# Medical Timeline and Pre-Visit Brief

**Patient:** Joseph Shawfield  **DOB:** 06/16/1970 (age 55)  **Sex:** M
**Location:** Volusia County / Longwood, FL
**Prepared:** 2026-06-22
**Purpose:** Organize a multi-month history for clinical review. This is a patient-prepared summary, not a diagnosis.

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## Current dominant symptoms
Symmetric swollen hands and wrists, diffuse body aches, and fatigue.

## Timeline

**Past ~2 years.** Multiple tick bites (regular outdoor and camping exposure in north-central Florida). One bite site developed a dark-scab eschar that persisted about 6 months, now healed, still felt at the site.

**Onset, several months ago.** Started with myalgia and heavy sore hips (hip bursitis). Fatigue, malaise, and sleep disturbance followed.

**Progression.** Symmetric swelling of the hands and wrists became the dominant feature.

**Episodic throughout.** Night sweats and chills. One or more episodes of dark urine. Stiffness that flares overnight after sugar or alcohol and resolves the next day. Intermittent gastric symptoms. Lightheadedness. Mild difficulty focusing on screens.

**06/02/2026.** Tick-borne antibody panel (ordered via PlushCare, run by Quest). Lyme, Anaplasma phagocytophilum, Babesia microti, and Ehrlichia chaffeensis all negative or not detected. The report noted that a blood smear or PCR is recommended for acute Babesia, that a single antibody is not sufficient, and that other Babesia species such as B. duncani may not be detected by this assay.

**06/10/2026.** Inflammatory and metabolic panel drawn (via JasonHealth, run by Quest), BEFORE starting prednisone. Key results:
- C-reactive protein 32.5 mg/L (HIGH, ref < 8.0). Markedly elevated.
- WBC 11.3 (HIGH); absolute neutrophils 8373 (HIGH); neutrophils 74.1 percent. Neutrophilic leukocytosis.
- Hemoglobin 13.5, hematocrit 42.0. Normal. No polycythemia and no anemia.
- Rheumatoid factor < 10 (negative), CCP < 16 (negative), ANA negative. No serologic evidence of rheumatoid arthritis or ANA-associated autoimmune disease.
- ESR 11 (normal).
- AST 9 and ALT 7 (low), total bilirubin 0.4 (normal), alkaline phosphatase 52 (normal). Liver not inflamed.
- Creatinine 0.64 (low), eGFR 112 (normal kidney function), BUN/creatinine ratio 28 (high, largely reflecting the low creatinine).

**After the 06/10 draw.** Started prednisone (approximately a one-week course). Rapid improvement in the hands.

**During the prednisone week.** Possible poison ivy exposure outdoors. No skin issues prior to this.

**About one week after prednisone (course ending or ended).** Severe blistering rash resembling poison ivy. Spouse in the same household was unaffected.

## Current medications
Prednisone, recent course of roughly one week. Confirm exact dose and dates. List any others.

## Differential under consideration (for discussion, not diagnosis)
- **Seronegative inflammatory arthritis.** RS3PE (sudden symmetric swollen hands) and/or polymyalgia rheumatica (girdle myalgia plus hip bursitis; PMR characteristically produces hip and shoulder bursitis). Supported by the dominant swollen hands, the girdle onset, the very high CRP, the negative RF, CCP, and ANA, and the rapid steroid response.
- **Psoriatic arthritis.** Raised by the new skin eruption. Also seronegative, which fits the negative RF, CCP, and ANA, and it causes swollen digits and hands. A dermatologic diagnosis of psoriasis would meaningfully support this. Note that stopping systemic steroids can trigger a psoriasis flare.
- **Crystal arthropathy (gout).** The sugar and alcohol triggered overnight flares fit a crystal pattern. Uric acid has not been tested.
- **Chronic tick-borne infection.** Bartonella (chronic, multi-system course) and spotted-fever group Rickettsia (matches the prior eschar) have not been tested. Being on prednisone raises the importance of excluding an active infection.

## Skin eruption, points for the clinician
- Most consistent with poison ivy or allergic contact dermatitis, possibly rebounding after a short steroid course, which is a recognized pattern when the course is too brief. Spouse unaffected is consistent, since the reaction is contact based and not contagious.
- Differential includes a drug eruption and a steroid-withdrawal psoriasis flare. Given the joint picture, psoriasis and psoriatic arthritis should be considered.
- Recommend in-person or dermatology evaluation, since blistering rashes are diagnosed visually and the distinction affects the joint workup.
- Seek urgent care if the rash involves the mouth, eyes, or genitals, spreads rapidly, or comes with fever or feeling systemically unwell.

## Recommended next tests and steps
- Uric acid (gout question; best measured at baseline, not mid-flare or freshly on steroids).
- Bartonella antibody panel, with PCR if indicated.
- Spotted-fever group Rickettsia IgG and IgM.
- Hepatitis B surface antigen and core antibody, and hepatitis C, given steroid use.
- Urinalysis, for the prior dark urine.
- Repeat CRP, to confirm it is falling on or after steroids.
- Rheumatology evaluation of the swollen hands. Dermatology evaluation of the rash.

## Questions for the doctor
- Is this seronegative inflammatory arthritis (RS3PE or PMR), psoriatic arthritis, gout, or a chronic tick-borne infection, or a combination?
- Does the skin eruption change the diagnosis, for example toward psoriatic arthritis?
- Should I be on a longer steroid taper, and is that safe given the untested infection status?
- Which specialist should coordinate this?