65 year old male with diffuse involuntary movements of left lower limb

 This is an online E Logbook 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 a series of inputs from an available global online community of experts to solve those patients' 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 in the comment box are welcome.

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A 65 year old male came to casuality with 
C/o diffuse involuntary movements of left lower limb since 2 years
C/o difficulty in swallowing ( solids > liquids) since 20 days

HOPI
 
Patient was apparently asymptomatic 2 years back , later developed involuntary movements of left upper limb and lower limb since 2 years.
Movements are present at rest , and decreased on doing work and later they got admitted and started in TAB.SYNDOPA PLUS ( initially 2 tabs twice daily) , movements subsided for 4 hours after taking medication and again started after 4 hours of medication and after 2 months used 3 tabs per day and also started on herbal medication for 3 months, for which movements subsided completely and recurred after stopping herbal medication . Now, since 4 months using tablet four times per day and only resting tremors are present 

PAST HISTORY

Not a K/C/O HTN,DM,ASTHMA

O/E: 
CVS: S1S2 heard 
RS: BAE+
P/A :soft and non tender 


CNS: 
Speech : delayed 

Tone        UL                  LL
RT           increased     increased 
LT            increased     increased 
power     
Rt            4/5                 4/5
Lt             4/5                 4/5
Reflexes 
                  Biceps   triceps   supinator
RIGHT       ++           ++          ++
LEFT          +++        ++           ++
                 Knee         ankle
Right           ++             +
 Left            ++             +
Vitals: 
temp: afebrile
Bp :100/60 mmhg
Pr: 99 bpm
Rr: 17cpm
Grbs: 126 mg/dl









Provisional diagnosis:
 ? Parkinson's  disease(lt>rt) 

Treatment: 
1) TAB.SYNDOPA PLUS 110 MG/PO/QID 
2)TAB.PAN 40 MG/PO/OD
3)INJ.OPTINEURON 1 AMP IN 100ML NS/IV/OD




SOAP NOTES DAY 1 

S: involuntary movements of left lower limb since 2 years 
Difficulty in swallowing (more to solids)  since 20 days 

O: 
Pt is c/c/c 
Oriented to time/place/person 

No pallor/icterus/cyanosis/lymphadenopathy/edema 

BP: 110/80 mmhg 
PR: 80bpm 
RR: 18cpm 
CVS: S1S2 +, no murmurs 
P/A: soft and non tender

CNS: 
Speech : delayed 

Tone        UL                  LL
RT           increased     increased 
LT            increased     increased 
power     
Rt            4/5                 4/5
Lt             4/5                 4/5
Reflexes 
                  Biceps   triceps   supinator
RIGHT       ++           ++          ++
LEFT          +++        ++           ++
                 Knee         ankle
Right           ++             +
 Left            ++             +

A: ? PARKINSON’S DISEASE 

P: 

1. TAB. SYNDOPA PLUS 100mg/25mg/PO/QID

2. TAB. PAN 40mg/PO/OD 

3. INJ. OPTINEURON 1 AMP in 100ml NS/IV/OD 

4. BP/PR/TEMP 4th hourly 

5. GRBS 12th hourly

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