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Parkinson’s disease focussed examination

NB: the OSCE instructions may be non-specific, for example: ‘Examine this patient with a tremor’, ‘Examine this patient’s gait and then proceed,’ or ‘Examine this patient neurologically’. Approach this situation by first asking a few generic questions (if allowed) or by inspecting for tremor/gait abnormalities. Then proceed with the relevant focussed examination to elicit other signs.

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent

General observations

  • General inspection: patient, around bed (mobility aids etc.)
  • Tremor: note any obvious tremor (if none, ask the patient to close their eyes and count down from 20 to distract them)
    • Asymmetrical resting pill-rolling tremor (4-8 Hz) 
    • Begins distally (fingers, hands, forearms), can involve chin and mouth 
    • Reduced with finger to nose testing 
    • Accentuated by distraction
  • Gait: ask patient to walk up and down the room
    • Shuffling (reduced stride length) 
    • Hesitant (difficulty initiating and turning (multiple steps))
    • Festinating (patient walks faster and faster so as to not fall over) 
    • Lack of arm swing (early sign due to increased tone) 
    • Unsteadiness (propulsion/retropulsion – tendency to fall forward or backward)
  • Posture: observe posture while walking (stooped)

Now work down the body:

Face

  • Facial inspection (hypomimia, decreased blinking, drooling)
  • Glabella tap test (Myerson’s sign = blinking fails to cease with continued tapping)
  • Speech: ask the patient to say a sentence, e.g. describe the room they are in (hypophonia, slow thinking, soft faint voice)

Focussed upper limbs

  • Tone: increased tone can be accentuated with distraction by asking patient to move contralateral arm up and down (lead pipe = increased tone; cogwheel rigidity = tremor superimposed on increased tone)
  • Bradykinesia
    • Open and close thumb and index finger like a ‘snapper’ as fast as possible (lack or decay of amplitude; slow and asynchronous)
    • Play imaginary piano (slow)
    • Open and close big imaginary doorknob (difficulty pronating and supinating)

Focussed lower limbs

  • Bradykinesia: heel tap (lack or decay of amplitude; slow and asynchronous)

Extras

  • Function: test undoing buttons, assess writing for micrographia
  • Exclude Parkinson-plus syndromes
    • Vertical eye movements (vertical limitation = progressive supranuclear palsy)
    • Horizontal eye movements (nystagmus = multisystem atrophy)

To complete

  • Thank patient 
  • ‘To complete my exam, I would look for cerebellar signs (multisystem atrophy), check postural blood pressure (significant drop may be present in multisystem atrophy) and undertake a mini-mental state exam (Lewy body dementia)I would also review any drug charts (parkinsonism drugs).’
  • Summarise and suggest further investigations you would consider after a full history

Here are some questions

Please list some causes of Parkinsonism

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What are the Parkinson-plus syndromes?

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What is the Parkinson’s disease tetrad?

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List some clinical features of Parkinson’s disease

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Which common class of drugs may cause drug-induced parkinsonism?

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