Академический Документы
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Культура Документы
Names :
1. Berliana Mayorindah
2. Dwi Ristanti Yarlinabudi
3. Hari Indah Lestari
4. Pingkan Septiani
5. Syifa Nuramalia Suryanto
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Case :
Ms. Johnson is a 61-year-old woman presenting on April 1, 2017 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. And the
day after day, when she are walking and sitting, she feel limp. She has crooked body. 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 Parkinsons disease and is afraid thats whats wrong with me,
too.
Medications include an antihypertensive, a statin, and an estrogen patch. Today her BP is
120/62. Height is 166 cm, weight 53 kg. 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. Lab data, including lipids, TSH and FBS are all
within normal limits.
Progress Note
Subjective
S: Mrs. Johnson is a 61-year-old woman presenting on April 1, 2017with a chief complaint
of a hand tremor that has worsened over the past three years.
History of the present illness and analysis of symptom
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. And the day after day, when she are
walking and sitting, she feel limp. She has crooked body. 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.
Current Health Status
Mrs. Johnson no known allergies. He is not currently taking any medication long-term. He
last took advil 400 mg this morning.
Past Medical History
Pasien reports being in good general health. Patients denies past major illness or injuries.
No past surgery. No blood transfusion
Objective
VS: HR 70 BP is 120/62. Height is 166 cm, weight 53 kg.
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.
Plan:
Therapeutic :
1. Acute Therapy
a. Omeprazole 20 mg PO qday x 2 weeks
2. After 2 weeks, attempt trial of treatment
a. During trial off treatment, use OTC H2 blocker (ranitidine) or antacids for sx
b. If recurrence in< 3 months, consider testing for H. pylori or EGD
Diagnostic Tests:
1. Consider GI referral for endoscopy and/or ambulatory pH testing if symptoms continue
(Kahrilas, 2012)
2. Consider stool antigen testing for H. pylori if symptoms continue
Education:
1. Lifestyle modifications: (Kahrilas, 2012)
a. Elevate head of bed
b. Avoid laying down for 2 hours after meal
c. Avoid fatty foods, chocolate, peppermint, EtOH, carbonated drinks, juices, especially
at evening meal
d. Chewing gum after meal may help symptoms
2. Keep diary of pain symptoms, relation to meals and activity, and associated symptoms
Follow Up:
1. Return to clinic in 3 weeks
2. Call for worsening symptoms
Patient Record
Patients name : Ms. Johnson
Age : 61 years old
Medical History : 1st April admitted for assessment
Cognitive Function: - (all of them are normal)
Mobility : Mobile but a hand tremor, she has crooked body, her body is limp
Requirement : Physiotherapy
Aims : Improve balance, mobility, and independence with ADLs
Letter
Dear Mr. Adnan,
This letter introduces Mrs. Johnson. She is 61 years old and was admitted for assessment on 1 st
april. Mrs. Johnson suffers parkinsons disease. She is mobile but she has hand tremor and she
has crooked body, limp. She requires physiotherapy in order to improve balance increase
mobility and independence with ADLs.
Yours sincerely.