60 YEAR OLD FEMALE WITH PARKINSON’S

This is an E log book to discuss our patients de identified health data shared after guardians informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most 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 and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS: 

- C/O GENERALISED WEAKNESS FOR 4 DAYS 

HISTORY OF PRESENT ILLNESS: 

THE PATIENT WAS APPARENTLY ALRIGHT 3 YEARS BACK THEN SHE HAD RESTING TREMORS IN THE LEFT HAND WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE AND THEN TO THE LEFT LEG WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE. TREMORS + WHILE SLEEPING, BRADYKINESIA + SINCE 3 YEARS, AGGRAVATED SINCE 4 DAYS 

DIFFICULTY IN PASSING STOOLS SINCE MONTHS 

GENERALIZED WEAKNESS SINCE 4 DAYS 

NO H/O FEVER, COLD, COUGH 

NO H/O PAIN PER ABDOMEN 

PAST HISTORY: 

THE PATIENT IS A KNOWN CASE OF PARKINSONS SINCE 3 YEARS USING: 

- TAB. LEVODOPA 100 MG SINCE 6 MONTHS

- TAB. CARBIDOPA 25 MG 

- TAB. CLONAZEPAM 0.5 MG SINCE 1 AND A HALF YEAR 

H/O HYSTERECTOMY 25 YEARS AGO 

NOT A KNOWN CASE OF DM II, HYPERTENSION, EPILEPSY, TB, ASTHMA, CAD, CVA, THYROID DISORDERS

PERSONAL HISTORY: 

APPETITE: NORMAL 

DIET: MIXED

SLEEP: ADEQUATE 

BOWEL: CONSTIPATED 

BLADDER: NORMAL 

NO ALLERGIES OR ADDICTIONS 

FAMILY HISTORY: 

NO H/O SIMILAR COMPLAINTS IN THE FAMILY 

GENERAL EXAMINATION: 

THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

MODERATELY BUILT AND NOURISHED 

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLULBBING, EDEMA, LYMPHADENOPATHY 

VITALS: 

TEMP: AFEBRILE 

PR: 82 BPM 

RR: 16 CPM 

BP: 110/70 MM HG

SPO2: 98% @ RA 

GRBS: 104 MG/DL 

SYSTEMIC EXAMINATION: 

CVS: S1, S2 HEARS, NO MURMURS 

RS: BAE+, NVBS 

TRACHEA: CENTRAL 

NO DYSPNOEA AND WHEEZE 

NO RHONCHI 

ABDOMEN: NON TENDER, SOFT, SCAPHOID, HERNIAL ORIFICES NORMAL 

LIVER AND SPLEEN NOT PALPABLE 

BOWEL SOUNDS HEARD 

CNS: 

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT 

SPEECH: SLURRED

NECK STIFFNESS ABSENT 

KERNINGS SIGN ABSENT 

CRANIAL NERVES: NORMAL 

MOTOR SYSTEM: NORMAL 

SENSORY SYSTEM: NORMAL 

GCS: 15/15 E4V5M6 

TONE: 

UL: INCREASED IN BOTH 

LL: INCREASED IN BOTH 

POWER: 

UL: BOTH 4/5

LL: BOTH 4/5

REFLEXES:             RT              LT

B:                           +3              +3

T:                           +3              +3

S:                           +2              +2

K:                           +3              +3

A:                           +3              +3

PROVISIONAL DIAGNOSIS: PARKINSONS DISEASE 

INVESTIGATIONS: 

HB: 10.6 

TLC: 10900

N: 58% 

PLT: 3.42

TB: 1.26

DB: 0.31

SGOT: 47

SGPT: 25 

ALP: 100 

TP: 7.5 

ALB: 3.8 

A/G: 1.05 

CREAT: 0.9 

NA: 134 

K: 3.7 

CL: 97 

CA: 1.12 

CUE: 

ALB: NIL 

PUS CELLS: 2-3 CELLS 

TREATMENT: 

- INJ. OPTINEURON 1 AMP IN 100 ML NS IV OD 

- TAB. SYNDOPA PLUS 125 MG PO QID 

- TAB. TRIHEXPHENADINE 2 MG PO OD 

- TAB. SHELCAL CT PO OD