MEDICAL
REPORT
C.O, 69YEARS, MALE,
WCA/6007/2023
Diagnosis: Movement Disorder
(Parkinson Disease).
Management:
ยท
Tabs Sinemet
125mg/12.5mg bd.
Background
history
The
above-named patient presented with two years history of global resting tremors which
worsens with anxiety, slowing of movement and speech, expressionless face, and
shuffling gait. Symptoms have progressively worsened & presently disabling.
No history of urinary or fecal incontinence, however, has episodes of
constipation. His nutrition was probed and found to be adequate. No past
history of trauma to the head, stroke or any neurological issues. There is no
history of memory loss, cognition of high mental function are well preserve for
his age. He is a retired banker with past history of minimal consumption of
alcohol, cigarette for which has been discontinued for the past 7years. He is a
known diabetic on medication with good glycemic control. He is on Tab
Glucophage 500mg daily
Neurological
examination: He was conscious, oriented in time,
place and person. Expressionless face, No cranial nerve deficit, normal visual
fields. Increase tone in both upper and lower limbs but worse on the upper
limbs. Cog wheel rigidity noted on the upper limbs, bradykinesia, shuffling
gait, resting tremors, the 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 8.5.
Neurologist reviewed and commenced Tabs Sinemet
125mg/12.5mg bd
He is to be seen in 5 weeks.
Please revert,
if need be, for further clarification
Yours
Sincerely,
Dr. Halima Ibrahim
For
team wellington clinics