1-6 PATIENT NOTE: TREMOR HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 56 YO M C/O TREMOR IN HIS LEFT HAND. STARTED 6 MONTHS AGO AND IS GETTING WORSE. NO ALLEVIATING FACTORS, HAND TREMORS WHEN HE IS AT REST, AGGRAVATED BY FATIGUE. NO CHANGES IN CAFFEINE INTAKE. HE HAS DIFFICULTIES WITH ACTIVITIES OF DAILY LIVING, SPECIFICALLY DRESSING, FEEDING, TRANSPORTATION AND ACCOUNTING. PATIENT REPORTS A DECREASE IN CONCENTRATION BELIEVED DUE TO HIS AGE, HE REPORTS WALKING SLOWER. DENIES INFECTION, CHEST PAIN, MEMORY LOSS, NUMBNESS, WEAKNESS, BOWEL AND BLADDER CHANGES. ROS: NEGATIVE EXCEPT AS NOTED ABOVE MEDICATIONS: ALBUTEROL INHALER PRN PMH: DIAGNOSED WITH ASTHMA AS A CHILD HAS NOT USED INHALER FOR YEARS PSH: NONE FH: NONCONTRIBUTORY SH: DENIES TOBACCO, ETOH AND DRUG USE. LIVES WITH WIFE AND SON, IS A RETIRED TRUCK DRIVER AND SCHOOL TEACHER PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. THE PATIENT IS IN NO ACUTE DISTRESS AND VITALS ARE WITHIN NORMAL LIMITS. THE HEAD AND NECK APPEAR NORMOCEPHALIC AND ATRAUMATIC. THE BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. THE HEART SOUNDS ARE NORMAL WITH S1/S2. HE APPEAR ALERT AND ORIENTED TO TIME, PLACE AND PERSON ON NEUROLOGICAL EXAM. HIS CN 2-12 ARE INTACT. THE MUSCLE STRENGTH IS 5/5 THROUGHOUT EXCEPT LEFT HAND AND ARM WHICH SHOW 3/5. HIS DTRS ARE INTACT THROUGHOUT AND SENSATION TO DULL AND PIN PRICK ARE INTACT. THE CEREBELLUM HEEL TO SHIN IS NEGATIVE, NAGATIVE ON ROMBERG AND GAIT WAS SHUFFLING IN NATURE. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. DIAGNOSIS #1: PARKINSONS DISEASE HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - left hand tremor at rest - decreased concentration - tremor aggravated by fatigue - strength 5/5 throughout

- walking slower, difficulty with activities of daily living

except left hand and arm 3/5

DIAGNOSIS #2: ESSENTIAL TREMOR HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - tremor in left hand, getting worse - decreased concentration - aggravated by fatigue - strength 5/5 throughout except left hand and arm 3/5 DIAGNOSIS #3: PHYSIOLOGICAL TREMOR HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - tremor left hand, getting worse - alert and oriented to time, - increased with fatigue place and person - decreased concentration DIAGNOSTIC STUDIES - TSH - MRI-BRAIN - AST/ALT - CBC - HEAVY METAL SCREEN