Parkinson's Disease

 

Thank you for asking me to examine Harry who presented with difficulty walking/a tremor/Parkinson’s disease and assess the severity.

 

The most salient findings were a shuffling gait, tremor, rigidity, bradykinesia and postural instability, which is suggestive of Parkinsonism. There was/was not associated  autonomic dysfunction and gaze palsy. Collectively, there was a mild/moderate/severe degree of disability.

 

On inspection the patient was comfortable and did / did not have any gait aids. There were/were not any shoe or ankle supports.

 

Gait

 

With walking, the patient adopted a stooped posture and progresses with a hesitant, shuffling, narrow-based gait with reduced arms swinging most marked on the left/right. There was/was not festination and was/was not freezing.

 

The patient could/could not walk heel to toe, suggesting the presence/absence of a cerebellar pathology. The patient could/could not walk on their toes (S1), and the heels (foot drop, L4 or L5). Romberg’s sign was/was not positive (eyes closed - posterior columns, eyes open - cerebellar).

 

Arms

 

On examination of the arms, there was an asymmetrical/unilateral/bilateral resting tremor with a pill-rolling character. The tremor diminished with finger-nose testing.

 

There was increased/normal tone with lead-pipe/cogwheel rigidity. This was/was not increased by movement of the collateral arm.

 

May do full upper limb here if prompted on stem

 

There was/was not difficulty in rapid alternative movements in the hands.

 

Face:

 

In the face, there was/was not a mask-like, expressionless face (‘there was hypomimia’). There was/was not infrequent blinking. There was/was not dribbling of saliva. There was/was not blepharoclonus (tremor of eyelids when gently closed). Glabellar tap was positive/negative.

 

Speech was normal/monotonous and low volume (hypophonia).

 

There was/was not weakness of upward gaze.

 

There was/was not a sweaty brow (autonomic dysfunction).

 

Extra:

• Frontal release signs:

  • Palmomental - stroke palm and look at mentalis muscle in chin

  • Palmar grasp - finger in hand and will grasp if positive

  • Snout

  • Glabellar tap

• There was/was not Micrographia.

• Functional opening jar test

• Postural hypotension

• Frontal lobe reflexes and higher centres

 

In summary, my findings are suggestive of Parkinson’s disease with mild/moderate/severe disability.

 

My differentials include:

• Parkinson syndrome

• Parkinsonism secondary to medications (anti-psychotics, methyldopa) - however the asymmetrical nature is more characteristic of PD

• A Parkinson’s plus syndrome:

  • Nil cerebellar signs of multi-systems atrophy - bilateral motor features, cerebellar signs, autonomic dysfunction, dysarthria

  • Nil supranuclear gaze palsy - vertical gaze palsy, prominent axial rigidity, bilateral motor features, dysarthria

  • Corticobasal syndrome: myoclonus,

 

I would like to proceed from here by:

• MRI brain to rule out other pathology such as Hummingbird sign in the midbrain of PSP, or hot cross buns sign in the pons of MSA

 

Severity:

• To fully grade severity, we could use the Unified Parkinson’s Disease Rating Scale, which takes into account four domains - 1) Intellectual function, mood, behavior, 2) Activities of daily living, 3) Motor examination, and 4) Motor complications