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. PHYSICAL EXAM: GA: PATIENT IS IN NO ACUTE DISTRESS VS: WNL HEENT: NORMOCEPHALIC, ATRAUMATIC, PERRLA CHEST: CLEAR TO AUSCULTATION BILATERALLY HEART: RRR, NORMAL S1/S2, NO RUBS, MURMURS, GALLOPS NEURO: ALERT AND ORIENTED TO TIME PLACE AND PERSON. CN 2-12 INTACT , MOTOR: STRENGTH 5/5 THOURHGOUT EXCEPT LEFT HAND AND ARM 3/5. DTRS INTACT THROUGHOUT, SENSATION TO DULL AND PIN PRICK INTACT , CEREBELLUM HEEL TO SHIN -, ROMBERG -, GAIT: SHUFFLING 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) - left hand tremor at rest - tremor aggravated by fatigue - walking slower, difficulty with activities of daily living DIAGNOSIS #2: ESSENTIAL TREMOR HISTORY FINDING(S) - tremor in left hand, getting worse - aggravated by fatigue -

PHYSICAL EXAM FINDING(S) - decreased concentration - strength 5/5 throughout except left hand and arm 3/5

PHYSICAL EXAM FINDING(S) - decreased concentration - strength 5/5 throughout except left hand and arm 3/5

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