Friday, May 06, 2016

Parkinsons Disease

1. Wash hand, Introduce, Consent.

This looks like Parkinson?

2. "Hello Sir, can you me your name and your address?" - monotonous, low volume speech?

3. General inspection - "I am just going to stand here and have a good overall look first"
 Walking aid? Looking at the patient, Expressionless, mask-like face, reduced blinking

3. "Any pain anywhere?"

4. Tremor -
Put both hands on a pillow/lap - thumbs and indexs top and radial surface bottom - to show pill rolling more evidently. Is it symmetrical? Coarse? Pill-rolling?
"Could you close your eyes for me, gently and count backwards from 10 to 9 to 8 and so on...?
- distraction method to enhance tremor
"Could you lift up your arms and spread out your fingers like this?"
- rule out postural tremor

5. Rigidity -
"Just going to examine the muscles and movements of the arms and hands, Can you go floppy and soft, just let me take the weight of the arm, relax and soft, relax and soft..."
- Supinate and pronate, extend and flex elbow, extend and flex wrist, both sides
Look for lead-pipe rigidity at the elbow, cogwheeling at the wrist.
"Could I ask you to tap your knee with your other hand like this, keep going while I examining this side? and the other side
- Synkinesis would accentuate the rigidity almost instantaneously

6. Bradykinesis
"I am going to need you to do this movement like twinkle stars, as fast as you could and keep going keep going keep going:
- decreased amplitude and speed as it goes
"Can you show me your hands movement as if you are opening the water tap?"

(proceed with power and reflex)

7. Postural Instability
"Sir, do you think you would be able to take a few steps across the room and show me how you walk?" Can you walk over to the door and make a U-turn back here as you would normally?
- Look for difficulty to initiate movement of getting off the chair and start walking, stooped posture, hesitation, shuffling, narrow based gait, reduced arm swing, difficulty in turning with accentuation of pill rolling.

9. Function
"Can I get you to show me how you unbutton your shirt, just a few buttons? and can you put that back?
"Can you write your name for me?" - holding pen and write

10. Rule out PSP
"Just going to check your eye movements. Can you keep your head straight and still, and use your eyes to follow my finger? Keep going keep going... all movements
 Look for vertical gaze palsies, and nystagmus for cerebellar disorders
"Could you close your eyes and  keep your arms straight, palms nice and flat up like this?"
- pronator drift
"Could you form a pointer like this and touch the tip of my finger and then the tip of your nose?" and the other side
- check for cerebellar sign

I will complete the examination with full neurological exam, supine and erect BP, MMSE, swallowing test and writing.


Mr X is an elderly gentleman with Mask-like and expressionless face, monotonous and low volume speech. He has asymetrical tremor at rest, predominantly on the right side with characteristic pill-rolling movements of the thumb. The tremor diminished with usage of the hand, but accentuated by walking and distraction. There is presence of lead pipe rigidity at the elbow joint, cogwheeling at the wrist joint and both accentuated by movement of the contralateral upper limb. He has bradykinesia with reduced amplitude and speed of his fingers movement. He has difficulty getting up from his chair and initiating walking, with stooped posture. Once walking, he showed shuffling, narrow based gait, with lack of normal arm swing, and slow in turning.

Functionally, he can dress up himself, able to walk unaided.

He does not have features suggesting PSP. There is no sign of PSP such as impairment of vertical gaze. There are no cerebellar sign to suggest MSA, or sign of corticobasal ganglia degeneration such as pyrimidal signs or dystonic arm.

All in all, he has features in keeping with my diagnosis of Parkinsonism, and most likely  due to Parkinsons Disease with good preservation of function, and no evidence of dyskinesia at this point in time.