30th January, 2023
MEDICAL
REPORT
L. S (DR), 66YEARS, MALE,
: WCA/6003/2023
Diagnosis: Movement Disorder
(Parkinson Disease).
Management: Neurologist
for continued care
·
Tab
Sinemet25/250mg daily.
Background
history
The
above-named patient presented with 6 month history of right hand involuntary
movement involving majorly the right thumb and index finger. Involuntary
movement was noticed at rest, worsens with anxiety and hunger. No history of
urinary or fecal incontinence, however, has episodes of constipation. His
nutrition was probed and found to be adequate. He is a known diabetic and
hypertensive on medication with good glycemic and blood pressure control. No
history of memory loss and shuffling gait, however, his wife noticed a
reduction in his walking pace and also noticed that he doesn’t laugh/smile as
he used to in the past. There is no preceding history of head trauma. He does
not take alcohol or nicotine.
He is on Tab Concor 2.5mg daily, Tab Caduet 5/10mg
(half tablet daily), Tab Sinemet 25/250mg daily, Tab Neurovite forte, Tab
Galvus Met 50/1000mg.
Neurological
examination: He was conscious, oriented in time,
place and person. Expressionless face, No cranial nerve deficit, normal visual
fields, Normal finding on fundoscopy. Increase tone in both upper limbs but
worse on the right. Lead pipe rigidity noted on the right upper limb. Rest of
his neurology is essentially normal.
Laboratory
Results: laboratory results were all with normal range save for HbA1c which was
elevated with a value of 6.9% and Low Total Cholesterol level. Copy of result
attached to this report.
Brain Imaging (MRI): revealed
normal study. No intracranial masses, no signs of cerebrovascular
insufficiency. No midline shift.
following the
above diagnosis the above outlined management plan is recommended.
But please
revert, if need be, for further clarification
Yours
Sincerely,
Dr.
Chizim Mordi
For
team Wellington Clinics