parkinsonism

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 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, and investigations, and come up with a diagnosis and treatment plan.

A 33 YR MALE  FLOWER POT MAKER BY OCCUPATION RESIDENT OF BONAGIRI CAME TO OPD WITH

CHIEF COMPLAINT:- 

Abnormal movements in his upper limbs since 5 years.

Difficulty in walking since 5 years.

HOPI:-   

       The patient is apparently  asymptomatic 5 years back then he started developing abnormal  involuntary movements in his upper limbs since 5 years. The movements were noticed during rest and also while walking.

Patient also complaints of difficulty in walking in the form of difficulty in initiation and once he walks, he walks with short sride length and freezes during turning.

There is also decreased swinging of hands while walking.

Difficulty in speaking.

he is able to appreciate smell, 

hes able to look towards all sides

 no h/o sensory loss over the face, 

no facial deviation

No h/o auditory disturbances

No h/o restricted tongue movements

No difficulty in swallowing

No h/o abnormal sweating

No h/o shooting pain

No h/o headache or vomiting.

No h/o seizures

PAST HISTORY:-

K/c/o schizophrenia since 2006 and he used anti-psychotics.

N/k/c/o DM , HTN ,ASTHMA, TB, EPILEPSY.

TREATMENT HISTORY:- 

Used anti-psychotics.

DAILY ROUTINE:-

FAMILY HISTORY:-

No significant family history.

PERSONAL HISTORY:-

MARITAL STATUS:- Married 

DIET:-Mixed 

APPETITE:-NORMAL 

SLEEP:- regular and adequate 

Bowel and bladder:- regular 

No history of any allergens 

No addictions

GENERAL EXAMINATION:-

Patient is conscious, coherent, cooperative 

moderately built and moderately nourished 

No Pallor Icterus cyanosis clubbing Lymphadenopathy Edema

VITALS : 

Temp: Afebrile 

PR: 80 bpm 

Rr:16 cycles /min 

BP: 110/60 mm of hg 

SYSTEMIC EXAMINATION : -

RESPIRATORY SYSTEM : -

Trachea Central 

NVBS 

CVS :-

S1 and s2 sounds heard

No cardiac murmurs

ABDOMINAL EXAMINATION : 

shape - scaphoid

Palpable mass - no

Liver - not palpable

Spleen - not palpable

Bowel sounds - normal 

NEUROLOGICAL EXAMINATION : 

Higher mental function 

The patient is conscious well oriented to time, place and person.

No delusions or hallucinations 

Cranial nerve examination:-

CN1:- smell sense RIGHT       LEFT 

                                    +               + 

CN2:- visual acuity normal     Normal 

CN3,4,6:- extra ocular movement : full and free in all directions. 

    Direct light reflex :-present 

    Consensual light reflex :-present 

    Ptosis :- absent 

    Accommodation reflex :-present 

CN5:-       Sensory : over face ,buccal mucosa : normal 

                   Motor: masseter ,temporalis : normal 

                    Reflexes :corneal : normal

                                 Conjunctival : normal 

 CN7:-    Motor : nasolabial fold : present 

            

                Reflexes: corneal conjunctival present 

 CN8:-   Rinnes:-  +

               Webers:-  not lateralised 

             Nystagmus :- absent     

          

CN9 ,10 :- uvula movements normal 

Motor system:

BULK: Inspection : normal

             Palpation : normal

MID ARM CIRCUMFERENCE: 

Upper limb                       R                       L 

Proximal muscles.      24cm.               24cm

Distal muscles             25cm                25cm

Lower limb                       R                       L 

Proximal muscles.      36cm.               36cm

Distal muscles             29cm               30cm                                                   

TONE: both upper limbs:- rigid while extension of the elbow joint( LEAD PIPE)

           both lower limbs- normal

POWER:          

 Elbow:

Flexion.     4/5.   4/5

Extension: 4/5.   4/5

Wrist:

Flexion:4/5.   4/5

Extension: 4/5.   4/5

Abduction : 4/5.   4/5

adduction:4/5.   4/5

Hand grip:- good

HIP:-

Flexion:4/5.    4/5 

Extension.  4/5.   4/5

Knee :-

Flexion 4-/5.    4-/5

Extension.   4/5.   4/5 

Plantarflexion:.   4/5.    4/5

Dorsiflexion.     4/5.  4/5

Toe.   4/5 4/5

Reflexes : 

SUPERFICIAL:

 Present 

 DEEP TENDON REFLEXES :

                Rt      Lft 

Biceps :  + 1     +1

Triceps:   +1      +1

Supinator: +1    +1 

Knee jerk: +2  +2

Ankle jerk: +1  +1 

Involuntary activities:-

https://youtube.com/shorts/6mLEcJBz_Bk?feature=share3

GAIT:-

https://youtu.be/o_qKxZHmEqI

SENSORY SYSTEM : 

Posterior column:

 fine touch  - normal  

  Vibration  - normal 

SPINO THALAMIC : 

Pain : present 

Temperature: present 

Crude touch - normal

CEREBELLAR SIGNS : 

Finger nose test :  normal 

Heel knee test : able to do

Dysdiadokinesia- absent

Romberg test - negative 

MENINGEAL SIGNS 

neck stiffnesses.  Absent 

Kernigs sign - absent 

Brudzinski sign - not visualised 

Drawing a circle:-

Investigations:-

 

Provisional diagnosis:-   

Drug induced Parkinsonism

TREATMENT:-

Tab Levodopa + carbidopa (100+25 mg) 

Peroral twice a day

tab amantidine (100) mg peroral once daily