[Answered]: Chief Complaint “My work performance has declined…

Chief Complaint “My work performance has declined because my tremor makes it difficult to type on the computer, and I am slower with most tasks.” HPI Lori Tanner is a 63-year-old, right-handed woman who presents to the neurology clinic because of a mild tremor in her right hand that has worsened over the past 6 months. It takes her longer to do things because it takes a little more effort to get movement started, and her muscles feel a little stiff. She also admits to difficulty falling asleep but has no issues staying asleep. The stiffness, slowness, tremor, and sleep problems have affected her job performance as a graphic designer, resulting in her contemplating early retirement. She also complains of constipation, depressed mood, lack of pleasure in her usual activities, and loss of sense of smell for about 2 years. Due to complaints of acid reflux, she is currently receiving treatment for it. PMH GERD times 1 month Broken left wrist after fall 1 year ago FH Mother died at age 89 of complications associated with a hip fracture, osteoporosis, and Alzheimer disease (clinical diagnosis without postmortem confirmation); father died from an ischemic stroke at age 58; two daughters are in good health. SH (–) Alcohol, (–) tobacco, married for 23 years ROS No complaints other than those noted in the HPI. She denies any other symptoms of autonomic dysfunction such as problems with swallowing, urination, drooling, or dizziness. She admits to occasional crying spells and low mood but denies panic attacks, hallucinations, vivid dreams, and paranoia. Meds Pantoprazole 40 mg PO once daily 30 minutes before meals Calcium carbonate (Tums*) 600 mg PO every morning and night Allergies None Physical Examination Gen The patient is a Caucasian woman who appears older than stated age. VS BP 118/74 mm Hg sitting, 116/70 mm Hg standing, P 70 bpm, RR 13; T 36.8deg C; Wt 53 kg, Ht 5′2′′ Skin Small amount of dry yellow scales in her eyebrows HEENT Decreased facial expression, decreased eye blinking; PERRLA; EOMI Neck/Lymph Nodes Supple, no masses, normal thyroid, no bruits Lungs/Thorax Clear, normal breath sounds, CTA CV RRR, no murmurs, no bruits Abd Soft, nontender, no palpable masses Genit/Rect No nodules palpated; no rectal polyps MS/Ext Normal peripheral pulses and postural stability; no CCE. Neuro • General neurologic exam intact, MoCA 30/30, HAM-D scale 11/66 (depressed mood, sleep problems; indicative of mild depression) • UPDRS: Total 15 o Part 1: Mentation, behavior, and mood score 3/16 (1 for depression; 2 for motivation/initiation). o Part 2: ADL score 5/52 (mild trouble with handwriting, cutting food, tremor, and dressing [putting on nylon stockings and buttoning small buttons]). She has no problems with gait. She has some reduced arm swing on the right when she walks. She has no problems with speech, salivation, swallowing, hygiene, turning in bed, falling, freezing, walking, or sensory effects. o Part 3: Motor exam 7/108 (mild problems with facial expression and overall bradykinesia). She has right-sided rigidity and rest tremor, appearing like classic pill-rolling tremor. She has problems with fine motor coordination on her right side noted by the rapid alternating movements, finger taps, hand movements, and foot tap tests. She has no problems arising from a chair or problems with posture or postural stability. • Handwriting sample: Somewhat slow and progressively smaller in size indicating signs of micrographia Labs Assessment 1. PD, untreated and uncontrolled, with mild depression 2. Insomnia, untreated and uncontrolled 3. Constipation, untreated and uncontrolled 4. Vitamin D deficiency, untreated 5. GERD Clinical Course The patient is told that she has PD, and the various treatment options are presented to her. She asks about treatment options that may delay disease progression. Questions 1. What subjective and objective information indicates the presence of PD? 2. Assess the severity of PD based on the subjective and objective information available. 3. Create and prioritize a list of the patient’s drug therapy problems (REFER BACK TO ASSESMENT). Include assessment of medication appropriateness, effectiveness, safety, and patient adherence. 4. What are the goals of pharmacotherapy in this case? 5. What nondrug therapies for PD might be useful for this patient? 6. What feasible pharmacotherapeutic options are available to treat this patient’s PD? 7. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient’s PD and other drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy. 8. What information / education should be provided to the patient/care partner to enhance adherence, ensure successful therapy, and minimize adverse effects?