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  #1  
Old 01-26-2014
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Listening Please identify my errors in this PN

66 yo m c/o tremor in R hand since 6 months . tremors worsened recekntly. present at res annd disappears on purposeful action. also wife complains he has slowed down a bit in the past yr. denies any h/o fals, drooling /TIA symptoms,past h/o of occasional tremor in college when sleep deprived but it was higher frequency
ROS: no chest pain, no SOB
PMH:high cholesterol
PSH:none
SH:denies EtOH /cig/drugs
SXHX:active with wife
NKDA
Medications none

VS: NL
HEENT: PERRLA,
NECK:no carotid bruit
HEART:S1S2nl
LUNG:CT&A B/L
NEURO:AAO* 3 , cranial nerves 2-12 grossly intact, L hand resting tremor+ , disappears on goal directed movement,
cerebellar signs: finger noose test WNL, romberg -ve,

1. PD
bradykinesia
slowed gait
exam - mild rigidity

2. Drug induced tremor
Albuterol +

3. Essential tremor
h/o tremor in college
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  #2  
Old 01-26-2014
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Apart from some obvious spelling errors (i'm not sure if they're strict about these):

Might be better to specify which "TIA symptoms"

Some supporting info found in the differentials aren't found in the Hx and PE portion (ex. albuterol, mild rigidity)

You forgot the diagnostics.

Also, it's probably better to maximize supporting info for the first differential (PD). Ex: I'll put negative findings to distinguish it from other differentials. I think there are three default spaces beneath history and PE to support each differential.

So it'll look like this:

1)PD
Hx:
- resting tremor
- slowed down
- no drooling, weakness

PE:
- slow gait
- L hand resting tremor
- mild cogwheel rigidity
- no tremor on purposeful movt


Hope it helps.
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  #3  
Old 01-26-2014
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Quote:
Originally Posted by rg99 View Post
66 yo m c/o tremor in R hand since 6 months . tremors worsened recekntly. present at res annd disappears on purposeful action. also wife complains he has slowed down a bit in the past yr. denies any h/o fals, drooling /TIA symptoms,past h/o of occasional tremor in college when sleep deprived but it was higher frequency

Is the gentleman right or left handed? - important for all neuro cases.
Coffee / caffeine / stimulant intake history?
History of repeated trauma to head?
Need more information for a PD history:
Any history of hyposmia / anosmia? (often associated with early stages of PD).
Any history of PD-plus symptoms? (autonomic, dementia / cog decline)
Activities of daily living, micrographia, etc.
Urinary incontinence?

ROS: no chest pain, no SOB (I'd just write "nil additional except as per above").
PMH:high cholesterol (write hypercholesterolemia or dyslipidemia)
PSH:none
FHX: A family history of neurological and other conditions is important to rule out.
SH:denies EtOH /cig/drugs. Need much more on ADLs here. How are the current symptoms affecting this chap's life? Coffee, etc.
SXHX:active with wife
NKDA
Medications none (then where is the albuterol coming from?)

General comment on appearance would be in order here (+/- hypomimia, atrophy, etc.)
VS: NL (would like to check for postural hypotension in case of autonomic dysfunction)
HEENT: PERRLA (need to specifically check for vertical gaze, glabellar tap, etc.)
NECK:no carotid bruit
HEART:S1S2nl (need to comment on pulse especially if stroke is on the radar). "RRR, S1+S2 with nil added gallop, rub, or murmurs"
LUNG:CT&A B/L
NEURO:AAO* 3 , cranial nerves 2-12 grossly intact, L hand resting tremor+ (why the L hand: the HPC describes R tremor), disappears on goal directed movement,
cerebellar signs: finger noose test WNL, romberg -ve, (need more cerebellar exam here as one of the main things to rule out when you suspect PD is a cerebellar lesion)

Other signs characteristic of PD:
Poverty of facial expression
Resting tremor of 3-5 Hz
Cogwheel rigidity
Bradykinesia
(if time, glabellar tap, vertical gaze)
Gait: loss of arm swing, hesitancy, shuffling gait, retropulsion.



1. PD
bradykinesia
slowed gait
exam - mild rigidity (what type of rigidity?)

2. Drug induced tremor
Albuterol + (where is this medication coming from?)

3. Essential tremor
h/o tremor in college
As pointed out by the other poster: you haven't listed your Diagnostic Investigations.
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  #4  
Old 01-26-2014
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Thanks a lot Dr pepper and usmleire
ok i forgot albuterol in medications and the work up i had written but i forgot to copy it fom the usmle PN page
Thanks for pointing out a lot of new things which I was not even thinking about. Powerty of facial expression and orthostatic vitals is very important I can remember but I didnt know about anosmia?
FA has missed a lot of points it seems.
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  #5  
Old 01-26-2014
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(need to comment on pulse especially if stroke is on the radar).?
can u plz explain why?
You mean peripheral pulses or something else?
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  #6  
Old 01-26-2014
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one more query, can we + and -

60 yo M c\o crampy, episodic LLQ pain since 1 day after having dinner from restaurant but no one else sick,each episode last for 2-3 sec & comes after 10-15 mins,6/10 intensity ,+diarrhea(loose stools,2-3 episodes with bright red blood),+ nausea and vomiting(1 episode, of food particle no blood or bile) + fever but no chills or sweating
ROS:no recent travel

is it okay to write + as i have written above, plz reply
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  #7  
Old 01-26-2014
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I dont think its needed , u could just write all symptoms etc , its understood that these symptoms are present ...+ is more comonly used after some test which is positive
correct me if I am wrong
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  #8  
Old 01-26-2014
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Quote:
Originally Posted by rg99 View Post
(need to comment on pulse especially if stroke is on the radar).?
can u plz explain why?
You mean peripheral pulses or something else?
Whether the pulse has a regular rhythm or not (AFib and stroke).
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  #9  
Old 01-27-2014
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36 YO F C/O 20 LBS WEIGHT GAIN IN PAST 3 MONTHS. H/O COLD INTOLERANCE, DRYNESS OF SKIN, HAIR FALL. ALSO NOTED CHANGE IN MENSTRUAL CYCLES SINCE 6 MONTHS . PREVIOUSLY CYCLES WERE 4 WEEKS , NOW 6 WEEKS WITH DECREASED BLOOD FLOW. DENIES CONSTIPATION, HAORSNESS, HIRSUTISM, FATIGUE. APPETITE GOOD . DIET CONSISTS OF MOSTLY HIGH FAT FOODS.
ROS : -VE EXCEPT AS ABOVE
PMH ; BIPOLAR DISORDER , ON Rx
MEDICATION; Li
PSH NONE
SHX : QUIT SMOKING 3 MONTHS BACK, ETOH ON WEEKENDS, NO DRUGS
FHX : THYROID DIS IN MOTHER
SXHX : ACTIVE WITH HUSBAND

HEENT: PERRLA, NO LID LAG
NECK : NO THYROMEGALY
NEURO : LOWER EXTR MOTOR 5/5, DTR- ACHILEES TENDON + 2 B/L
SENSATION INTACT TO COARSE TOUCH, DP +2 SYMMETRIC
HEART: S1S2 NL, NO M/R/G
LUNG CT& A B/L
ABDOMEN: NT/ND

1.HYPOTHYROIDISM
DRY SKIN , HAIR FALL , OIGOMENORRHEA, COLD INTOLERANCE
P/E DRY SKIN

2.NICOTINE CESSATION WEIGHT GAIN
SMOKING CESSATION 3 MNTH BACK

3.Li INDUCED WEIGHT GAIN
H/O Li INTAKE

INV:
TSH fT4, fT3
LIPID PANEL
CBC
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  #10  
Old 01-27-2014
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Quote:
Originally Posted by rg99 View Post
36 YO F C/O 20 LBS WEIGHT GAIN IN PAST 3 MONTHS. H/O COLD INTOLERANCE, DRYNESS OF SKIN, HAIR FALL. ALSO NOTED CHANGE IN MENSTRUAL CYCLES SINCE 6 MONTHS . PREVIOUSLY CYCLES WERE 4 WEEKS , NOW 6 WEEKS WITH DECREASED BLOOD FLOW. DENIES CONSTIPATION, HAORSNESS, HIRSUTISM, FATIGUE. APPETITE GOOD . DIET CONSISTS OF MOSTLY HIGH FAT FOODS.
You should ask the patient about symptoms of depression, etc. if the thyroid is involved (especially since she has a background of BPAD).
Any acne?

ROS : -VE EXCEPT AS ABOVE
PMH ; BIPOLAR DISORDER , ON Rx
For ANY woman (especially of child-bearing age), you MUST go through a comprehensive Obs / Gyn History, especially since she describes oligomenorrhea. Pregnancies, complications (esp if there's a hint of Sheehan syndrome), smear history, etc.
MEDICATION; Li (how long she is taking Li may be very important)
PSH NONE
SHX : QUIT SMOKING 3 MONTHS BACK, ETOH ON WEEKENDS (any EtOH history requires a CAGE questionnaire), NO DRUGS
FHX : THYROID DIS IN MOTHER
SXHX : ACTIVE WITH HUSBAND (contraceptive use? - important while on Lithium)

Vitals: any bradycardia, etc.?
HEENT: PERRLA, NO LID LAG (any coarse facial features?)
NECK : NO THYROMEGALY (also comment on +/- thyroid bruit, lymphadenopathy, etc.)
NEURO : LOWER EXTR MOTOR 5/5, DTR- ACHILEES TENDON + 2 B/L
SENSATION INTACT TO COARSE TOUCH, DP +2 SYMMETRIC
HEART: S1S2 NL, NO M/R/G
LUNG CT& A B/L
ABDOMEN: NT/ND (Bowel sounds present / hypodynamic?)
Skin: Acne? dry? lack of hair? pretibial myxedema?

Depending on the length of time on Lithium and the dose, Li-induced hypothyroidism would be my #1 on the DDX. Very common in BPAD patients on Lithium.

1.HYPOTHYROIDISM
DRY SKIN , HAIR FALL , OIGOMENORRHEA, COLD INTOLERANCE
P/E DRY SKIN

2.NICOTINE CESSATION WEIGHT GAIN
SMOKING CESSATION 3 MNTH BACK

3.Li INDUCED WEIGHT GAIN
H/O Li INTAKE

INV:
Any woman with a history of recent oligomenorrhea needs a hCG test (urine or otherwise) and probably needs LH:FSH ratio. May also need pelvic exam.
TSH fT4, fT3
LIPID PANEL
CBC
Fasting Glucose / HbA1c
I'd add in a pelvic ultrasound (for ovaries) to check for PCOS
Counseling: I would definitely counsel re: Lithium use and not getting pregnant, etc.
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  #11  
Old 01-27-2014
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Thanks very good points and definitely very important to counsel not to get pregnant while on Li
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