The patient arrives with a tick attached to the skin (Fig. 182.1) and is often frightened or disgusted and concerned about developing Lyme disease, Rocky Mountain spotted fever (RMSF), or “tick fever.” Alternatively, the patient may only have a history of having removed a tick within the past week or so and now has developed a spreading erythematous rash at the previous site of attachment (Fig. 182.2). By this time, systemic signs and symptoms consisting of myalgia, arthralgia, fever, headache, and fatigue may be present.