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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