ADDITIONALLY: per interview and available records review, patient referred for Physical Medicine & Rehabilitation Consultation regarding evaluation and management of functional limitations, and associated impairments related to the diagnosis of:
--
______________________________________________________________________________________
EXAMINATION:
GENERAL: well nourished, well developed individual with no acute distress behaviors;
EYE: Conjunctivae are clear, non-icteric; Pupils are round, and reactive
ENT: Oropharyngeal muscosa is pink, and moist; hearing was functional to usual
conversational voice
NECK: supple, no palpable thyroidmegaly or masses
C-Spine: Range of motion at Neck for: rotation, side-bending, flexion, and extension was
functionally normal. Palpation of PSMs demonstrated no TTP.
Inspection did not reveal obvious swelling or deformity from the front, back and sides.
CV: pulse is regular rate; peripheral edema is not present; No extremity pallor
SKIN: no obvious rashes to observed areas of bilateral upper and lower extremities
no significant palpable induration of soft-tissues of bilateral upper and lower extremities
MSK: Strength was normal bilateral upper extremity, without functional instability.
Strength was normal bilateral lower extremity, without functional instability.
Tone was normal to bilateral upper and lower limbs.
Functional active range of motion of bilateral upper and lower limbs
NEURO: muscle stretch reflexes were symmetric without hyperreflexia of bilateral upper limb.
muscle stretch reflexes were symmetric without hyperreflexia of bilateral lower limb
Sensation was intact to light touch at bilateral upper and lower extremity
Sensation was intact to pinprick at bilateral upper and lower extremity
No ankle clonus. No Hoffman's sign in hands.
PSYCH: Alert, Oriented to person, place, day. No agitation, affect was pleasant, and...