Question

"A 60 year old man presents to your office with imbalance and a few falls. He has had some severe bumps and bruises from the falls, which prompted him to come in to see the doctor. Symptoms seemed to begin about 6 months previously, and are slowly getting worse. Also noted is a tremor that primarily involves the right hand, and is most prominent when at rest and when walking. In fact, the patient barley notices it but it is very bothersome to his wife. His movements, according to his wife, seem very slow and stiff.

The patient does not make good eye contact when being spoken to, and gaze is directed downwards. Facial expression is limited, and there seems to be a paucity of spontaneous movements. All movements, including walking, speaking, reaching, etc. are very slow but performed accurately. There is a tremor, most prominent in the right hand, which is most noticeable at rest and goes away when reaching for objects. It is also enhanced when walking, and writing is poor. Walking is slow with short, shuffling steps. "

I would just like help with the Diagnosis please !

Answer 1

In the above case firstly we need to pay attention to all the symptoms exhibited by patient to reach a diagnosis.

The patient has following symptoms:

1. Postural instability : patient complains of falls due to imbalance.

2. Patient complains that the condition is gradually worsening. This means that the disease is progressive.

3. Tremors: the tremors are present during rest and when walking which disappears while doing some work. The tremors are seen only in right hand.

4. Bradykinesia and rigidity : patient complains of slow movement and stiffness.

5. Lack of facial expressions

6. Shuffling gait : the step length is short and arm swing is lost

7. Poor hand writing.

The above symptoms points towards Parkinson’s disease. Parkinson’s disease is slowly progressive degenerative neurological disorder. In Parkinson’s the nerve cells present in the area of substantia nigra that control movement are affected causing there degeneration. This results in impaired dopamine secretion causing slowness of movement and incoordination.

The patient exhibit three most important symptoms of Parkinson’s which are tremors at rest, bradykinesia and rigidity. Other important symptoms of patient which are seen in Parkinson’s disease includes incoordination, shuffling gait, lack of expression, shuffling gait, poor handwriting (micrographia).

Differential diagnosis in this case are :

1. Alzeihmers disease

2. Huntingtons disease

3. Movement disorders like chorea and dystonia

4. Other disease degrading striatonigral pathway

5. Essential tremors