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Physical Examination of Parkinson's Disease
Physical Examination of Parkinson's Disease


1. Introduce yourself and wash your hands
==Vitals==
*orthostatic hypotension


2. Listen for the patient's characteristic speech pattern
==General==
*Microphonia
*depressed affect
*Soft
*loss of spontaneous movements
*Faint
*[http://en.wikipedia.org/wiki/Palilalia Palilalia] - repetition of last word similar to stuttering
*Hard to understand


3. Inspection
==Facies==
*Mask like facies
*blank and expressionless face with ↓ blinking ('''mask like facies''')
*Flexed posture
*'''sialorrhea''' (drooling)
*Few spontaneous movements
*facial '''seborrhea''' (dry flaking skin)
*Stooped posture
*'''blepharospasm''' (forced involuntary closing of eyelids)
*Sialorrhea (Drooling)
*'''blepharoclonus''' - flutter of closed eyelids
*'''Titubation''' - tremor of head
*'''glabellar tap''' positive
*'''supranuclear palsy''' - weakness of upward gaze
*seborrheic brow - a sweaty or greasy brow
*diaphoretic brow - due to autonomic dysfunction


4. Tremor
==Speech==
*Resting
*'''microphonia'''
*Pill rolling (4-8Hz)
*soft, faint and hard to understand
*Begins distally, fingers hands, forearm, feet and can involve the chin and mouth
**[http://en.wikipedia.org/wiki/Palilalia Palilalia] - repetition of last word similar to stuttering
*Decreased tremor with finger to nose testing
*slow thinking
*Increaqsed tremor in left hand if clenching the right hand
*Increased tremor with serial 7's


5. Gait
==Tremor==
*Ask to ris, walk, turn quickly, stop and start
*pill rolling (4 - 8 Hz)  
*March a petite pas (shuffling gait)
*begins distally (fingers, hands, forearm), can involve chin and mouth
*Difficulty initiating, stopping, turning and with balance
*resting tremor (less prominent with movement)
*Propulsion/retropulsion (difficulty maintaining balance if tapped)
**↓ with finger to nose testing
*Festination (walk faster and faster so that they do not fall over)
**↑ tremor in L hand if clench R hand or serial 7's
*Lack of arm swing
*Kinesia paradoxica (can do rapid movements but not slow ones)
*Bradykinesia


6. Dampening - difficulty with repeated movements such as tapping the thumb and index finger together
==Dampening==
*difficulty with repeating movements
*effort dampens when asked to repeated tap thumb and index finger together


7. Tone
==Gait and Posture==
*test at both wrists
*have patient rise from a chair, walk, and turn, look for:
*begins as weakness, tremor, motor slowness, stiffness, fatigable in a single limb or hemiparetic
**difficulty initiating, stopping, and turning ('''en bloc turning''')
*cogwheel rigidity
**shuffling gait ('''march a petit pas''')
**'''propulsion/retropulsion''' - tendency to fall forward or backwards)
**'''festination''' - patient walks faster and faster as to not fall over
**lack of arm swing
*stooped posture
*'''Kinesia paradoxica''' (can do rapid movements but not slow ones)
 
==Cog-Wheel Rigidity and Tone==
*test by flexing-extending the patient’s elbow or supinating-pronating their wrists
*↑ when patient moves head side to side
*if no hypertonia, ask the patient to move their head side to side.  This maneuver should increase cogwheeling rigidity
*if no hypertonia, ask the patient to move their head side to side.  This maneuver should increase cogwheeling rigidity
*Dorsal tendon reflexes are unaffected
*Dorsal tendon reflexes are unaffected


8. Face
===Mental Status===
*Titubation - tremor of head
*MMSE
*blinking absence
*blepharospasm - involuntary closure of the eyelids
*blepharoclonus - flutter of closed eyelids
*sialorhea - excessive drooling
*masked facies
*glabellar tap positive
*speech - monotone, soft, faint, repetition of last word
*supranuclear palsy - weakness of upward gaze
*seborrheic brow - a sweaty or greasy brow
*diaphoretic brow - due to autonomic dysfunction
 
9.  Orthostatic hypotension
 
10.  Writing
*micrographia
 
11.  Mental status - do an Minimental Status Exam and also look for
*dementia
*dementia
*slowed thinking
*slowed thinking
*depression
*depression
*insomnia
*insomnia
*drug effects
 
==Other OSCE modules==
==Other OSCE modules==
{{OSCE2}}
{{OSCE2}}
[[Category:OSCE]]
[[Category:OSCE]]
[[Category:Medicine]]
[[Category:Medicine]]

Revision as of 07:20, 17 May 2007

Physical Examination of Parkinson's Disease

Vitals

  • orthostatic hypotension

General

  • depressed affect
  • loss of spontaneous movements

Facies

  • blank and expressionless face with ↓ blinking (mask like facies)
  • sialorrhea (drooling)
  • facial seborrhea (dry flaking skin)
  • blepharospasm (forced involuntary closing of eyelids)
  • blepharoclonus - flutter of closed eyelids
  • Titubation - tremor of head
  • glabellar tap positive
  • supranuclear palsy - weakness of upward gaze
  • seborrheic brow - a sweaty or greasy brow
  • diaphoretic brow - due to autonomic dysfunction

Speech

  • microphonia
  • soft, faint and hard to understand
    • Palilalia - repetition of last word similar to stuttering
  • slow thinking

Tremor

  • pill rolling (4 - 8 Hz)
  • begins distally (fingers, hands, forearm), can involve chin and mouth
  • resting tremor (less prominent with movement)
    • ↓ with finger to nose testing
    • ↑ tremor in L hand if clench R hand or serial 7's

Dampening

  • difficulty with repeating movements
  • effort dampens when asked to repeated tap thumb and index finger together

Gait and Posture

  • have patient rise from a chair, walk, and turn, look for:
    • difficulty initiating, stopping, and turning (en bloc turning)
    • shuffling gait (march a petit pas)
    • propulsion/retropulsion - tendency to fall forward or backwards)
    • festination - patient walks faster and faster as to not fall over
    • lack of arm swing
  • stooped posture
  • Kinesia paradoxica (can do rapid movements but not slow ones)

Cog-Wheel Rigidity and Tone

  • test by flexing-extending the patient’s elbow or supinating-pronating their wrists
  • ↑ when patient moves head side to side
  • if no hypertonia, ask the patient to move their head side to side. This maneuver should increase cogwheeling rigidity
  • Dorsal tendon reflexes are unaffected

Mental Status

  • MMSE
  • dementia
  • slowed thinking
  • depression
  • insomnia

Other OSCE modules

v • d • e
Observed structured clinical examination

Acute Confusion - Acute Coronary Syndrome Orders - Anemia - Arterial Blood Gasses - Asthma - Blood Pressure - Chest pain - Chest XRay - CHF - Coma - COPD - Cranial Nerves - Diabetic History - Diabetic Foot - Dysphagia - EKGs - Gallbladder and Liver - Liver Disease - Gait and Balance - Headache - Hematemesis - Hypertension - Jugular Venous Pulses - Knee Exam - Lymph Nodes - Community Acquired Pneumonia - Parkinson Disease - Peripheral Arterial Insufficiency - Pneumonia Examination - Precordial Exam - STD's - Spleen - Swollen Leg Exam - Thyroid Exam - Upper vs Lower Motor Neuron Lesions - Urinary Incontinence

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