17/05/2024
A case presentation of Parkinson's disease:
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**Patient Information:**
- Name:...............
- Age: 67
- Gender: Male
- Occupation: Retired officer
- Address: ............
**Chief Complaint:
- Tremor in right hand and leg for the past 2 years
- Difficulty in walking and maintaining balance
**History of Present Illness:
- Symptoms started gradually two years ago with a slight tremor in the right hand
- Tremor worsened over time and now affects the right hand and leg
- Stiffness and slowness of movement (bradykinesia) developed gradually
- Episodes of freezing while walking
- Increased difficulty in initiating movement
- No significant relief with rest
**Past Medical History:
- Hypertension, controlled with medication
- No history of head trauma or neurosurgery
- No history of exposure to toxins
**Family History:**
- Father had Parkinson's disease, diagnosed at age 72
**Social History:
- Non-smoker
- No history of illicit drug use
**Medications:
- Lisinopril 10 mg daily for hypertension
- Aspirin 75 mg daily for cardiovascular prophylaxis
**Physical Examination:
- Vital Signs: Stable
- Neurological Examination:
- Resting tremor in right hand and leg
- Rigidity in right upper and lower limbs
- Bradykinesia: Slowed finger tapping and difficulty with rapid alternating movements
- Postural instability: Difficulty in maintaining balance, retropulsion on pull test
- Normal cranial nerve examination
- No other focal neurological deficits
**Assessment and Plan:
- Clinical diagnosis of Parkinson's disease based on the presence of resting tremor, bradykinesia, rigidity, and postural instability
- Initiate treatment with levodopa-carbidopa combination therapy to alleviate symptoms
- Refer to a neurologist for further evaluation and long-term management
- Counsel patient and family regarding the progressive nature of Parkinson's disease and the importance of adherence to medication and follow-up appointments
**Follow-up:
- Schedule a follow-up appointment in 4 weeks to assess response to treatment and adjust medication dosage as necessary
- Provide education and support resources for the patient and family to cope with the chronic nature of Parkinson's disease