case presentation of parkinsonism

2. Case Presentation
By
Dr Hania Afzal
Resident Medicine

3. • Biodata
Mr Haroon, a 56 yrs old male pt, retired
from air force as W.Off known hypertensive for
32 years, is resident of Sargodha
• P/C
Presented in OPD with c/o
Anxious behavior and difficulty in falling
asleep…… for 5 years
Progressive tremors for 7 years
Myalgia for 7 years

4. • HOPC
USOH till 2014, when he started noticing
tremors in thumbs of both hands, aggravated
by stress, improved by involving in some
activity and is associated with generalized
myalgia.
He is taking medications for tremors but
symptoms are progressive in nature.
Patient is hypertensive for 32 years and is on
medications(no workup done for 2ndry HTN)

5. • HOPC
His wife died in 2017, since then he remains
anxious and has to take anxiolytics off and
on but not on any regular anti anxiety or anti
psychotic medications

6. • Past Medical Hx
No history of admissions, taking medicine
for HTN and tremors
• Past Surgical Hx
Appendectomy in 1991
• No hx of blood transfusions, allergies,
addictions or pets at home

7. • Family Hx
Positive for DM and HTN, no other disease
runs in family
• Socioeconomic Hx
He has 3 daughters, 1 son and lives in his
own home with available facilities

8. • Clinical examination
A middle aged anxious looking man, well
oriented in time, place and person, lying
comfortably on hospital bed having resting
tremors in hands and feet, nodding head
with vitals of BP: 140/80, pulse: 75/min,
Temp: afebrile, SaO2 95% on air, BSR:
110mg/dL

9. Wasting of muscles of hands and face
With coarse resting tremors in hands,
sweaty palmer surfaces, but no clubbing,
koilonychia, leukonychia, palor, jaundice,
lymph nodes, thyroid swelling or pedal
edema. JVP was not raised.

10. • CNS examination
1. Motor Patient had short stepping/shuffling
gait(bradykinesia) with absent arm swing, increased
tone(cogwheel rigidity) with intact reflexex, positive
Myerson sign(glabellar sign), normal power, absent
clonus, fasciculations, cerebellar signs and negative
babinski
2. Cranial nerves All cranial nerves are intact
3. Sensory Fine touch, crude touch, 2 point
discrimination, temperature, vibration and pain
senses are normal with normal corneal, conjunctival
reflexes

12. • Abdominal examination revealed
appendectomy scar with soft nontender
abdomen
• Chest was bilateral clear
• CVS revealed S1, S2

13. DDs
• Parkinson’s disease
• NPH
• Neurodegenerative disorder
• Wilson
• Depression
• Essential tremors
• Huntington
• Multi system atrophy
• Supranuclear palsy

14. Investigations
• CT brain and MRI brain are normal

15. Management
• Sinemet (carbidopa,levodopa)
• Kemadrine (procyclidine)

16. Parkinson’s disease

17. What it is…..
Any combination of
• Tremor
• Rigidity
• Bradykinesia and
• Progressive postural instability
Described by James Parkinson in 1817

18. Occurs in…
• All ethnic groups
• Both genders
• 45-65 years of age

19. Etiology…
• Idiopathic
• Familial
• Postencephalitic
• Toxin exposure
Mn
CS2
• CO poisoning
• Neuroleptics

20. Pathophysiology…
Dopamine depletion 2ndry to degeneration
of dopminergic nigrostriatal system
Imbalance of dopamine and acetylcholine

21. Clinical findings
Motor Menifestations
• Tremor
• Rigidity
• Bradykinesia
• Postural instability

22. • Nonmotor symptoms
Affective disorder(depression, anxiety, apathy)
Psychosis
Cognitive changes/ dementia
Fatigue
Sleep disorders
Anosmia
Autonomic disturbance
Sensory complaints/pain
Seborrhoeic dermatitis

23. Signs
• Tremor of 4 to 6 cycles/sec(enhanced by stress
decreased by voluntary activity)
• Rigidity
• Bradykinesia
• Infrequent blinking
• Fix facial expressions
• Myerson sign
• Sliva drool
• Micrographia
• Shuffling gait with no arm swing
• Tendency to fall

24. Treatment
• Symptomatic
• General Measures
• Medical
1. Amantadine
2. Levodopa with carbidopa
3. Dopamine agonists
4. Ropinirole
5. Pramipexole
6. Selective MAO inhibitors(Rasagiline)
7. COMT inhibitors
8. Anticholinergic medications
9. Antipsychotics
• Stimulation and ablative treatment
• Gene Therapy