Parkinson Disease Case Study

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Harvard University *

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1023

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Medicine

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Dec 6, 2023

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Parkinson Disease Chief Complaint Provided by caregiver: “His medicine for Parkinson’s doesn’t seem to be working as well anymore.” History of Present Illness E.A. is a 68 yo man who presents with his caregiver to the neurology clinic for his routine three-month evaluation. He feels that he still has some “good days,” but there seem to be more “bad days” now. His medications do not seem to be as effective as they have been in the past. He complains that he often awakens in the morning with a painful cramp in his left foot. He also complains of “feeling more wooden” recently. His tremors have become less pronounced during the last three weeks. His appetite has decreased and he states that he is “just not interested in food.” He eats three small meals daily: 1⁄2 bowl oatmeal, 1⁄2 banana, and orange juice in the morning; 1⁄2 sandwich, cup of soup, and serving of melon medley for lunch; and small portions of meat, potatoes, and vegetables and slice of whole grain bread for supper, which he rarely finishes. His caregiver states that he is not interested in wood-carving anymore and that he appears depressed much of the day “until the kids come home from school.” He is always happy to see the children, even smiles when they visit with him. During the day, he will often sit in his chair staring at the television for hours, often not moving. Last week, he fell sideways out of his chair when reaching for a peanut that fell onto the floor, but he was not injured. He has to be reminded to blink his eyes once in a while, and the caregiver will often tap his brow lightly to initiate and maintain a blink response. The family will often play cribbage with him and are very patient as E. slowly lays down his cards and pegs his points. Non-disabling dyskinesia secondary to therapy occurs less than 25% of the day and becomes most prominent in the evening when he is tired. Past Medical History DM type 2 x23 years• Three amputations of the RLE—at the ankle 15 years ago, at the knee 9 years ago, at the hip 7 years ago• PD x 11 years GERD x 2 years• Hyperlipidemia x 2 years Family History Father died from HTN-related cerebral hemorrhage at age 64• Mother died from renal failure secondary to DM at age 73• One brother alive and well• No children Social History (-) for alcohol, tobacco, and illicit drug abuse; 2 cups caffeinated coffee each morning• Retired farmer of 31 years• Married for 42 years, wife passed away 3 years ago• Relocated after his wife’s death and now living with family of four in Wyoming; mother/wife of family is LPN and caregiver in the home• E. has his own room in the house• Enjoys playing board games and cribbage with his family• Family has constructed a ramp in front of the house for wheelchair accessibility.

Review of Systems The patient has no complaints other than those noted in the HPI. He denies nausea, vomiting, sweating, heartburn, tearing, paresthesias, blurry vision, constipation, and dizziness. He also reports no problems at this time with chewing, swallowing, and urination. He is sleeping “OK” at night and often takes a short afternoon nap. Physical Exam The patient is an elderly, overweight white male in NAD who appears his stated age. He is well groomed, cleanly shaven, and his overall personal hygiene seems to be very good. He is sitting in a wheelchair and appears interested and cognizant of all that is going on around him. He speaks in a soft, monotone voice. Vital Signs: Skin •Normal turgor• Erythema and dry, white scales on forehead and in nasal folds• Mild dandruff of scalp, within and behind the ears• No bruises noted HEENT •Speaks only in short, simple phrases• Mask-like facial expression• Eye blinking, approximately 1/minute• PERRLA•EOMI•R & L funduscopic exam without retinopathy• TMs intact• Nares clear• Oropharynx without redness, exudate, or lesions• Mucous membranes moist• Wears dentures Neck/LN •Flexion of the head and neck prominent• No masses, bruits, or JVD• Normal thyroid Lungs/Thorax •CTA & P• No crackles or wheezes• Localized kyphosis with an exaggerated lordosis of the lumbar spine Heart NSR without murmurs Abd •Soft, NT, and ND• Liver and spleen not palpable• No palpable masses•( + ) BS Genit/Rec

Prostate moderately enlarged but no nodules palpated• No rectal polyps or hemorrhoids MS/Ext Resting tremor, bilateral, L > R• Rigidity• Poor postural stability• Poor fine motor coordination• Peripheral pulses moderately subnormal• DTRs 2+; Muscle strength 4/5 throughout• Left foot with normal sensation and vibration Neuro CNs intact; Activities of Daily Living: He can do nothing alone, can help slightly with some chores, severe invalid Blood Test Results Urinalysis (-) protein•( - ) microalbuminuria Patient Case Question 1. Identify this patient’s single major risk factor for Parkinson disease. The patients single major risk factor is his age. According to John Hopkins Medicine, the average age of onset it 60 years old. As a person ages, their risk for having PD increases. This is due to the cells in the substania nigra that continue to die off as we age. This area produces dopamine which transmits messages between the nerve that control motor functions and when dopamine function is reduced by the dying cells, the motor functions decrease. When cells are 50 to 60% gone (dead) PD is manifesting. Men also have a higher risk of developing PD. Johns Hopkins Medicine. (2022, April 10). Parkinson’s disease risk factors and causes. https://www.hopkinsmedicine.org/health/conditions-and-diseases/parkinsons- disease/parkinsons-disease-risk-factors-and-causes#:~:text=Age.,Gender.

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Patient Case Question 2 . Identify this patient’s cardinal signs of Parkinson disease. Explain the pathophysiology of each cardinal sign. The patients’ cardinal signs of Parkinson’s disease include postural instability, tremors, bradykinesia, and rigidity. The pathophysiology of postural instability starts with the basal ganglion. The basal ganglion is a critical factor in maintaining balance. According to a review on PD, basal ganglia are hypodopaminergic (low dopamine) in PD postural instability occurs. When the basal ganglion and cerebellum degenerate, other parts of the cognitive, sensory, and motor regions of the brain need to compensate for better stability and orientation. When a deficit occurs, such as impaired vision, stress or reduced peripheral sensations, postural instability is worsened (Kurthi & Burugupally, 2019). In Parkinson's disease, a tremor is primarily attributed to the progressive loss of dopamine-producing neurons in a brain region called the substantia nigra. This dopamine deficiency disrupts the delicate balance between two neurotransmitters, dopamine and acetylcholine, in the basal ganglia. The imbalance leads to excessive stimulation of the thalamus, a relay station in the brain, causing abnormal firing patterns in motor circuits (Bereczki, 2010). These irregular signals manifest as the characteristic resting tremor seen in PD patients. Bradykinesia and rigidity also fall within the same pathophysiology of these previous cardinal signs. As explained, with loss of dopamine-producing neurons in the substantia nigra, the inhibitory signals from the basal ganglia to the thalamus become overly dominant, preventing the initiation and implementation of motor commands (Bereczki, 2010). As a result, people with PD experience slowness of movement, muscle stiffness, and a reduced range of motion. Bereczki D. (2010). The description of all four cardinal signs of Parkinson's disease in a Hungarian medical text published in 1690. Parkinsonism & related disorders , 16 (4), 290–293. https://doi.org/10.1016/j.parkreldis.2009.11.006 Kurthi, B., & Burugupally, S. P. (2019). Postural Instability in Parkinson’s Disease: A Review. Brain Sciences , 9 (9), 239. https://doi.org/10.3390/brainsci9090239 Patient Case Question 4. Does this patient satisfy the minimum criteria for a definitive diagnosis of Parkinson disease? Yes, this patient does satisfy the minimum criteria for a definitive diagnosis for PD. At minimum, a patient must present with bradykinesia with either a tremor or rigidity. This patient presents with all three even though his tremors have lessened in the past few weeks. He presents low fine motor function, tremors, poor postural stability, and mask-like facial expressions with blinking at 1/min. The patient also expressed, “feeling more wooden.” Postuma, R.B., Berg, D., Stern, M., Poewe, W., Olanow, C.W., Oertel, W., Obeso, J., Marek, K., Litvan, I., Lang, A.E., Halliday, G., Goetz, C.G., Gasser, T., Dubois, B., Chan, P., Bloem, B.R., Adler, C.H. and Deuschl, G. (2015), MDS clinical diagnostic criteria for Parkinson's disease. Mov Disord., 30: 1591- 1601. https://doi.org/10.1002/mds.26424 Patient Case Question 3. Evaluate control of this patient’s hyperlipidemia

It seems that the patients control over his hyperlipidemia is poor. Desirable levels for HDL in men should be around 60 mg/dL and above. He is also overweight weighing at 205 pounds at a height of 5’9”. His BMI is 30.3 (obese). When obese, a person’s levels of adipose tissues are higher, increasing his risk factors for this condition worsening if no interventions are implemented in a timely manner. Factors that can worsen hyperlipidemia are foods high in saturated or trans fats, sedentary lifestyle, and being stressed or depressed. Due to the patient being confined to a wheelchair and spending most of his day sitting without moving he is putting himself at risk by not implementing some activity on a daily basis. Additionally, he has become depressed from all the limitations he encounters with his medical conditions. Adebisi, M., Teddy, E., Salim, M., Liuyi, Mahmud, A., Kanton, A., & Mustapha, A. (n.d.). Obesity may increase the prevalence of parkinson’s disease while parkinson’s may reduce obesity index in patients . Obesity may Increase the Prevalence of Parkinson’s Disease while Parkinson’s may Reduce Obesity Index in Patients. https://www.clinmedjournals.org/articles/ijnd/international- journal-of-neurodegenerative-disorders-ijnd-2-012.php?jid=ijnd CDC. (2022b, September 2). Adult BMI calculator . Centers for Disease Control and Prevention. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calcul ator.html Patient Case Question 4. Which laboratory tests indicate that this patient’s diabetes could be better controlled? The laboratory tests that indicate E. diabetes could be better controlled are his glucose levels (289 mg/dL and HbA 1c level (8.2%). Typical levels for glucose are between 70 to 100 mg/dL. The patients’ levels are approaching to very dangerous levels that require medical attention. This level may explain his decreased craving for food. Gastroparesis is a disorder that affects the movement of food from the stomach to the small intestine, it can slow or stop the flow. When someone has diabetes, damage can occur to the nerves, such as the vagus nerve which controls the muscles of the stomach and small intestine. Gastroparesis is one of the most common conditions that occur with diabetics. For the patients HbA 1c level of 8.2%, he is far above the ideal level of 5.7% (considered normal/non-diabetic). If he were to manage his levels by increasing his activity, eating a healthy diet, and most importantly losing weight he will lower these levels significantly. His PD diagnosis will make this difficult process, but it is necessary considering his dangerously high levels. CDC. (2022, July 28). Diabetes and digestion . Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/library/features/diabetes-digestion.html#:~:text=digest%20your %20food.-,Diabetes%20is%20the%20most%20common%20known%20cause%20of %20gastroparesis.,today%20and%20down%20the%20road.

Parkinson Disease Case Study

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