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general medicine final short case

Chief complaint:
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

Chief complaint :  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 15 months back .Then he gradually developed tremors of left hand . The intensity  of tremors gradually increased  from past 2 months.on any physical activity there is decrease in tremors seen but during rest there was increase in tremors ( intermittent type )
No history of trauma
No history of rigidity and bradykinesia 
No history of postural instability 
No history of reduced eye blinking,drooling 
No history of loose stools ,constipation
No history of sleep disturbances
No history of dysphagia

Tremors video 
https://youtube.com/shorts/24l0gX5ybDI?feature=share

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 - tobacco chewing
Regular consumption of khaini 5gms since 5 years
Family history - no known relevant family history 

Patients writing is recorded 
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


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
Cerebellar Signs:

Titubation- absent
Nystagamus- absent 
Dysdiadochokinesia- absent 


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

Clinical images
Investigations

Ecg 

 provisional daignosis :
 Tremors under evaluation?
Treatment:
Tab. Syndopa 110 mg bd
Tab.zincovit 

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