Numbness
Age: years old
Gender:
HISTORY:
Presents with a - history of
Location is on
Type of sensation is
Onset is and is
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
Contributing factors:
no history of: , , , , , ,
no use of: , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Cervical spine: on , range of motion
Lumbar spine: on , range of motion
Extremities: , , cap refill sec, pulses , ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
ASSESSMENT:
DDx: peripheral neuropathy, carpal tunnel syndrome, cervical radiculopathy, peripheral polyneuropathy, diabetic neuropathy, multiple sclerosis, vitamin B12 deficiency, alcohol use disorder, stroke, transient ischemic attack, complex regional pain syndrome, Guillain-Barré syndrome, HIV-associated neuropathy, chemotherapy-induced peripheral neuropathy, spinal cord compression, syringomyelia, amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease, hereditary neuropathies, vasculitis, hypothyroidism, Lyme disease, sarcoidosis, heavy metal poisoning, entrapment neuropathies, Raynaud's phenomenon
PLAN:
Investigations:
- Blood work: , , , , , , ,
- Nerve conduction study
- EMG
- X-ray
- MRI of the spine
Treatments:
-
-
- Physical therapy
- Occupational therapy
- Splinting
Further care:
- Referral to neurologist
- Referral to orthopedic surgeon
- Referral to plastic surgeon
- Follow-up in
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: