Reflexes 2+/2+ bilaterally.ĭifferential Diagnosis: Based on the subjective and objective data a list of differential diagnosis can be developed. Sensory exam reveals pain, vibration, light touch and stereognosis intact. Grips and arms strong and equal bilaterally. Gait, heel - to - toe, heel and toe walking, knee bends, and hopping all within normal limits. No atrophy, fasciculations, tremors noted. Cranial nerves II-XII grossly intact except for 7th left peripheral cranial nerve palsy. Neurologic: Pupils equal and reactive to light. Radial, femoral, dorsalis pedis and posterior tibial pulses equal bilaterally.
#Pink brisk full
Extremities: Full range of motion of all extremities. Palpation reveals no masses or organomegly. Cardiovascular: S1S2 without murmur, rate and rhythm regular. Chest: Lungs clear, bilateral breath sounds, equal and resonant. HEENT: Unremarkable except for left facial asymmetry. General: Alert and oriented times 3, BP 90/50 p 100 RR 20 T 99po ht 45 in wt 48 lbs (95th percentile). Physical Examination: Slim, cheerful five year old hispanic female in no apparent distress. Displays normal sexual curiosity and identifies coins and four out of five colors. Dresses and undresses with minimal supervision. Endocrine: Denies weight gain or loss, heat or cold intolerances, thirst or polyuria. Mental Health: Denies irritability, troubled speech, learning disabilities. Neuro: Denies seizures, lack of coordination, tingling, difficult speech, tremors, tics or weakened grips. Musculoskeletal: Status post fractured radius 2 years ago. GU: Denies urgency, frequency or bloody urine. GI: Denies abdominal pain, nausea and vomiting. Heart: Denies murmur, chest pain or swollen extremities. Respiratory: Denies cough, shortness of breath, or wheezing. Neck: No masses/node enlargement or pain with movement or palpation. Mouth and Throat: Denies hoarseness or lesions. Nose and Sinuses: Denies olfactory deficits. Ears: Denies prosthetic devices, infections, and tinnitus. Eyes: Denies use of corrective or prosthetic devices, diplopia, pain, or photophobia. Head and Face: Denies dizziness and frequent headaches. Review of Systems: General: Well nourished child of appropriate height and weight for stated age. She enjoys drawing, playing with other children, chores and trying on new outfits, and demonstrates interest in kindergarten and attends church. The neighborhood is noisy, dirty and unsafe in some areas. Personal/Social History: Patient lives in an apartment. Grandparents are living with history significant for angina in maternal grandmother. The patient has two female siblings - a 4 year old with resolved case of Bell’s palsy and a healthy 1 year old. Birth history is non-contributory and growth and development are consistent with anticipated standards.įamily Medical History: Mother is age 40 is well. Immunizations are up to date, and a PPD done 2/97 is negative. Past Medical History: Unremarkable except for one episode of right otitis media 6 months prior. No gait disturbances, weakness, numbness, hyperacusis, tingling and taste disturbances noted. She denies excessive eye tearing, fever, cough, vomiting, diarrhea, cold or recent travel. Mother states that food tends to dribble from the left side of her mouth and she has difficulty with left eye closure. History of Present Illness: A five year old hispanic female is accompanied by her mother with complaint of twisted face upon awakening this morning.
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