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Subjective: History of The Present Illness and Analysis of Symptom

Mrs. Johnson, a 61-year-old woman, presented with a worsening hand tremor over the past three years that impacts her daily activities like cooking and writing. Her tremor is worse when using her hands but not at rest, and is slightly improved when drinking alcohol. On examination, she has a mild bilateral hand tremor and slight head tremor, but is otherwise normal. The plan is to treat with medication and consider further testing if symptoms do not improve.

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Nurul Ilmi Utami
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95 views

Subjective: History of The Present Illness and Analysis of Symptom

Mrs. Johnson, a 61-year-old woman, presented with a worsening hand tremor over the past three years that impacts her daily activities like cooking and writing. Her tremor is worse when using her hands but not at rest, and is slightly improved when drinking alcohol. On examination, she has a mild bilateral hand tremor and slight head tremor, but is otherwise normal. The plan is to treat with medication and consider further testing if symptoms do not improve.

Uploaded by

Nurul Ilmi Utami
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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

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