Here is a case study of a patient with parkinsonism

1. A CASE STUDY ON PARKINSONISM AND DRUG
INDUCED PARKINSONISM
PRESENTED BY :
Shaik Shaheera
III PHARM D
19AB1T0024.
UNDER THE GUIDANCE OF :
Mr. Sateesh .S. Gottipati
B.PHARM.,M.S(USA),CIP(USA)
Associate professor
Dean of academics and chief
Preceptor
Department of pharmacy
practice.
VIGNAN PHARMACY COLLEGE
(Approved by AICTE, PCI-New Delhi and affiliated to JNTUK)
Vadlamudi, Guntur (dist), pin.code: 522213

2. PARKINSONISM
DEFINITION :
It is a chronic degenerative syndrome that primarily effects neurons of basal
ganglia. A disorder of the central nervous system that effects movements, often
includes tremors. Nerve cell damage in the brain causes dopamine leaves to drop,
leading to the symptoms of parkinson’s.
ETIOLOGY :
• Heridity
• Usage of antipsychotic drugs
• Encephalitis
• Atherosclerosis
• Neurotoxins
• Drugs: reserpine, methyl dopa
• Abnormal, protein processing
• Toxic iron accumulation
• Faculty immune system

3. CLINICAL MANIFESTATIONS:
1. BEGINNING STAGES :
 Mild tremours
 Loss of postural reflexes
 Arms
 Rigidity
 Bradykinaesia
2. SECONDARY MANIFESTATIONS :
 Facial expression : less, blinking eyes
 Speech problem : low volume, slurred speech
 Blurred vision
 micrographia
TYPES OF PARKINSONISM:
• Post encephalactic parkinsonism: which occurs after large endemic encephalitis.
• Drug induced parkinsonism : Phenathiazines.
• Toxin induced : co, hg, Mn, exposure

4. PATHOPHYSIOLOGY :

5. SOAP NOTES
 PATIENT DETAILS :
• NAME : xxxx
• AGE : 57 yrs
• SEX : male
• Date of admission : 18-11-21
• Date of discharge : 20-11-21
• UMR No : GN-210500685
 SUBJECTIVE :
C/O : shaking of whole body, general weakness.
Onset : since 1 month

6.  OBJECTIVE :
• VITALS :
 Temp – 98.7 F
 P.R – 80/min
 R.R- 20/min
 H.R- 80/min
 B.P- 120/80 mmHg
 Height – 171 cms
 Weight – 91 kgs
 BMI – 31.06 kg/sq.mt
• PHYSICAL EXAMINATION :
 decreased arm suring
 Rest and postural tremor
 Bradykinaesia
 Marked faces
 Hyporeflexia in lower limbs

7. • PAST MEDICAL HISTORY :
 Diabetes mellitus
 Hypertension
 History of febrile illness
 Wound debridment
 Left great toe amputation on 10-6-21.
• PAST MEDICINAL HISTORY :
 Amesulpride- 100 mg – TID – since 20 days
• FAMILY HISTORY : Nill significant
• PERSONNEL HISTORY :
 APPETITE – normal
 BOWEL- normal
 MICTURITION – normal
• LAB INVESTIGATIONS :
 AFB stain : negative for acid fast bacilli
 GRAM stain : no microbes

8. • APTT: 27’0 A secs
• HIV: non reactive
• HBS Ag: non reactive
• SERUM CREATININE: 1.0mg/dl (0.7-1.2mg/dl)
 LFT:
PARAMETERS TEST VALUES REFERENCE
Total protein 7.3g/dl 6.3-8.2g/dl
Albumin 4g/dl 3.5-5.0g/dl
Globulin 3.2g/dl 1.5-3.0g/dl
A/G ratio 1.2 1.5-3.0
Total bilirubin 0.4mg/dl Adults: 0.2-1.3mg/dl
Direct bilirubin 0.1mg/dl 0.0-0.2mg/dl
Indirect bilirubin 0.3 -
SGOT/AST 25U/L 17-59U/L
SGPT/ALT 39U/L 21-720/L,9-520/L
Alkaline phosphatase 74U/L 38-126U/L

9.  CBC :
PARAMETERS TEST VALUE REFERNCE
HB 11.9g/dl 12.0-15,0 g/dl
Total WBC 6700 cells/cumm 4000-11000
cells/cumm
Total RBC 4.47 millions/cumm 3.8 -4.8
millions/cumm
4.5-5-5 million/cumm
Platelet count 2.47 lakhs/cumm 1.5-4.0 lakhs/cumm
PCV 35% 37-39%
MCH concerntration 33.9% 31.5-34.5%
Mean cell volume 79H 83-101H
Absolute lymphocyte
count
2040 cells/cumm 1000-3000cells/cumm
N/L ratio 2.0 % 0.78- 3.53%
neutophills 54% 55-70%

10.  ASSESSMENT :
A 57 yrs old male patient with known case of diabetes mellitus,
hypertension with care of difficulty in walk, tremors of body, general weakness
and excessive drowsiness since 1 month , urinary hesitance, decreased appetite,
acute febrile illness, admitted in hospital and conformed with “ DRUG INDUCED
PARKINSONISM “.
 CSF ANALYSIS :
 CSF glucose : 112mg/dl
 CSF protein : 96 mg/dl
 Total WBC : 20 cells / mm cube
 Total RBC : 1000 cells/mm cube
PLAN:
PHARMACOLOGICAL TREATMENT :-

11. S.
No
DRUG NAME GENERIC NAME DOSE FREQ
DAYS
QT
Y
ROA
1 Tab. Trivolib
(anti diabetic)
Glimipride-2mg + metformin-
500mg + voglibose-0.2mg
2mg 1-0-1 5 5 ORAL
2 Tab. Istamet
(DPP4 inhibitor)
Sitagliptin-50mg +
metformin-500mg
50/500
mg
0-1-0 5 5 ORAL
3 Inj.human mixtard 30% soluble insulin +
70%isophane insulin
30/70m
g
30 units 5 1 SC
4 Tab. Stamlo
(ca+ channel blocker)
Amlodipine-5mg 5mg 1-0-0 5 5 ORAL
5 Cap. Ecosprin-AV(NSAID) Aspirin-75mg+ atarvostatin-
10mg
10/75m
g
0-0-1 5 5 ORAL
6 Tab.CILD-DOC(platelet aggregatiom
inhibitor)
Cilastazol -50mg 50mg 1-0-0 5 5 ORAL
7 Tab. Syndopa(anti parkinson
agent)
Levodopa-100mg+
carbidopa-25mg
- ½-1/2-1/2 5 5 ORAL
8 Tab. Pancitane (anti cholinergic) Trihexyl phenidiyl-2mg 2mg ½-0-1/2 5 5 ORAL
9 Tab.Nuhenz vit B12+ alphazoic acid-
200mg+ benfotiamine-
200mg+ chromium-200mg+
vit b6-3mg+ folic acid-1.5mg
- 0-1-0 5 5 ORAL
10 Tab. Pantosec(proton pump inh.) Pantaprazole-40mg 40mg 1-0-0 5 5 ORAL
11 Oint. Benovate-
N(corticosteroid+antibiotic)
Betamethasone valarate+
neomycin
20gms - 5 1 Dressing
12 Betadine scrub(antiseptic) Povidone iodine solution-5% 50ml - 5 1 dressing

12. FARM NOTES
 FINDING 1 :
 FINDING : Sitagliptin + Glimipride
 ASSESSMENT : Pharmacodynamic synergism, which induces the risk of hypoglycaemia
 RESOLUTION : Those adjustment is needed.
 MONITORING : Monitoring of blood glucose levels
 FINDING 2:
 FINDING : Carbidopa + amlodipine
 ASSESSMENT : Carbidopa increases the effects of amlodipine by pharmacodynamic
synergism
 RESOLUTION : When carbidopa given along with amlodipine done adjustment of
amlodipine is required
 MONITORING : Monitor BP levels .