Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is called Peter Pancakes – a 70-year-old gentleman presenting with tremors. Please take a history and perform an appropriate examination.
Patient History:
Peter Pancakes, a 70-year-old gentleman, retired.
Over the past few years, you have been getting worsening tremors in your left hand. It tends to get worse when lying still rather than on movement. So, you always keep yourself active.
You feel like your left arm is stiffer than the right, but all of your limbs have been quite stiff all the time, to be honest. Your daughter also noticed you have been moving and thinking a lot slower than usual- you forget things very easily, but you think this is because of old age.
You also feel low in mood generally. You feel tired because you think this is due to difficulties falling asleep. You often feel like you need to be more steady despite having a stick to move around; you have fallen at home a few times, which resulted in a few hospital stays. Thankfully, there weren’t any head injuries.
You are always constipated, but you have laxatives which improve it slightly. You have often noticed some drooling from your mouth without any reasons, which can be really embarrassing! If asked specifically, your sense of smell has reduced.
No sexual dysfunction. Waterworks normal. No abnormal sweating. No hallucinations/delusions. No fluctuating consciousness. No difficulty swallowing. No history of head injury.
Ideas, Concerns, Expectations:
You think you might be getting dementia, but you are unsure. You are concerned as these symptoms are affecting your activities of daily living - you want to at least function as a normal human being. You would like some investigations to find out what is going on.
Past Medical History:
Osteoarthritis, Hypertension
Drug History:
Amlodipine
NKDA
Family History:
Father has dementia – but you do not know which type of dementia, but he had similar symptoms e.g. tremors.
Social History:
Do not drink alcohol or smoke.
Retired, used to work as a gardener.
Use a stick to walk around.
Examination Findings:
Facial masking, stooped/flexed posture, forward tilt, reduced arm swing, shuffling gait.
Tremor +/- pill rolling at the left hand, which worsens at rest at Hz 4-6 and improves with voluntary movement.
Cogwheel rigidity is worsened by performing an action in the opposite limb ( contralateral synkinesis).
Hypomimia.
Micrographia.
Difficulty initiating movement.
Difficulty turning around when standing – having to take many small steps.
Difficulty in stopping.
Infrequent blinking.
Quiet and slow voice.
Reduced dexterity.
Postural instability can be demonstrated by pull test/imbalance.
Conjugate gaze disorder may be present.
No ataxia.
No postural hypotension.
Normal power and reflexes.
Differentials:
Parkinson’s Disease +/- Dementia
Benign Essential tremor
Progressive supranuclear palsy
Huntington’s disease
Wilson’s disease
Investigations:
Clinical diagnosis - should be made by a specialist in Parkinson’s Disease with the UK Parkinson’s Disease Society (PDS) Brain Bank Criteria.
Referral to Parkinson’s specialist for further investigations/ management
Dopaminergic agent trial (improvement in symptoms)
Consider CT/MRI Brain if unclear diagnosis +/- atypical features
Consider SPECT if unclear diagnosis +/- atypical features
Consider a PET scan with fluorodopa – to localise dopamine deficiency in basal ganglia
Consider transcranial sonography, if available, with expertise to differentiate PD from atypical/secondary parkinsonian disorders.
Consider genetic testing e.g. Huntington’s gene if appropriate
Consider Olfactory testing if unclear diagnosis +/- atypical features
Consider Serum ceruloplasmin/ 24h urine copper for Wilson’s disease
Syphilis serology if appropriate
Management (Parkinson’s Disease):