Wellington Case Report. Movement Disorder (Parkinson Disease).

                                                                                                                    30th January, 2023

 

MEDICAL REPORT

L.S, 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

 


 

 

26 Apr, 2023
© 2024 Wellington Clinics Abuja. All Rights Reserved.