Parkinsonism examination

Parkinsonism examinationCreated OnJune 2, 2020Last Updated OnJune 2, 2020byadmin You are here: Main Clinical Examination Parkinsonism examination < All Topics Table of Contents Physical examination: Introduction Wash hands Introduce yourself Confirm the patient’s details Explain the examination Gain consent General Posture: stooped Gait: note the speed, length of each steps, smoothness of turning. Slow to start walking (Failure of gait initiation) Rapid, short, stride length, tendency to shorten (Festination) Reduce arm swing Imbalance while turning Observe the face: Expressionless (Hypomimia), reduce/less frequent blink rate. Hand: Observe for tremor Resting tremor (3-4Hz, moderate amplitude) Asymmetric, often first in arm/hand. Pill rolling character May affect legs, jaw and chin. But not head Intermittent present at rest, briefly abolished by movement, exacerbated by walking Aspects Resting Tremor Postural Tremor Frequency 5-10 Hz 3-4 Hz Amplitude Small in early stage, increases with progression Small to moderate Symmetry Bilateral symmetrical Asymmetrical Measure blood pressure: look for orthostatic hypotension (Autonomic dysfunction) Glabellar tap: Tapping gently over the patient’s glabellar with your finger from behind and observe patient blinks. Normally, blinking to the first 2–3 taps and then there is no response. Glabellar reflex is positive when the blinking continues as long as the tapping is continued – Seen in Parkinsonism and Diffuse degenerative diseases. Speech: soft, indistinct speech (Dysphonia) Motor system By assessing tone of the upper limb, you may encounter: Cog wheel rigidity Lead pipe type Power, deep tendon reflexes, plantar respond will be normal. Bradykinesia Ask the patient to perform some movement, at least 10-20 repetitions for each movement, one limb at a time. There will be fatigue and decrease in size of repetitive movement. Tapping finger or toes Hand grip Pronation and supination Pull test To assess the postural instability. Position yourself closely behind the patient, and between him/her and a wall. Clearly explain the test to the patient – “I’m going to give you a quick tug on your shoulders and what I want you to do is to take one or two steps backwards to catch your balance. I will be behind you at all times and won’t let you fall.” Tug the patient’s shoulders backwards. Normal individual will correct their balance in one or two quick steps. Functional Ask patient to unbutton his/her shirt and button back – Parkinsonism patient will have difficulty in doing those. Ask patient to write/copy a sentence, their writing will get smaller and smaller (Micrographia) Sensory Normal Cerebellum Normal Abdominal examination Inspection: Abdomen can be distended due to constipation Auscultation: Reduce/Absent bowel sound (Autonomic Dysfunction) Investigation: Urine drug testing (To look for drug-induced parkinsonism) Antipsychotic drugs (typical and atypical) Metoclopramide Prochlorperazine Tetrabenazine Sodium valproate Lithium Manganese MPTP (methyl-phenyl-tetrahydropyridine) CT scan/MRI To exclude: strokes tumors multi-infarct state hydrocephalus lesions of Wilson disease Serum ceruloplasmin – To screen Wilson Disease Sphincter electromyography Genetic testing Lumbar puncture Post-mortem autopsy Management: Pharmacological Treatment Levodopa –...

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