A 60year old man came to hospital with complaints of tremors in right hand

 Hi, I am Presley C (roll no :96), 5rd semester medical student. This is an online E-log book to discuss our patient’s health data after taking his consent. This also reflects my patient-centered online learning portfolio.

A 60year old male agricultural worker by occupation came to hospital with complaints of tremors in right hand

Chief complaints

Patient complaints of tremors in right forearm and hand

History of presenting illness

Patient was apparently asymptomatic 2years back

He then developed shivering of right hand and arm which was

•   Insidious on onset and gradually progressive
• Initally shivering was localised to fingers only, later radiated to Palm.
•   numbness present
• Decreased power in right hand
• inability to hold things,unable to eat food, unable to work.
•   pain in right thigh
•   Shivering of right hand aggravated due to stress, anxiety fear, present for sometime during sleep.
•   Shivering is present throughant the day Intensity increases and decreases.

History of past illness

Not a known case of

•  Diabetes 
• Hypertension
• Epilepsy
• Asthma
• Tuberculosis

No history of trauma in the past

Personal history

• Sleep:adequate 
• Diet: mixed
• Bowel and bladder movements: normal
• Addictions: 

• Alcohol since 25yrs occasional drinker (stopped 3 years back)
• Cigarettes since 25 years(stopped 6years back)

• No allergies

Family history 

No significant family history

General examination

• Patient was conscious coherent well and oriented to time space and person 
• Patient was examined in a well ventilated room after taking his consent
• Moderately built and well nourished
• No pallor
• No icterus
• No cyanosis
• No lymphadenopathy
• No pedal oedema
• No clubbing of fingers

Vitals

• Temperature:afebrile
• Pulse:84 beats per minute
• Bp:110/80mm Hg
• Respiratory movements: 16 cycles                                         minute

SYSTEMIC EXAMINATION

Cardiovascular system 

• No thrills 
• No cardiac murmurs
• Cardiac sounds: S1 and S2

Respiratory system

• dyspnea absent 
• No wheezing
• No Vesicular breath sounds .
• Position of trachea - central

Abdomen

• Abdomen is scaphoid
• No tenderness
• No Palpable mass 
• Bowel sounds anew present 
• No bruits
• No free fluids

Central nervous system

Patient was conscious and coherent well oriented to time, space and person

• Speech is normal 
• Cranial nerves normal 
• Motor system normal 
• Sensory system normal 
• Glasgow scale normal 

REFLEXES

                                      Right.                       Left 

Biceps                             ++                           ++ 

Triceps                            ++                            ++

Supinator                        ++                             ++

Knee                                ++                             ++

Ankle                             ++                               ++

CEREBELLAR SIGNS 

finger nose in coordination 

Knee heal in coordination 

GAIT 

Normal.

Provisional diagnosis

Essential tremors