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QuickScroll  Case 1

Observe this lady and proceed.

Discussion:

    This is a very popular case in MRCP PACES Station 3. There are a few possibilities this case can be asked in your MRCP PACES examination.The diagnosis is obvious, this unfortunate lady has Parkinson's disease.Usually examiners will ask you to examine the gait, lower limbs/upper limbs or even just talk to this patient. In this short video clip, you notice the following abnormalities.......

Slowness of movement ( bradykinesia)-This lady walks in a stooped posture and has difficulty to initiate her movement.
Poverty of movement- You notice she has expressionless facies, infrequent blinking and loss of arm swing.

After this initial observation, for a complete diagnosis of Parkinson's disease, you need to demonstrate two other features/clinical signs of Parkinson's disease, namely,

     Rigidity ( defined as an increase in resistance to passive movement)- I would ask patient to sit on the bed and demonstrate Leadpipe and Cog-wheel rigidity. For Leadpipe rigidity, just flex and extend the patient's forearm. Wheareas for Cog-wheel rigidity, try to twist gently the patient's wrist.

 Tremor-It often begins with rhythmic flexion-extension of the fingers (pill rolling tremor),hand or foot or with rhythmic pronation-supination of the forearm). Remember that in Parkinson's disease, it is usually resting,asymmetrical and intensified by emotional stress. Therefore, I would ask patient to rest his/her hands on a pillow and observe the tremor. Sometime if the tremor is not obvious, I would ask patient to use his other hand to imitate the movement of drawing a big circle so that the other's hand tremor can be intensified!

    After you are convinced that your patient has Parkinsonism, try to demonstrate other physical signs ( which include signs to suggest Parkinson Plus syndrome or signs to suggest underlying cause for the Parkinsonism)as below,

    Glabellar tap-Tap the forehead just above the nasal bridge and you notice the patient blink continuously.
    Seborrhoeic dermatitis- Look hard at the patient's forehead.
    Impaired vertical gaze-Patients have conspicuous failure of voluntary saccadic gaze in a vertical plane especially downward with later involvment of horizontal gaze. This feature suggest Steele-Richardson-Olzewski syndrome.
    Eye-Look for jaundice or Kayser-Fleischer rings to suggest Wilson's disease ( underlying cause).
    Speech-Talk to patient and you notice he/she has monotonous speech
    Hand writing- Just ask patient to write his/her name- You notice tremulous and small handwriting ( micrographia)
    Lower limbs-Look for rigidity as well as cerebellar signs ( to suggest Striatonigral degeneration).   
    Autonomic dysfuntion-Look for postural hypotension which may suggest Shy-Drager syndrome.
    Chest wall-Look for any surgical scar over the chest to suggest deep brain stimulation operation.

If you think that the Parkinsonism is not due to Parkinson's disease especially in young patients ( and you also do not think he/she has Wilson's disease), suggest to examiners you would like to get the following history from patient,

Drug history- especially antipsychotic drugs or drug abuse ( MTP-1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine).

Previous history of brain infection (encephalitis lethargica).

Head trauma.

Common questions examiners would ask you,

1) How do you diagnose Parkinson's disease?

Remember this useful criteria ( Ward/Gibb Criteria )

    Clinical evidence of disease progression.
    Two out of three signs-tremor,rigidity and bradykinesia
    At least two out of these three features- response to levedopa,asymmetry of signs, asymmetry of onset.
    Absense of cinical signs to suggest Parkinson plus syndrome.   
    Exclusion of secondary causes.
   
2) How do you manage this lady? ( Remember Education, physiotherapy, psychiatric, pharmocology and surgery)- These answers apply to all questions when you examiners ask you how to manage a patient in your MRCP PACES examination.

Conclusion:

This lady has Parkinsonism due to underlying Parkinson's disease .

Extra points:

Source:

1) Harrison's Principles of Internal Medicine, Fauci
2) 250 Cases in Clinical Medicine

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