A simplified approach to diagnosis of Parkinson disease and atypical Parkinson syndromes through analysis of clinical cases

1. Case-based
approach to
Parkinsonism
Yasser A. Alzainy MSc.

2. Case - 1
Male with slow movement and
gait issues

3. A 63-year-old-man presents to his neurologist with
complaints of a gradual onset of slowness of movement,
and balance issues over the past year. He has noticed that
his handwriting has become smaller, and he has difficulty
buttoning his clothes and getting up from a chair. His
daughter also mentions that he tends to shuffle his feet
while walking and has experienced few falls in the last few
months.
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4. • He is a retired accountant with no family history of
neurological disorder.
• His medical history is only remarkable for hypertension
(controlled with medication)
• No other significant medical conditions.
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5. Clinical examination
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6. Write your name
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7. Speech: is soft, monotonous, and lacks modulation
(hypophonia).
Reflexes: normal and symmetrical.
Sensory Examination: There are no signs of sensory
deficits.
Cognitive Assessment: His cognitive functions, including
memory, attention, and executive functions, appear intact.
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8. Diagnosis
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9. Idiopathic Parkinson
Disease
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10. Plan for management?
• Start medical treatment for PD
• F/U appointment to assess for therapeutic response
• Consider a brain MRI
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11. Case - 2
A Female with difficulty opening
her eyes

12. A 69-year-old-housewife presents to our clinic with
complaints of increasing difficulties with balance, falls,
especially when descending downstairs in addition to
difficulty in opening her eyelids over the past year. She
also mentions that she has experienced stiffness and
slowness of movement, which she initially attributed to
aging.
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13. • No known history of neurological disorders in the
immediate family.
• Aside from hypertension and IHD, her medical history is
unremarkable.
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14. Clinical examination
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15. Other findings on
examination:
• Postural instability: retropulsion
• Moderate rigidity
• Cognitive Assessment:
o mild cognitive deficits, including executive function
impairments and difficulty with complex tasks.
• Reflexes and sensory examination: Unremarkable
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16. Diagnosis
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17. Progressive
supranuclear palsy
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18. Plan for management?
• Start medical treatment for (levodopa; symptomatic)
• Counselling and supportive care
• Referral for physical, occupational and speech
therapy
• MRI brain (supportive evidence)
• Arrange for regular follow ups
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19. MRI brain
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20. MRI brain
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21. Case - 3
A male with recurrent dizziness
and incontinence

22. A 54-year-old man presents with a 1-year history of light-
headedness when standing from a seated position. This
had worsened over time, and he uses a wheelchair to get
around for fear of having a syncopal episode.
On directed questioning, he reports urinary urgency and
constipation for several years, with urge incontinence for
the past 6 months in addition to erectile dysfunction.
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23. • He is a retired policeman.
• He is a smoker with occasional alcohol use.
• No known history of degenerative neurological
disorders in his family.
• He has a history of corneal implantation and HCV.
Otherwise, his medical history is unremarkable.
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24. Clinical examination
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25. Other findings on
examination:
• Orthostatic hypotension
o His sitting blood pressure is 120/80 mm Hg.
o Standing blood pressure is 80/60 mm Hg, associated with
significant light-headedness.
• Dysarthria, hypophonia
• Cognitive Assessment
• His cognitive functions are relatively preserved, with no
significant impairment in memory or executive functions.
• Reflexes and sensory examination: unremarkable
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26. Diagnosis
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27. Multiple System
Atrophy-P
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28. Plan for management?
• Start medical treatment for (levodopa; symptomatic)
• Treatment for orthostatic hypotension
• Care for nocturnal hypertension
• Tilt table Test?
• Referral for physical, occupational and speech
therapy
• MRI brain (supportive evidence)
• Arrange for regular follow ups
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29. MRI brain
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30. Thank you
Yasser A. Alzainy MSc.
yasser.alzainy@gmail.com