parkinson's disease
Doctor Information
Philip Mason, age 68
Past medical history:
Prostate cancer
Hypertension
Drug History:
Prostap injections every 3 months
Amlodipine 2.5mg od
Allergies:
Allergic to penicillin and aspirin
Letter from A+E sent yesterday
Dear Doctor,
Problem: fall, laceration to eyebrow and skin tear right arm
Investigations: FBC, U+E, Ca, CRP normal, urine dip normal.
Management: steristrips used for wounds, advised to see GP re fall
Yours sincerely,
Dr Shepherd, locum SHO
Past medical history:
Prostate cancer
Hypertension
Drug History:
Prostap injections every 3 months
Amlodipine 2.5mg od
Allergies:
Allergic to penicillin and aspirin
Letter from A+E sent yesterday
Dear Doctor,
Problem: fall, laceration to eyebrow and skin tear right arm
Investigations: FBC, U+E, Ca, CRP normal, urine dip normal.
Management: steristrips used for wounds, advised to see GP re fall
Yours sincerely,
Dr Shepherd, locum SHO
Patient Information
Philip Mason, age 78
History: You were asked to book an appointment by the hospital doctor. Two days ago you tripped over the rug in the lounge and fell on the floor. You couldn't get up so you pressed your alarm and an ambulance came for you. The doctor sorted out a few cuts that you had, and did some bloods which you were told were ok.
If asked only: You have been falling quite often these days, you always seem to trip over. You must be getting more clumsy in your old age. You are not dizzy when standing up or walking, and your vision was recently checked and is fine. Sometimes your legs just don't want to move. There is no chest pain or palpitations before the falls. Most of the time you can get up if you are near furniture, and you just carry on. You do not black out at all. Your arms and legs can get quite stiff, it is like you need oiling to move!
Your memory is getting worse but you are managing to cope around the house with day to day things - you just have to leave yourself reminders. You still drive a car and enjoy doing this, it is only time you really get out of the house and see your friends. You have noticed that your writing has changed, strangely it is a bit smaller than usual. Your hand does shake but it is mostly while you are sitting watching TV so it doesn't really bother you.
Your vision does not appear to have changes, you don't get any dizzy spells. You have no weakness nor numbness in any limbs. Your speech is so far unaffected.
You live alone in a bungalow, your wife Doreen unfortunately passed away last year. Your son Christopher comes round twice a week for lunch and helps with a few bits around the house. You venture out every day to see Bob and Ethel, your friends, and sometimes you play bridge at the local village hall. No-one has really mentioned anything to you about your symptoms because you are all getting older and no-ones health is perfect.
You admit to feeling down every now and then, especially in the evening. You had been married to Doreen to 52 years, and she died of bowel cancer after an operation. You miss her a lot. You have no thoughts of self harm, and try to keep yourself as busy as possible to stop yourself getting upset. You worked as an engineer all your life and loved it. You don't smoke or drink alcohol.
Ideas: You probably have that dementia that folks get when they are old
Concerns: You aren't worried, even about the falls, you just trip that is all.
Expectations: To be told you are fine and can go home.
If the diagnosis of Parkinson’s disease is discussed with you, you are surprised as you have never heard of it. You are very relaxed and reassure the doctor that you are certain you will be fine. If a referral is suggested, you say you don't to waste anyone’s time, but if a good argument is made, and the prognosis explained, you agree to go for the appointment.
History: You were asked to book an appointment by the hospital doctor. Two days ago you tripped over the rug in the lounge and fell on the floor. You couldn't get up so you pressed your alarm and an ambulance came for you. The doctor sorted out a few cuts that you had, and did some bloods which you were told were ok.
If asked only: You have been falling quite often these days, you always seem to trip over. You must be getting more clumsy in your old age. You are not dizzy when standing up or walking, and your vision was recently checked and is fine. Sometimes your legs just don't want to move. There is no chest pain or palpitations before the falls. Most of the time you can get up if you are near furniture, and you just carry on. You do not black out at all. Your arms and legs can get quite stiff, it is like you need oiling to move!
Your memory is getting worse but you are managing to cope around the house with day to day things - you just have to leave yourself reminders. You still drive a car and enjoy doing this, it is only time you really get out of the house and see your friends. You have noticed that your writing has changed, strangely it is a bit smaller than usual. Your hand does shake but it is mostly while you are sitting watching TV so it doesn't really bother you.
Your vision does not appear to have changes, you don't get any dizzy spells. You have no weakness nor numbness in any limbs. Your speech is so far unaffected.
You live alone in a bungalow, your wife Doreen unfortunately passed away last year. Your son Christopher comes round twice a week for lunch and helps with a few bits around the house. You venture out every day to see Bob and Ethel, your friends, and sometimes you play bridge at the local village hall. No-one has really mentioned anything to you about your symptoms because you are all getting older and no-ones health is perfect.
You admit to feeling down every now and then, especially in the evening. You had been married to Doreen to 52 years, and she died of bowel cancer after an operation. You miss her a lot. You have no thoughts of self harm, and try to keep yourself as busy as possible to stop yourself getting upset. You worked as an engineer all your life and loved it. You don't smoke or drink alcohol.
Ideas: You probably have that dementia that folks get when they are old
Concerns: You aren't worried, even about the falls, you just trip that is all.
Expectations: To be told you are fine and can go home.
If the diagnosis of Parkinson’s disease is discussed with you, you are surprised as you have never heard of it. You are very relaxed and reassure the doctor that you are certain you will be fine. If a referral is suggested, you say you don't to waste anyone’s time, but if a good argument is made, and the prognosis explained, you agree to go for the appointment.
Examination Findings
Examination Findings:
Observations
Pulse 77 regular
Blood pressure 139/78 - No lying / standing drop
Face shows lack of expressivity
Voice is monotone
Shuffling gate, unstable getting up from chair
Resting pill-rolling tremor both hands, no cog-wheeling, but rigidity is noted in most joints.
Glabellar tap positive.
If asked to write, micrographia demonstrated
Rest of neurological examination is unremarkable - no weakness or numbness demonstrated.
Observations
Pulse 77 regular
Blood pressure 139/78 - No lying / standing drop
Face shows lack of expressivity
Voice is monotone
Shuffling gate, unstable getting up from chair
Resting pill-rolling tremor both hands, no cog-wheeling, but rigidity is noted in most joints.
Glabellar tap positive.
If asked to write, micrographia demonstrated
Rest of neurological examination is unremarkable - no weakness or numbness demonstrated.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently, or use instruments proficiently Uses an incremental approach using time and accepting uncertainty |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears unsure of how to operate/use instruments Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Simultaneously manages multiple health problems, both acute & chronic Encourages improvement, rehabilitation, and, where appropriate, recovery. Encourages the patient to participate in appropriate health promotion and disease prevention strategies Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity Unable to construct a problem list and prioritise Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue Shows commitment to equality for all |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views/values |
Management
Explanation: Parkinson’s disease is a disorder that affects part of the brain - it is the part that controls movement and balance. It can cause symptoms such as stiffness, tremor, and slow movements. Unfortunately there is no cure for this disorder but there is a large team of specialists who can help control the symptoms and make day to day life easier.
Clinical Features:
This scenario starts as a falls history, for which there are many causes. Once you have excluded syncope, postural hypotension, visual impairment and musculoskeletal causes, you can focus your history more on the symptoms of Parkinson’s disease (PD). As with other conditions that can cause memory and neurological impairment, assess for depression.
Cardinal symptoms / signs of Parkinsonism (TRAP)
Other clinical features include
secondary motor symptoms:
non-motor symptoms:
Remember that there are many causes of parkinsonism, so if the patient presents without the tremor or with symetrical tremor, early onset postural instability, autonomic dysfunction, gait abnormalities, hallucinations, dementia, then consider alternative diagnoses such as Multi system atrophy (MSA), progressive supranuclear palsy (PSP), Lewy body dementia (sometimes known as Parkinson's Plus). Remember to exclude possible drug causes: olanzapine, risperidone, haloperidol, prochlorperazine, Quetiapine, amisulparide - to name a few.
Click here for further information on drug induced parkinsonism
Click here for further reading about the presentation of Parkinson's Disease
Management:
Any suspicion of PD requires referral to secondary care for assessment by a neurologist. In your consultation, you should make your suspicions known to the patient, and how this condition is likely to affect their quality of life. It can seem a bit bleak going through the symptoms, making them understand there is no sure and it is likely to get worse, but you are likely to make them scared and miserable. Try and put a positive spin on it - many people keep their independence, and there are a team of specialists that look after different aspects of care. For example a neurologist, who may initiate medication, a PD nurse, physiotherapist and occupational therapist to help with mobility and any adaptations that are required around the house, and local community groups for support and advice.
Clinical Features:
This scenario starts as a falls history, for which there are many causes. Once you have excluded syncope, postural hypotension, visual impairment and musculoskeletal causes, you can focus your history more on the symptoms of Parkinson’s disease (PD). As with other conditions that can cause memory and neurological impairment, assess for depression.
Cardinal symptoms / signs of Parkinsonism (TRAP)
- Tremor 4-6Hz, (usually asymetric in origin for Parkinson's disease)
- Rigidity,
- Akinesia / bradykinesia,
- Postural instability
Other clinical features include
secondary motor symptoms:
- hypomimia,
- dysarthria,
- dysphagia,
- micrographia,
- shuffling gait,
- dystonia,
- glabellar reflexes
non-motor symptoms:
- autonomic dysfunction,
- cognitive abnormalities,
- sleep disorders
- anosmia,
- paresthesias
- pain
Remember that there are many causes of parkinsonism, so if the patient presents without the tremor or with symetrical tremor, early onset postural instability, autonomic dysfunction, gait abnormalities, hallucinations, dementia, then consider alternative diagnoses such as Multi system atrophy (MSA), progressive supranuclear palsy (PSP), Lewy body dementia (sometimes known as Parkinson's Plus). Remember to exclude possible drug causes: olanzapine, risperidone, haloperidol, prochlorperazine, Quetiapine, amisulparide - to name a few.
Click here for further information on drug induced parkinsonism
Click here for further reading about the presentation of Parkinson's Disease
Management:
Any suspicion of PD requires referral to secondary care for assessment by a neurologist. In your consultation, you should make your suspicions known to the patient, and how this condition is likely to affect their quality of life. It can seem a bit bleak going through the symptoms, making them understand there is no sure and it is likely to get worse, but you are likely to make them scared and miserable. Try and put a positive spin on it - many people keep their independence, and there are a team of specialists that look after different aspects of care. For example a neurologist, who may initiate medication, a PD nurse, physiotherapist and occupational therapist to help with mobility and any adaptations that are required around the house, and local community groups for support and advice.