Parkinson disease (OSCE)

Physical Examination of Parkinson's Disease

Vitals

• orthostatic hypotension

mask face patient / expressionless / slow gait

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