A 34-year-old man comes to the physician after several days of | Uworld | Step 2ck

A 34-year-old man comes to the physician after several days of difficulty walking. He also describes some "funny" sensations in his feet He has no recent skin rash, diarrhea, or joint pain. He has had lower back pain for the last week due to a lifting injury while he was moving. He visited friends in Connecticut 1 month ago and while there developed an upper respiratory infection that lasted 4 days. He smokes 1 pack of cigarettes a day and admits to occasional IV drug use. He has not been sexually active for 3 months. His temperature is 36. 7° C (98° F), blood pressure is 120/80 mm Hg, pulse is 90/min, and respirations are 16/min. Chest examination is unremarkable. The abdomen is soft and nontender. The liver span is 8 cm and the spleen is not palpable. Cranial nerves II-XII are intact Muscle strength is reduced in the lower extremities but well preserved in the upper extremities. Lower-extremity sensation is decreased. Mild hyperreflexia is noted bilaterally in the lower extremities . Stroking the soles of the feet elicits extension of the great toe.