mr. Green, 52, found an expanding ring-shaped rash on his thigh ten days after a tick bite.
Listen
4 min

After listening

Say the next question

Read the patient’s answer, say your next question aloud, then reveal the model.

Patient
“Yes, I went camping in the Connecticut woods about ten days ago. I walked through some high brush.”

Ask a direct follow-up about finding and removing a tick.

Model interview

Full transcript

  1. Doctor

    Mr. Green, I'm Dr. Ahn. What brings you in today?

  2. Patient

    I've got this strange red ring on the back of my thigh that keeps getting bigger. I found it three days ago.

  3. Doctor

    Can you tell me exactly what it looks like, and how it's changed since you first noticed it?

  4. Patient

    It started as a small red spot, but now it's a ring about the size of a dinner plate, bright red around the edge with normal-looking skin in the middle.

  5. Doctor

    Is it painful or itchy, or do you not feel it at all?

  6. Patient

    I don't really feel it at all. It doesn't hurt or itch.

  7. Doctor

    Have you been outdoors recently, hiking or in wooded areas?

  8. Patient

    Yes, I went camping in the Connecticut woods about ten days ago. I walked through some high brush.

  9. Doctor

    Did you find a tick on your skin during or after that trip?

  10. Patient

    Actually, yes. I found a small tick attached to my leg and pulled it off.

  11. Doctor

    Do you remember roughly how long it had been attached before you removed it?

  12. Patient

    I'm not totally sure, maybe most of the day. I didn't notice it until that evening.

  13. Doctor

    Have you had a fever, headache, neck stiffness, or felt unusually tired?

  14. Patient

    I've had a mild headache and some stiffness in my neck, and I've felt more tired than usual.

  15. Doctor

    Any joint pain or swelling anywhere?

  16. Patient

    No, my joints feel fine.

  17. Doctor

    Have you noticed any other rashes, weakness on one side of your face, or your heart racing or skipping?

  18. Patient

    No, nothing like that. Just the one spot on my thigh.

  19. Doctor

    Do you have any ongoing health conditions or take any regular medicines?

  20. Patient

    I have high cholesterol, and I take a statin, atorvastatin, every day.

  21. Doctor

    Any medicine allergies?

  22. Patient

    No, none that I know of.

  23. Doctor

    What do you think might be causing this?

  24. Patient

    Honestly, I thought maybe it was a bad spider bite, or that part of the tick's head got left in my skin and I'm reacting to it.

  25. Doctor

    What's worrying you the most?

  26. Patient

    I've read that Lyme disease can cause serious joint and nerve problems if it's not treated, and I'm worried that's what this is.

  27. Doctor

    What were you hoping we'd do today?

  28. Patient

    I want a blood test to confirm it, and if it is Lyme disease, I want a strong course of antibiotics right away.

  29. Doctor

    Let me make sure I have this right. Ten days ago you removed an attached tick after being in wooded brush in Connecticut. Three days ago you noticed a small red spot on your thigh that has expanded into a twelve-centimeter ring with a clear center and red border, painless the whole time. You've also had mild fatigue, headache, and neck stiffness, but no fever, joint pain, facial weakness, or racing heart. Is that accurate, and is there anything else?

  30. Patient

    That's all correct, nothing else.

  31. Doctor

    Thank you. This expanding ring after a tick bite is a classic sign of early Lyme disease, and it's actually a clinical diagnosis. Blood tests are often falsely negative this early, so I won't delay treatment waiting for them. I'm going to start you on a course of doxycycline today, and we'll go over how to prevent future tick bites.

  32. Patient

    Okay, that makes sense. I appreciate you explaining why we're not waiting on the blood test.

Flow at a glance

The route through the history

  1. Invite the patient's description
  2. Characterize the rash's appearance and growth
  3. Ask about pain or itch
  4. Establish tick and outdoor exposure history
  5. Screen for systemic and disseminated symptoms
  6. Review background, medicines, and allergies
  7. Explore the patient's own theory and fears
  8. Summarize, treat empirically, and explain why serology is skipped

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Editorial record

Tied to one reviewed case

This model uses a fictional Bedside English case as its source. The page and pre-generated WAV audio are checked against the same transcript and source-case fingerprints.

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