2. Establish the extent of the parkinsonism 3. Establish the possibility of a secondary cause
Establish the 4 cardinal signs
Say to examiner that you would first like to establish the 4 cardinal
signs of parkinsonism 1. Rigidity Assess the tone of the upper limbs (increased)
Synkinesia to exaggerate (perform distracting movement in
Distinguished from spasticity by the increased tone not being
Reflexes are normal in parkinsonism, with hyper-reflexia in
Finger-thumb “open close” action. The amplitude of repeated
4-6 Hz, worsened by distraction and improved by goal orientated
For this bit, I assess gait at the same time. Features on the gait:
Unsteadiness on turning (taking several steps to turn)
Heel and toe strike ground together, or even toe then heel.
Then ask the examiner if you would like a demonstration of
postural instability. You would stand behind the patient, and
suddenly pull back on the shoulders. Normally, we would take one
or two steps backs and control ourselves. In parkinsonism, they
may need four or five steps, or even fall (!)
Hopeful y your examiner wil not ask for this.
Establish the extent of the parkinsonism Top to toe approach
Drooling Globel ar tap – a rubbish sign with awful specificity and sensitivity.
Ask the examiner if they want you to do it. If they do, tap lightly
on the middle of the forehead. Our eyes blink for the first 2 or 3,
but then we suppress the blink response in normal health. In
parkinsonism, this does not happen, and the response persists.
Enquire about sense of smell, and offer to test
Assess speech - monotonous and quiet in parkinsonism
Say you would like a SALT to assess swallow – impaired in
parkinsonism. If they insist you do it, start with one teaspoon of
Assess handwriting – micrographia, becomes more apparent the
Establish the possibility of a secondary cause The secondary causes are generally less responsive to levodopa. Vascular parkinsonism: Enquire about CV risk factors/previous
CVAs Lower body affected more than upper body. Lewy Body dementia: Perform a MMSE
Core features include fluctuations in symptoms, visual
hallucinations and parkinsonism. Lewy body dementia and
parkinsonism can be thought of as a spectrum, with Parkinson’s
dementia on the ‘motor predominant’ side and Lewy body
dementia on the ‘dementia predominant’ side.
Remember to never give typical antipsychotics to a patient with
Lewy body dementia. You wil seriously worsen everything.
Drug induced parkinsonism: Inspect the drug chart Medications to blame are dopamine antagonists: metoclopramide
(has central and peripheral actions), antipsychotics (especial y
typical, which principally antagonise dopamine at the D2 receptor)
Assess autonomic function e.g. lying/standing blood pressure,
enquire about urinary dysfunction, constipation etc.
The term Shy Drager is old fashioned, and used to refer to cases
where autonomic dysfunction was the main problem. However,
MSA pretty much always involves the autonomic system, and now
is classified as MSA-P or MSA-C depending on whether the
parkinsonism or cerebellar dysfunction is dominant. Supranuclear palsy: Test vertical eye movements Suggested by vertical gaze palsy with prominent postural instability and falls in the first year of onset Wilson’s disease: Look for Kayser –Fleishcer rings The most common early neurological sign in Wilson’s is an
Other early symptoms include difficulty speaking, excessive
salivation, ataxia, mask-like facies, clumsiness with the hands and
Look for medication side effects
With long term L-dopa use, findings on examination may include:
Hal ucinations Screen for depression To complete your examination, you would like to screen for
depression. This needs to be differentiated from dementia, and can be treated
using SSRIs (if apathy dominates) or tricyclics (if sleep disturbance
NICE guidelines “two questions” (yes to either prompts ful
1. During the last month have you been feeling down, depressed
2. During the last month have you often been bothered by having
little interest or pleasure in doing things?
24-Hour Urine Test, Collection Instructions _____________________________________________________________________________________________ The information your doctor receives from your test(s) is only as accurate as the collection procedure you follow. Therefore, it is important that you collect the urine in the following manner: 1. You must begin all 24-hour urine collections with an empty bla
Den gyllene regeln som den formuleras i Bibeln är ”Allt vad ni vill att män-niskorna skall göra för er, det skall ni också göra för dem. Det är vad lagen och profeterna säger.” (Matt. :). Den återfinns på olika sätt i de flesta religioner och livsåskådningar. t.ex. i hinduismen: ”Detta är summan av plikterna: Gör inte mot andra något som skulle vålla dig smärta