A 56 year old with bradykinesia

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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, investigations and come up with diagnosis and treatment plan.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

Maheshwari Jagathkari

CASE REPORT

A 56 year old came with the chief complaints of 

Generalized weakness since 1 year along with the complaint of doing things slowly.

Patient was apparently asymptomatic 1 year back then she became weak gradually so much so that she is unable perform household chores which she could do 1 year back.

Her attendant also added that she has been doing things slowly that is now she takes almost an hour to complete a task which she could previously finish in 15 min.

Patient is able to walk on her own but finds it difficult to get up from sitting or supine position.

Patient also has difficulty in holding things like broomstick, combing hair, mixing food.

Patient complaints of bilateral knee pain and lower back ache non radiating type.

H/O headache present lasts for 1 hour relieves by itself.

H/O tingling sensation present all over the body.

Patient attender complaints that her voice has changed over months.

No h/o fall, memory impairment, altered sensorium, behaviour changes, visual disturbances, swallowing difficulty.

No H/O deviation of mouth to one side, slurring of speech.

Daily routine

Patient wakes up at around 5am and freshens up slowly and takes tea at around 7 am and has breakfast at 9 am and then she watched TV for sometime, she takes a nap for about an hour or two, then she has lunch at around 1 pm after which she again takes a nap, has tea at 6pm, dinner at 9pm and goes to bed by 10 30 pm .

Past history

 

Patient is not a known case of diabetes, hypertension, asthma, epilepsy, tuberculosis, thyroid disorders, CAD, CVA.

No similar complaints in the past.

Family history

No similar complaints in the family.

Personal history

Patient has a mixed diet with reduced appetite since 1 year with regular bowel and bladder movements without any addictions.

General examination

Patient is cooperative

Pallor is present.

Bilateral pedal edema till the level of below the knees is present.

No features indicating the presence of icterus, cyanosis, clubbing, lymphadenopathy.

CNS EXAMINATION

Right Handed person, uneducated 

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

MMSE 21/30

speech : muttered and monotonous speech

Behavior : normal 

Memory : Intact.

Intelligence : Normal

Lobar Functions : Normal.

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:

Intact

MOTOR EXAMINATION:        

               Right                                   Left

   

BULK  UL   Normal                        Normal

            LL   Normal                        Normal

TONE  UL        COGWHEEL RIGIDITY

             LL   Normal                       Normal

POWER UL     5/5                          5/5                          LL       5/5                        5/5

Musculoskeletal system examination

UPPER LIMB

LOWER LIMB

REFLEXES

                           Right                   Left

BICEPS               ++                        ++

TRICEPS             ++                        ++

SUPINATOR        ++                        ++

KNEE                   ++                        ++

ANKLE                 ++                       ++

PLANTAR            --                          --

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch

pain

temperature

DORSAL COLUMN SENSATION:

Fine touch

Vibration

Proprioception

CORTICAL SENSATION:

Two point discrimination

Tactile localisation.

steregnosis

graphasthesia.

CEREBELLAR EXAMINATION:

  Finger nose test

  Heel knee test 

  Dysdiadochokinesia

  Dysmetria

 Rebound phenomenon

GAIT: festanant gait

Unable to perform tandem walking

ABDOMINAL EXAMINATION

INSPECTION

No distention,No scars

Umbilicus - Inverted

Equal symmetrical movements in all the quadrants with respiration.

No visible pulsation,peristalsis, dilated veins and localized swellings.

PALPATION

No local rise of temperature, Abdomen is soft with no tenderness.

No spleenomegaly, hepatomegaly.

PERCUSSION

Liver span is 12cm, No hepatomegaly

Fluid thrill and shifting dullness absent.

No puddle sign.

AUSCULTATION

Bowel sounds present.

CVS- S1 and S2 heart sounds heard. 

RS- Bilateral air entry is present, normal vesicular breath sounds heard.

PROVISIONAL DIAGNOSIS

PARKISONS DISEASE (TYPICAL)

INVESTIGATIONS

Hb-13.2

Tlc-7700

Platelets-3.5 lakhs

PCV- 40.3

RBS- 91

BLOOD UREA-28 mg/dl

SERUM CREATININE-0.7mg/dl

SERUM IONIZED CALCIUM-1.19mmol/l

SERUM SODIUM-145mEq/l

SERUM POTASSIUM-4.1mEq/l

SERUM CHLORIDE-106mEq/l

LFT

Total bilurubin-1mg/dl

Direct bilurubin- 0.2mg/dl

SGOT(AST)- 17IU/l

SGPT(ALT)- 9IU/l

ALKALINE PHOSPHATASE-148IU/l

TOTAL PROTEINS- 7.4gm/dl

ALBUMIN- 4gm/dl

A/ G RATIO- 1.23

COMPLETE URINE EXAMINATION

NO ALBUMIN, SUGAR

PUS CELLS- 2-3

EPITHELIAL CELLS- 2-3

 SEROLOGY

ANTI HCV- NON REACTIVE

HBsAG-NEGATIVE

MRI BRAIN

TREATMENT

T.LEVODOPA(100MG)+CARBIDOPA(25MGPO/TID 

TAB.NEUROBION FORTE