PC to (GP) Hx PC vitals

Exam

Mental

Cranial Nerves

Motor

Sensation Sc Hx

Rx 9/12 later

Jennifer Williamson (65, F) Retired receptionist Difficulty sewing (6/12) R worse than L Right arm doesnt feel right Must concentrate hard to do up buttons and she looks a bit glum Good health HR = 84 reg BP = 150/90 supine T = 36.8 Optic discs clear with sharp borders () Visual acuity excellent for age Chest clear Abdo soft no tenderness or masses Alert, cooperative, orientated Memory and knowledge good Speech clear and language good range of eye movement is full.............CN III, IV, VI pupillary reflexes intact.......................CN III visual fields complete to confrontation................ Corneal, jaw-jerk and gag reflexes are intact............. palate and uvula elevate symmetrically........... tongue protrudes in the midline................CN XII Shoulder shrug is symmetrical................. slight, high-frequency hearing loss L>R Grip strength intact and symmetrical Deep tendon reflexes = n No dysmetria or past-pointing in any extremity No pronator drift, postural reflexes intact.....................................................not cerebellar Cutansous sensation and propreioception intact Husband Rupert, married 40 yrs Retired for 5yrs Lives with Rupert One child, Mary, lives in Perth Suggested to make an appointment in 1/12. Not attended finding fine hand mvmts harder trouble rolling over trouble getting out of a low chair. voice is getting softer and quieter hand-writing letters smaller cranial nerves, strength and reflexes = normal postural reflexes are slightly compromised (when pushed it takes many small steps to regain balance) Trouble knife and fork, needs help in toilet, sometimes gets stuck in bed and cant roll GAIT R arm swings less, R foot catches as they climb stairs, stiff When tired R foot goes to sleep. When distracted there is a spontaneous tremor 4Hz Asked to pick up a pen R and wave L. Fumbles pen Elbow joint feels mildly rigid and movement is stiff. Dead pan expression slow expression change and blink rate Parkinsons Rx = Levodopa with benserazide or carbidopa (L-DOPA (100mg) and carbidopa (10mg) - Sinemet) 3/day and nd every 2 day until Sx improve Extremely distressed because although she was improving now she Uncontrollable jerking mvmts Face twitching Advised to reduce dose of carbidopa/L-DOPA to 25mg/100mg 4/day (instead of 25mg/250mg 3/day) Mvmts cease in 8 hours. Now has freezing moments near when she is due for next dose advised to have a tablet 6/day This works until psychotic hallucinations meds reduced to 5/day and Quetiapine (antipsychotic) added Psychosis settles Enquires about deep brain stimulation OT for advice on ADLs

Repeat exam Several weeks later neurologist

Diagnosis

2/52 later

Alt Rx