65 year old male with tremors and urinary incontinence

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I’ve been given this case to solve in an attempt to understand the topic of “patient 

clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.

Following is the view of my case :

Date of admission : 12/11/2022 

Chief complaints :

C/O Tremors since 5 years,

Giddiness since 2 months

Uncontrolled urination since 2 months 

Slurring of speech since 3 months

History of presenting illness:

Patient was apparently asymptomatic 5 years ago then he developed tremors in upper limbs which was insidious in onset and gradually progressive and involved lower limbs,3 months back his speech got slurred, drooling of saliva started,since 2 months patient was unable to control micturition and he started to felt giddiness and falls suddenly while walking and he is complaining of constipation since 2 months

No H/O Fever, Vomitings, burning micturition,chills, SOB

Past history:

He is a K/C/O Parkinson's disease and he is using Syndopa 125 mg and trihexiphenidyl 2mg since 3 years

No history of similar complaints in the past

N/K/C/O DM,Htn,Tb,Asthma, epilepsy,CAD,

Thyroid disorders

Family History:

Not Significant

Personal History:

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements- irregular, constipation and urinary incontinence is seen

Addictions - no

No known allergies

Drug history : 

No significant drug history

General examination:

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person 

at the time of examination

He is examined in a well lit room, with consent taken.

He is moderately built and moderatly nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

Vitals : on the day of admission (12/11/2022)

Temperature - afebrile

Pulse rate - 82 bpm

Respiratory rate - 16 cpm

Blood pressure - 120/80 mmHg

SpO2 - 99% on Room air

GRBS - 127 mg/dl

Postural hypotension not present:

- Supine BP - 120/70mmHg & On Standing 120/80mmHg

Systemic examination:

CVS : S1 and S2 heart sounds heard 

NO murmurs and thrills

RESPIRATORY SYSTEM : Bilateral air entry present position of trachea - central 

 Vesicular breathsounds heard

CNS : mask like expression less face is seen

Festinant gait present

Able to do finger nose test,knee heal test,no dysdiadokokinesia,

Not able to walk in a straight line

ABDOMEN :

Soft 

 On deep palpation -non TENDER no palpable masses

Bowel sounds heard 

NO organomegaly

Investigations:

On 12/11/2022:

On 13/11/2022:

HEMOGRAM:

SERUM CREATININE:

SERUM ELECTROLYTES:

SERUM CALCIUM:

COMPLETE URINE EXAMINATION:

BLOOD SUGAR-RANDOM:

BLOOD UREA:

LIVER FUNCTION TEST:

Anti HCV Antibodies-RAPID:

HBsAg-RAPID:

HIV1/2 RAPID :

X-ray :

Ultrasound Report:

ECG Report:

On 14/11/2022:

Diagnosis:

Parkinson's disease

Treatment:

1)Tab.Syndopa 125 mg PO/TD

2)Tab.Trihexyphenidyl 2 mg PO/BD

3)Inj. Optineuron 1amp in 500ml NS IV/OD