IDIOPATHIC PARKINSON'S DISEASE BY PAWAN BHASIN - ROLL NUMBER 124

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SUMMARIZED HISTORY OF THE PATIENT

A 49 year old (multi language) English,sanskrit and Telugu language lecturer presented with a 2 month history of progressive asymmetric involuntary movements of his right index and middle fingers along with joint stiffness.

(Shaking of right hand and Stiffness of Elbow and Wrist joint)

The patient first noticed them happening nearly 6 months ago, which was very small in amplitude , affecting these two fingers only. He attests that these movements often worsened with rest and abated with activity. 

-Initially the shaking of hands was not a troublesome to him  but since the past 2 months he has been unable to correct English, Sanskrit and Telugu papers because it started involving his thumb and maintaining stability of his hand was proving difficult.

-He descibes these movements as involuntary, rhythmic to and fro oscillations. 

-He also says that his handwriting has become ugly with very small letters (micrographia)

The patient reports that he feels stiffness in his wrists (Right>Left), which has now ascended to his elbows. He says the stiffness is present throughout the range of motion. 

-He also says that since the last 1 month, the same involuntary movements also started appearing in his left hand. 

-He says that his walking has become difficult with small, short steps and a forward stoop, as he feels that although he weighs 60 kgs, his body feels like it weighs 100 kgs. 

He does not report any difficulty in reading the newspaper, holding the paper, turning pages or folding it back. 

-He does not have any difficulty in brushing his teeth or combing his hair. 

-He also denies having difficulty in holding objects, such as holding a water bottle to drink nor any difficulty in mixing food and eating it. 

-He does not have any difficulty in wearing a vest or in buttoning or unbuttoning of his shirt. 

-No difficulty in lifting his lower limbs and wearing a trouser and nor does he have any difficulty in buttoning his trouser. 

-On asking about -difficulty in taking the stairs - he reports that he has been having difficulty in taking stairs up, in that he feels he sometimes might lose balance. 

-He has no difficulty in descending stairs. 

-The patient denies having swaying of his trunk while walking or overshooting his hand while picking up objects. 

-He reports that he hasn't been having morning erections since 2 months and also reports a loss of sexual desire(libido)

-He also says that since 2 months his bowel habits have been incredibly erratic, in that he sometimes has an immediate urge to defecate when he has tea and sometimes goes 2 to 3 days with constipation. 

-Denies feeling dizzy or lightheaded when waking up in the morning. 

-He denies having stiffness in his lower limbs, denies cotton wool sensation of floor, denies burning pain or inability to feel hot or cold stimuli. He also denies buckling of knees but, however, he reports that he has been having a great difficulty to walk in the dark since 2 months and says that he feels like he would definitely fall without support. 

- His brother gives a positive confirmation

for all his symptoms and also says that he previously used to be a Happy and hardworking man with good oratory skills, however, since the last 2 months he says his brother's speech lacks that 'edge' which be previously had. On asking further, the brother says that he has been speaking in a monotonous drab since 2 months. 

The patient denies ever having urinary incontinence, memory deficits, the brother vehemently denies the patient ever being anti-social, he does not have any difficulty in forming new memories or any visual deficits. 

PAST HISTORY and FAMILY HISTORY :-

-He has no relevant past or family medical history. 

GENERAL EXAMINATION

49 Y old moderately built moderately nourished

Conscious , coherent and cooperative and is

Comfortably seated on the bed well oriented to time , place and person.

There is no palor , no ictrus, no cyanosis , no Koilonychia, no generalised lymphadenopathy and no pedal edema

Vitals

PR - 90 BPM

BP - 180/110 mm Hg

Temp - Afebrile

RR - 15

Standing (for 3 mins)

BP - 160/110 mm Hg

BEDSIDE GENERAL - SYSTEMIC EXAMINATION :-

Problem Representation - 

A middle aged man presenting with a 6 months history of gradually progressive, asymmetric rest tremor with autonomic features is provisionally diagnosed with 

1. Idiopathic Parkinson's Disease

2. Multiple System Atophy - Parkinsonian Type (MSA-P)

3. Progressive Supranuclear Palsy - Parkinsonian Type (PSP-P)