Parkinson disease (OSCE)

Physical Examination of Parkinson's Disease

Vitals
mask face patient / expressionless / slow gait
 * 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 (far 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