History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Preliminary Differential Diagnosis
Essential Differential Diagnosis
Relevant Testing
Test Interpretation
Relevant Follow-up
Test Interpretation 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Leg Tingling in 20-yr-old Woman
Physical Examination
General appearance
: Young woman in no apparent distress.
Vital signs
:
Temperature: 37° C
Pulse: 75 beats/min
BP: 120/80 mm Hg
Respirations: 12/min
Skin
: Warm, dry; no erythema or rash.
HEENT
: Unremarkable
Pulmonary
: Unremarkable
Cardiovascular
: Unremarkable
Gastrointestinal
: Unremarkable
Genitourinary
: Unremarkable
Musculoskeletal
: No visible or palpable lesions or tenderness along spine. Joints nontender, full range of motion.
Neurologic
:
Cranial nerves: 2 through 12 intact
Motor exam: Strength and muscle tone normal in both upper and both lower extremities. No muscle atrophy or abnormal movements seen.
Sensory exam: Sensation intact bilaterally to light touch, pinprick, temperature, vibration, and joint position
Reflexes: Normoactive and symmetric throughout
Coordination: Normal
Gait and balance: Normal
Detailed movement exam: Normal
Rectal examination: Normal perineal sensation and normal rectal sphincter tone
Mental status
: Alert, oriented x3. Normal affect. Euthymic mood. Normal memory, judgment, and insight.
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