GENERAL MEDICINE:SHORT CASE

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This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.



Chief complaint:
A 53 year old male came to OPD complaints of involuntary shaking of hands since 2 months

History of present illness:
Patient was apparently asymptomatic 15 months back then gradually developed tremors of left hand which gradually increased in intensity from the past two months tremors decreased on doing physical activity and increased on rest and of intermittent type (on and off)
No history of trauma
No history of postural instability
No history of rigidity and bradykinesia
No history of reduced eye blinking, drooling,and soft voice
No history of dysphagia
No history of sleep disturbances
No history of loose stools, constipation

History of past Illness:
Patient visited to a hospital on 19/9/2021 and was prescribed propranolol 40mg patient used the medication for 4-5 days and stopped from then he was taking on and off medication. On 23/9/22 he went to govt hospital where he was prescribed with Thp 2mg, ropinirole 0.25mg he used these for one month and symptom did not resolve again on 28/10/2022 he went to govt hospital and was prescribed syndopa 110 mg,Thp 2mg.propranolol 20mg(he did not use medications)
No history of diabetes mellitus,CAD,HTN, CVA, epilepsy, asthma, Tb

Personal history:
Appetite - normal
Bowel- normal
Micturition- normal
Mixed diet
Addictions - teetotaler
Khaini usage since five years , regular daily 5gms
Family history - no known relevant family history 

General examination:

Patient is conscious, coherent cooperative,well Oriented to time place and person.moderately built and nourished.no features indicating the presence of- icterus, cyanosis, clubbing of fingers,edema,lymphadenopathy
 Vitals:
Temp - afebrile 
Bp- 120/70mmHg
PR-68bpm
CVS- s1 ,s2 ( ), no murmurs
Systemic examination:
 Examination of CNS:
He is a right handed person
HIGHER MENTAL FUNCTIONS...

Conscious, oriented to time, place and person
Speech: normal
Behaviour:normal
Memory: normal
Intelligence: normal
No hallucinations and delusions

Cranial nerve examination:
1st - normal
2nd- normal
3,4,6 - normal
7th-normal
8th-normal
9th-normal 
10th-normal 
11th-normal
12th- normal

Motor examination::. Right.               Left
 Tone.                   UL.      Ll.              UL. Ll
                                Normal.           Normal
Power..                     Normal.         Normal
 
Reflexes: right.     Left.
Biceps-.  2 .          2
Triceps.  2 .          2
Supinator 2 .        2
Knee.        2 .         2
Ankle.     2 .         2
Plantar  flexion.   Flexion

Sensory examination:: 

Spinothalamic tract :. Right.            Left 
Pain.                             Normal.      Normal
Crude touch.               Normal.      Normal
Temperature..             normal.      Normal
 Posterior column:-
Fine touch..                  normal.     Normal
Vibration..                      normal.    Normal
Position sense.           Normal.     Normal

Rombergs sign-- absent
 Cortical:
Sterognosis..            Normal.       Normal
Tactile localisation Normal.       Normal
Cerebellar Signs:

Nystagamus- absent 
Dysdiadokokinesia- absent 
Titubation- absent

Examination of respiratory system.
Normal vesicular breath sounds  present
Bilateral air entry present
Symmetrical movement of the chest on both sides

Abdominal examination:
Abdomen is scaphoid,no scars present,no sinuses present,no engorged veins, no visible pulsations, all quadrants are moving equally with respiration and on palpation abdominal is soft, non tender no lump ,no rigidity no guardity.

Examination of cvs:
S1 and S2 heard, no murmurs heard

 Clinical images:



provisional diagnosis:
 Tremors under evaluation?
 Treatment:
16/1/23
 Tab.syndopa 110mg po/bd
 Tab.zincovit po/od
17/1/23
 Tab.syndopa 110mg po/bd
 Tab.zincovit po/od
18/1/23
 Tab.syndopa 110mg po /bd
 Tab.zincovit po/od


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