GM Elog Case-4

RISHIK 

R No 37

A 50yr OLD MALE WITH IDIOPATHIC PARKINSONISM

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

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

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

I've 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. 

Patient came with Chief Complaints of :

Unintentional Shaking movements in his Rt Hand Since 4 months

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 4 months ago after which he noticed some abnormal, unintentional movements in his Rt hand intially Middle two fingers that gradually progressed to involve his entire upper limb

# The movements appears to be

- large in amplitude

- Not Symmetrical

- Worsened when the hand is at rest

- Aggrevated during Emotional situations

- Relieved if hand is indulged in work

# Pt also complaints of similar complaints in the other limb which he noticed a few days back but are much less severe compared to that of Rt limb

# There is no H/O of gross limitation of movements but However patient tells thay his writing had become very small in size

# Patients attendees tells that his speed of movements has significantly reduced but no difficulty to perform an action

# No H/O Stiffness of limbs

# No H/O involvement of Lower limbs

# No H/O Fever, Trauma, Headache

PAST H/O :

- No similar complaints in the past

- Not a K/C/O DM, HTN, Asthma, TB, Epilepsy

- No Drug H/O

FAMILY H/O :

- No similar complaints in any of his Family members

PERSONAL H/O :

- Sleep: Adequate

- Appetite: Normal

- Diet: Vegetarian

- Bowl & Bladder: Regular

- No Addictions

- No Known Allergies

GENERAL PHYSICAL EXAMINATION

- Patient was C/C/C; Well Oriented to time, place & person

- Moderately Built & Nourished

Provisional Diagnosis:

Idiopathic Parkinsonism