Neuroscience · Year 2 · from Neuroscience
Case 1: Parkinson's Disease
Patient Presentation
Demographics: 68-year-old male, retired engineer
Chief Complaint: Progressive tremor of right hand and slowness of movement over 18 months
History of Present Illness: The patient first noticed a fine tremor in his right hand approximately 18 months ago, initially appearing only when he was at rest watching television. Over the past year, the tremor has become more prominent and he has developed difficulty buttoning his shirt and using utensils. His wife reports that he has become noticeably slower in all his movements and his handwriting has become smaller and more difficult to read. He has also noticed stiffness in his right arm and leg, and his posture has become more stooped. He denies any cognitive changes, hallucinations, or significant mood disturbance. No history of head trauma, antipsychotic use, or exposure to toxins. Family history is negative for movement disorders.
Physical Examination:
- General: Alert, oriented, mildly hypomimic (reduced facial expression)
- Mental status: MMSE 29/30, no evidence of dementia
- Cranial nerves: Reduced blink rate, hypophonic speech, otherwise intact
- Motor:
- Resting tremor of right hand (4-5 Hz, pill-rolling type), suppressed with movement
- Mild resting tremor of right foot
- Cogwheel rigidity in right upper and lower extremities
- Bradykinesia demonstrated by finger tapping with progressive decrease in amplitude
- Strength 5/5 throughout
- Sensory: Intact to all modalities
- Reflexes: 2+ throughout, plantar responses flexor bilaterally
- Gait: Reduced right arm swing, shortened stride length, mild shuffling, no festination
- Postural reflexes: Mildly impaired on pull test
Workup:
- Brain MRI: No evidence of vascular parkinsonism, normal pressure hydrocephalus, or structural lesion. Mild age-appropriate atrophy.
- DaTscan (dopamine transporter imaging): Reduced uptake in left putamen consistent with presynaptic dopaminergic deficit
Diagnosis: Idiopathic Parkinson's disease, Hoehn and Yahr Stage 2
Treatment:
- Started carbidopa-levodopa 25/100 mg three times daily with meals
- Physical therapy referral for gait training and balance exercises
- Occupational therapy for fine motor skills
- Follow-up in 6 weeks to assess response and titrate medication
Clinical Pearl: The cardinal motor features of Parkinson's disease can be remembered by the mnemonic TRAP: Tremor (at rest), Rigidity (cogwheel type), Akinesia/Bradykinesia, and Postural instability. Asymmetric onset is characteristic, and excellent response to levodopa supports the diagnosis. Red flags suggesting Parkinson-plus syndromes include early falls, poor levodopa response, early dementia, prominent autonomic failure, and symmetric presentation.