53Y/M WITH COMPLAINTS OF UL TREMORS

16jan,2023This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan.


Unit 1


Dr. Zain

Dr. Raveen

Dr. Chandhana

Dr. Venkat sai

Dr. Vivek

Dr. Prachethan 



A 53 yr old male barber by occupation resident of   Coochbehar, west bengal came to OPD with complaints of UL resting tremors of left hand since 15 months. 

patient was apparently asymptomatic 15 months back then developed tremors gradually increased in intensity and he developed coarse tremors from-the past two months. He is able to hold the objects with the left hand, but due to tremors, he is not able to perform the activity

He stopped his barber profession from the past 2 months and started working in his farm.

Pt is khaini usage since 5 years , regular, daily 5gms


NO H/o trauma

NO H/o postural instability

No H/o rigidity, and bradykinesia

No H/o sleep disturbances

No H/o reduced eye blinking

NO H/o drooling of saliva

No h/o dysphagia

No H/o Loose stools, constipation

Not a k/c/o DM, HTN, CAD, asthma, epilepsy, TB, and thyroid disorders 


ON EXAMINATION 


Pt is C/C/C

BP:120/70mm hg

PR:68bpm

RR:20/min

Temp : Afebrile 


CVS:S1S2 +,No murmurs 

RS :Bilateral air entry present 

       Normal vesicular breath sounds heard 

PA- soft, non tender, bowel sounds heard 


CNS-


Higher mental functions

- Conscious

- Oriented to  time, place and person

- Memory - Intact

- Speech - Intact 


Cranial nerve examination 


          • 1 - olfactory sense - normal


          • 2- visual acuity present


          • 3,4,6 - no ptosis Or nystagmus


          • 5- corneal reflex present 


           • 7- normal


          • 8- Normal hearing


          • 9,10- position of uvula is central ,Gag reflex- present


          • 11- sternocleidomastoid contraction present


          • 12- no deviation of tongue


Motor system 


Gait- normal 





Reflexes 

                          Right            Left            

Biceps                2+                   2+   

Triceps                2+                   2+    

Supinator            2+                   2+

 Knee.                  2+                 2+

Ankle.                  2+                     2+

Plantars-       Flexion          Flexion 


Power                       Lt        Rt

Upper limb -          5/5       5/5


Lower limb  -         5/5       5/5                                  

               


TONE                        Lt        Rt

 Upper limbs           N        N                

 Lower limbs           N         N               


No Involuntary movements

 SENSORY SYSTEM


I – SPINOTHALAMIC       R     L

1. Crude touch                 N     N 

2. Pain.                              N.    N

3. Temperature.               N.     N

II – POSTERIOR COLUMN

1. Fine touch.                    N.    N

2. Vibration.                      N.     N

3. Position sense.             N.     N

4. Romberg’s sign  -Equivocal 

III – CORTICAL

1. Two point 

    discrimination.               N.    N

2. Tactile localisation.       N.    N

3. Graphaesthesia.            N.    N

4. Stereognosis.                N.    N

 CEREBELLAR Tests

No Nystagmus

Finger Nose test - normal

Heel Knee test - normal

Dysdiadokokinesia - absent 

Titubation- absent 



Provisional diagnosis 

Tremors under evaluation





INVESTIGATIONS







Treatment 

Tab SYNDOPA 110 mg PO BD 

Tab ZINCOVIT PO OD

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