Long case
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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.
Following is the view of the case
CHEIF COMPLAINTS:
62 year old male patient resident of Nalgonda farmer by occupation came to the hospital with
Chief complaints of
Involuntary movements of Left lower limb since 1 year
Stiffness of all 4 limbs since 6m
Difficulty in swallowing since 2m
HOPI
Patient was apparently asymptomatic 2 years back then he developed tremors which was mainly present in Left upper limb after 1 year to Left lower limb which was gradual in onset, occurs at rest, subsides by voluntary movements and also subsides during sleep as told by family members.
Tremors decreased with levodopa medication.
Rigidity since 6m, which made him stiff and is responsible for his flexed attitude.
He has history of difficulty in initiation of movements , to start there is clumsiness of movements and now difficulty to perform his day to day activities without assistance like going to bathroom.
Difficulty to start walking and getting up from chair .
Difficulty in climbing stairs without assistance.
Difficulty in wearing clothes and removing clothes
He is unable to wear and remove footwear without assistance because of stiffness.
No history of slippage of footwear
No history of weakness in upper and lower limbs.
He has history of falls (3-4 times)
He has history of postural instability
No history of giddiness
He has history of dysphagia since 2 months which is gradual in onset, episodic in
nature which was initially to solids and later slowly to liquids.
Dysphagia more to solids than liquids
No history of regurgitation
No history of heart burn.
No history of pooling of saliva.
No history of thyromegaly (any neck swelling)
His relatives told that his voice has turned into slow dull and soft.
No history of headache
No history of vomiting
No history of siezures
No history of Fever
No history of head injury
No history of jaundice
No history of STD
PAST HISTORY
History of similar complaints , 2yrs back, tremors in the Left upper limb which subsided gradually with medication, (levodopa.) Started on od dose initially and increased to Tid dose due to recurrence of tremors after 4-5 hrs and later to Qid dose since 3m
No h/o Diabetes, systemic hypertension, bronchial asthma, pulmonary koch’s, epilepsy, CVA, CAD, and Thyroid disorder
Personal History
Diet: Balanced
Appetite: Normal
Bowl/Bladder:Regular
Sleep: Increased duration, excessive day time sleepiness
Addictions: Non smoker and non alcoholic
Family history
His wife is schizophrenic patient.
GENERAL EXAMINATION
Patient conscious, cooperative, Moderately built and moderately nourished
Masked facies characterised by
Infrequent blinking with staring look
(Spontaneous ocular movements are lacking)
Loss of facial expressions ( blank)
Widened palpebral fissure
Coarse and static tremor of Left lower limb
Rate of blinking of eye is reduced
Left hand has contractures
And fixed flexion deformity
GCS 15/15
Height-175cms Weight-65kgs
No pallor, No icterus, no cyanosis, no clubbing , no lymphadenopathy, no edema,no koilonychia
VITAL DATA:
Temp: 100.2 F
PR: 85/min regular, normal volume, normal character, no radio radial and no radio femoral delay
BP: 100/70mmhg in Left upperlimb on supine
position
On standing 100/60 mmHg in same limb
RR:16/min
CNS :
HIGHER MENTAL FUNCTIONS:
Patient is oriented to person place and time
Right Handed person, studied upto 4th standard.
Conscious, oriented to time place and person.
Speech : slow, and monotonous speech without any fluctuations.
Hypophonia
Memory: recent and remote memory intact
No delusion and hallucinations
Emotional lability absent.
MMSE : 22/30
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
Normal fundus: fundal glow present.
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION:
BULK : normal
TONE : Hypertonia in all 4 limbs.
Leadpipe rigidity is seen in Left upper Limb.
Cog wheel rigidity is seen in Left wrist > right
INVOLUNTARY MOVEMENTS:
Resting Tremors present
Describing the involuntary movements:
1. Involuntary movements i.e. tremors observed when patient is unaware
2.Body part affected - Left lower limb
3. Frequency of movement - coarse
4. Amplitude of Movement - low amplitude
5. Timing of movement - predominantly at rest and subsided on voluntary movement
6. Aggravated at rest and relieved on voluntary activity
7. Static tremor.
8. Tremor is more prominent in left lower limb unilateral.
POWER :
U/L. L/L
Rt 4/5 4/5
Lt 4/5 4/5
SUPERFICIAL REFLEXES:
CORNEAL ; LE: present. RE: present
CONJUNCTIVAL : LE: present RE: present
ABDOMINAL : present
PLANTAR : Flexor in both limbs
DEEP TENDON REFLEXES:
BICEPS ++ ++
TRICEPS ++ ++
SUPINATOR ++ ++
KNEE +++ +++
ANKLE + +
Clonus : absent
Glabellar tap : present
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch. Normal
pain. Normal
temperature. Normal
DORSAL COLUMN SENSATION:
Fine touch. NAD
Vibration. NAD
Proprioception. NAD
CORTICAL SENSATION:
Two point discrimination. NAD
Tactile localisation. NAD
stereognosis. NAD
graphasthesia. NAD
CEREBELLAR EXAMINATION:
Normal
No hypotonia and pendular knee jerk : absent
Intention tremor : absent
Rebound phenomenon absent
Nystagmus: absent
Titubation: absent
Rhombergs test : couldn't elicit
GAIT:
Festinant gait,
Short shuffling gait.
Stance: Patient mildly bending forward
Difficulty in initiation of movements ,
Freezing suddenly
Started walking with rapid, short shuffling steps
Paucity of automatic movements of both upper limbs ( no swinging movement of arms)
Impaired balance on turning.
unable to perform tandem walking.
SIGNS OF MENINGEAL IRRITATION: absent
Autonomic functions:
No resting tachycardia
No postural hypotension
No excessive sweating
Other systems examination
CVS:
S1,S2 heard,
no murmers
RESPIRATORY SYSTEM:
Chest - symmetrical, No paradoxical movements
Normal vesicular breath sounds heard
No abnormal/added sound
ABDOMEN:
Abdomen is soft, non tender.
No organomegaly
No ascites
Bowel sounds+
Leadpipe rigidity??
Left upper limb Cog wheel rigidity
Tone
GAIT
1)Lt triceps
2) Glabellar tap present
3)Lt triceps reflex
4)Lt Supinator Reflex
5)Rt Biceps
6)Rt Triceps
7)Rt Supinator
8)Resting Tremors
9)Rt Ankle Jerk
10)Lt Ankle Jerk
11)Lt Plantar Reflex
12)Rt Plantar Reflex
13)Knee Jerk
14)Lt Biceps
CBP :
HB : 12.3g/dl
TLC : 6,600
PLATELETS. .2.14 lakh
RBS :97 mg/dl
Sr. Cr : 1.1 mg/dl
Sr. Urea : 33 mg/dl
Na: 139 meq
K : 4.0
Cl: 101
LFT :
TB : 2.39
DB : 0.8
ALT :34
AST: 30
ALP: 131
Albumin: 4
TP : 6.3
ECG
Provisional Diagnosis :
Idiopathic Parkinson's disease
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