Case Study: Chief Complaint

866 Words 4 Pages
Chief Complaint
Rule out Parkinson 's disease.

History
The patient is a 64-year-old right-handed white female who presents with her daughter for evaluation of several symptoms. These include balance problems and a tendency to fall backwards, change in her voice and micrographia. They are wondering whether or not she has Parkinson 's disease. She stated that her voice went first about two years ago. She notes that it is getting a little lower, [____]and softer. It is not persistently hypophonic. It waxes and wanes. Her sister recently had problems with laryngeal cancer, but she had a negative workup for that. That has been pretty stable. At times, she can speak normally, and then at the end of a sentence she may be whispering, but
…show more content…
Her balance is off. She has a wide-based gait. She states she feels dizziness, as if her eyes are lagging behind. She tends to fall to the right or backwards. There is no spinning sensation with this. She does not have it while sitting or rolling over in bed. It is more like a lightheadedness than a vertigo. She notes that she has problems maintaining her balance in the shower and when she closes her eyes. She has problems walking in the dark and on uneven surfaces. If she furniture surfs, (runs her hand along a wall or across the back of the couch) it significantly improves her balance. Walking, holding onto a grocery cart also helps. The patient does have diabetes type 2. She has chronic noncompliance with medications, followups, and has not been compliant with metformin for quite some time. She has recently restarted it. She also has thyroid disease, but claims compliance with her thyroid medication. She drinks wine only twice a week. She does not have a pill-rolling tremor. There is no …show more content…
Depression.
Asthma.
Low-tension glaucoma.
Low back pain.
Status post ESIs and facet nerve ablation.
Splenectomy with excision of the tail of the pancreas for cysts.
Deviated septum repair.
Sinus surgery with tonsillectomy.
Lumbar surgery.
TAH/BSO.
Bladder prolapse repair.
Allergies
Dust mites and molds. No known drug allergies.

Medications
Metformin ER 500 mg twice a day, levothyroxine 0.75 mcg a day, vitamin D 1000 units a day, she had been advised to increase that to 2000 units, multivitamin, biotin, bupropion 150 mg, Prozac 40 mg, Zolpidem 5 mg, lorazepam 1 mg twice a day as needed, singular 10 mg, fluticasone 50 mcg, albuterol sulfate, Aleve as needed.

Examination
Constitutional
Weight 108 pounds. Height 5 '. Respirations 12. Pulse 69.

General
She is in no obvious distress.

Cardiovascular
Reveals no bruit.

Mental Status
She is oriented x3, alert, cooperative. Good short-term, long-term, and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration.

Cranial Nerves
Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. She had normal blink frequency. She had normal facial symmetry, sensation, and movement with no masked facies. Tongue and uvula were midline. Her voice was not hypophonic. Normal auditory

Related Documents

Related Topics