GENERAL MEDICINE

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 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 on comment box is welcome
Chief complaint:
A 53 year old male came to OPD with complaint of involuntary shaking of hands since 2 months.
History of present illness:
Patient was apparently asymptomatic  one year back .Then he gradually developed tremors of left hand . The intensity  of tremors gradually increased  from past 2 months tremors decreased on doing physical activity and increased on rest which is of intermittent type(on and off)he is able to hold objects with right hand but not able to do activity
No history of dysphagia
No history of loose stools; constipation 
No history of rigidity
No history of trauma
No history of sleep disturbance
No history of drooling
No history of similar complaints in family members
No history of reduced eye blinking
History of past illness

No history of diabetes mellitus,CAD,HTN, CVA, epilepsy, asthma, Tb

Personal history:
Diet: mixed
Appetite:normal
Bowel- normal
Micturition- normal
Addictions - teetotaler
Regular consumption of khaini 5gms since 5 years
Family history - no known relevant family history 

General examination:

Patient is conscious, coherent cooperative,well Oriented to time place and person.moderately built and nourished   no pallor,no icterus, no cyanosis, no clubbing of fingers, no edema,no lymphadenopathy,
 Vitals:
Temp - afebrile 
Bp- 120/70mmHg
PR-68bpm
CVS- s1 ,s2 (+), no murmurs
Systemic examination:
 Examination of CNS:

Speech: normal
Behaviour:normal
Memory: normal
Intelligence: normal
No hallucinations and delusions

Cranial nerve examination:
1st - normal
2nd- normal
3,4,6 - normal
7th-normal
8th-normal
9th-normal 
10th-normal 
11th-normal
12th- normal

Motor examination::. Right.               Left
 Tone.                   UL.      Ll.              UL. Ll
                                Normal.           Normal
Power..                     Normal.         Normal
 
Reflexes: right.     Left.
Biceps-.  2+.          2+
Triceps.  2+.          2+
Supinator 2+.        2+
Knee.        2+.         2+
Ankle.     2+.         2+
Plantar  flexion.   Flexion

Sensory examination:: 

Spinothalamic tract :. Right.            Left 
Pain.                             Normal.      Normal
Crude touch.               Normal.      Normal
Temperature..             normal.      Normal
 Posterior column:-
Fine touch..                  normal.     Normal
Vibration..                      normal.    Normal
Position sense.           Normal.     Normal

Rombergs sign-- absent
 Cortical:
Sterognosis..            Normal.       Normal
Tactile localisation Normal.       Normal


Examination of respiratory system.

Symmetrical movement of the chest on both sides
Bilateral air entry present.
Normal vesicular breath sounds  present

Abdominal examination:
Abdomen is scaphoid,no scars present,no sinuses present,no engorged veins, no visible pulsations, all quadrants are moving equally with respiration and on palpation abdominal is soft, non tender no lump ,no rigidity no guardity.

Examination of cvs:
S1 and S2 heard, no murmurs heard

Tremors video
https://youtu.be/p8_re175A6Y

Clinical images






Provisional diagnosis
Tremors under evaluation 
TREATMENT:
Tab. Syndopa 110 mg bd
Tab.zincovit 
Tremidon 25mg
Betacap 40 mg
Nicotine gums


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