Case Report Session

Parkinsons Disease

Athikah Khairunnisa

0810312113

Preceptor: Prof. Dr. H. Basjiruddin Achmad, sp. S (K)

Patient Identity
Name Age Occupation MR No : Mr. A : 65 years old : Pensionary : 05.16.70

A 65 years old male patient came to Policlinic RSUP Dr. M. Djamil Padang, on April 1st, 2013 with: Chief Complain : Trembling of the whole body

Present Illness History:

Trembling of the whole body since 2 months ago. Patient felt trembling in his right upper limb for the past 1 years. Then left upper limb start to tre mbling 2 weeks after that. At first, patient felt th e tremble when resting dan decreased when he moves. But for the past 2 months, patient felt the tremble in the whole body continuously so that h e has difficulty to do daily activities.

 Patient complain that his step was became short er for the past 7 months. Patient often tripped th e household furniture when walked and felt hard to start and stop walking. Patient feels stiffness in his limbs Patient Family tells that patient tends to falls wh en he was standing.

Past Illness History

No history of suffering from this disease previou sly No history of trauma, accident, and falls in sit p osition No history of hypertension, diabetes, and cardiovascular disease

Family Illness History: No family members known to be suffering from t his disease Employment, Social Economic, and Habitual History: Patient is a pensionary with enough physical acti vity. No house environtment with pesticide contamin ation and house near chemical industry.

Physical Examination
General Condition : Moderately ill Awareness : Compos Mentis Cooperative Blood Pressure: 140/90 mmHg Pulse : Easily palpable, regular, 110x/minute. Temperature : 36,8o c Breath : Abdominothoracal pattern, regular, 28x/minute Body weight/height : 80kg/165 cm

Internal Examination
Lymph nodes : No enlargement Neck : JVP 5-2 cm H2O. Carotid bruit (-) Lungs : Inspection : Symetric in static and dynamic Palpation : Vocal fremitus right simetris with vocal fremitus left Percussion : Resonant Auscultation : Vesicular, ronkhi - / -, wheezing -/-

Cor Inspection Palpation Percussion Auscultation Abdomen Inspection Palpation Percussion Auscultation

: : Ictus are not visible : Ictus cordis palpable 1 finger medial LMCS RIC V : With normal limits : Regular, HR= 112x/minute, Murmur (-), Galloup (-) : : Distended/flat, mass (-) : Liver and spleen no enlargement : Tympanic : Bowel sounds (+) normal

Vertebrae corpus Inspection : deformity (-) Palpation : tenderness (-), Gibus (-), crepitating (-)

Neurological Examination
1. GCS: E4M6V5 = 15 2. Meningial signs;
Nuchae Rigidity Brudzinsky 1 Brudzinsky 2 Kernig sign : (-) : (-) : (-) : (-)

3. Increased of intracranial pressure :

Projectile vomiting : (-) Progressive headache: (-)

4. Cranial Nerve
NI : Smelling ability is good N II : Visual field is good N III, IV, VI: Pupil round, isocor, 3 mm / 3 mm, light reflex direct and indirect + /+, ptosis (-), movement of the eye ball is free. NV : corneal reflex in both eyes (+), spontaneously open the mouth (+), move the jaw to the right and left (+) N VII : right nasolabial fold same with the left, wrinkle of the forehead is symmetric, close the eyes (+)

N VIII

: Listening function is good, nistagmus (-) N IX and X: faringeal arch is symmetric, uvula is in the middle, 1/3 tounge sensation is good, and Gag reflex (+) N XI : Can raise his right and left shoulder and turned head to left or right N XII : there is no tounge deviation, atrophy (-), fasiculation (-).

5. Motor

:hipertonus with Cog Wheele Phenomenon, eutropi. resting tremor (+), rigidity (+) 6. Sensoric : Exteroceptive and propioseptif is good 7. Autonomic Nervous System: Mixturition : Neurogenic bladder (-) Defecation : good Sweat : hypersecretion

8. Physiological Reflex: Biceps : ++/++ Triceps : ++/++ KPR : ++/++ APR : ++/++ 9. Pathological Reflex: Babinsky : -/ Chaddock : -/ Oppenheim : -/ Schuffer : -/ Gordon : -/ Hoffman Tromner: -/-

10. Sublime Function : consciousness is good, decreasing in intellectual, emotional reaction is good 11. Dementia signs : Glabella reflex : (-) Snout reflex : (-) Palmomental reflex : (-) Grasping reflex : (-) Sucking reflex : (-)

12. Parkinsons signs: Tremor : (+) Rigidity : (+) Bradykinesia : (+) Postural instability : (+) Parkinsons face : (+) Shortening of the footstep : (+)

Diagnosis
Clinical diagnosis : Parkinsons Disease Topical diagnosis : Substantia Nigra Etiological diagnosis : Idiopathic Secondary diagnosis : -

Management
Low salt dietary Medication given: Levodopa 100 mg per day (p.o) Trihexyphenidil 3 x 2 mg (p.o)

Discussion
A 65 years old male patient came to Neurology Policlinic RSUP Dr. M. Djamil Padang, on April 1st, 2013 diagnosed with Parkinsons disease. The diagnosis of Parkinsons disease is based on careful history taking and physical examination. There are no laboratory test or imaging studies that confirm the diagnosis. From history, weve found that the patient has complain about trembling of his whole body, stiffness of the limbs, his step was became shorter, tends to fall when he was standing.

Parkinsons disease typically develops between the ages of 55 and 65 years and occurs in 1 to 2 % of persons over the age of 60 years. Approximately 0.3 % of the general population is affected, and the prevalence is higher among men than women, with ratio of 1.6 to 1.0. This patient is a male and 65 years, it is concurrent with that statement. From the physical examination, it is concurrent to the diagnosis, Parkinsons disease.

Parkinsons diseases motor manifestation of the disorder commonly include resting tremor, a soft voice, small handwriting (micrographia), stiffness (rigidity), slowness of movements (bradykinesia), shuffling steps, difficulties with balance. A classic symptom is resting tremor, although 20% of patients do not have it. Parkinsons disease also has a multitude of nonmotor manifestations, including disturbances of mood, cognition, and sleep.

The diagnosis of Parkinsons disease is not necessarily cause to begin drug therapy. Drug therapy is warranted when the patient is sufficiently bothered by symptoms to desire treatment or when the disease is producing disability. If the patient needs treatment for motor symptoms, efficacious agents for initial therapy include levodopa, dopamine agonist, anticholinergic agents, amantadine, and selective monoamine oxidase B (MAO-B) inhibitors.

Except for comparisons of individual dopamine agonist with levodopa, there are no robust comparisons of efficacy among these agents, but clinical experience suggest that the dopaminergic agents are more potent than the anticholinergic agents, amantadine, and selective MAO-B inhibitors. For this reasons, dopaminergic drugs are often the initial therapy recommended for patients with troublesome symptoms.

 Thank you