CLINICAL SKILLS EVALUATION

PATIENT NOTE

HISTORY: Describe the history you just obtained from this patient. Include only information
(pertinent positives and negatives) relevant to this patient's problem(s).
Charles Andrews is a 66 yo M who came in for the evaluation of tremor for the past 6 months. Of note
was a previous episode during college. Tremors present at rest, lasting for a few minutes, worse with
drinking coffee and stimulant drinks., occurring intermittently. She is a coffee drinker of 3 cups per
day that cut down to 1 cup per day for the past month since worsening of the tremors. No associated
blurring of vision, headache, chest pain, palpitations and neurologic deficits.
ROS: none except above
PMH: no HTN, thyroid d/o; Asthma; +HLD
Meds: albuterol PRN last used was 1 yr ago
All: nka
FH: Father with tremor
PSHx: none
SH: retired professor, no weight gain; coffee drinker, low cholesterol diet; denies tobacco, alcohol and
illicit drug use; not exercising

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's
problem(s). Be careful to include only those parts of examination you performed in this encounter.
VS: BP 135/85; T 98.5F; R 16; HR 70
GS: stooped posture, with resting tremor speaking slowly
Heart: RRR, no m/r/g
Neuro: CN II-XII intact, + resting tremors, festinating gait, stooped posture, slowed speech, pill
rolling tremors, rigidity, intact motor 5/5, sensation, and +2DTR all extremities, negative finger to
nose test

DATA INTERPRETATION: Based on what you have learned from the history and the physical
examination , list up to 3 diagnoses that might explain this patient's 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 the 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 #2: Parkinson disease

History Finding(s) Physical Exam Finding(s)

resting tremor rigidiity
FH of tremor resting tremor
festinating gait

Diagnosis #1: Essential tremor

 History Finding(s) Physical Exam Finding(s)
resting tremor resting tremor
coffee drinker and tonic drinker
previous episode in college
worse at the end of the day

Diagnosis #3: Physiologic tremor

History Finding(s) Physical Exam Finding(s)

drinking coffee resting tremor
resting tremor
worse at the end of the day

Diagnostic Study/Studies
TSH
Urine Drug screen
BMP (Glu and electrolytes)
Brain MRI