Physical Examination Findings

Some potential working diagnoses should be strain / sprain, fibromyalgia, Lyme disease, rhabdomyolysis, non-organic disease.

Height: 67 in.

Weight: 124 lbs.

Temp: 100.1

Pulse:  92 regular, smooth, symmetrical

BP: 108/72

Upper and lower extremity ranges of motion are unrestricted and symmetrical with pain reported through all ranges. Moderate tenderness to deep touch reported throughout the extremities. All orthopedic tests are negative. The skin is warm and dry with no evidence of cyanosis. A three part peripheral neurological examination reveals DTR are 2+, brisk and symmetrical. Cutaneous sensation to light touch is intact bilaterally. Motor testing reveal all upper and lower extremity muscles evaluated are 4/5. Cerebellar testing was unremarkable. The patient was oriented to time, place and person but had difficulty on serial 7 computation and short term memory recall tests.

Question: What is your working diagnosis at this point and what imaging or laboratory studies would you order?