Case: Ms. Johnson is a 61-year-old woman presenting today with a chief complaint of a hand tremor that has worsened over the past three years. The tremor occurs when she uses her hands for activities such as slicing vegetables, sewing, putting on her lipstick, or typing at her computer. Her handwriting has become messy and sprawling and very difficult to read. She has worked for 23 years as an executive assistant; as a result of her tremor and the associated difficulties, she is considering retirement. She notes that on the rare occasion that she consumes alcohol, the tremor is somewhat improved.
Family history is positive for two grandparents who also “had the shakes” later in life. She assumes that they both had Parkinson’s disease and is afraid “that’s what’s wrong with me, too.”
Medications include an antihypertensive, a statin, and an estrogen patch. Today her BP is 120/62. Height is 5’6”, weight 139 lbs. On physical examination, mental status, cranial nerves, sensation, muscle strength, tone, and deep tendon reflexes are all normal. There is a mild tremor bilaterally in both hands as she writes her name. No tremor at rest. There is no bradykinesia or rigidity noted. Voice is somewhat tremulous. There is a slight involuntary back-and-forth horizontal rotation of the head.
Lab data, including lipids, TSH and FBS are all within normal limits.
WHAT IS YOUR DIAGNOSIS AND HOW WOULD YOU PROCEED?
Student is presented with a medical case study scenario.
Student will then be asked to create a case study report with 6 content area subheadings. Make sure you answer all the questions comprehensively. Use complete sentences.
1. Diagnosis Name
What is the name of the disease/disorder?
What are the reasons for your diagnosis?|
3. Causes/Risk Factors
What are some of the factors that put this patient at risk for the disease?
What other questions might you have for the patient that would provide you with more data?
4. Clinical Manifestation
Describe the clinical features of the disease that are present in the individual.
5. Diagnostic Procedures
What types of procedures were done on the patient and what were the results?
Are there other diagnostic procedures that you would like to have performed? If so, which ones and why?
Describe the treatment plan that you would prescribe for this patient.