At physical exam rounds, we went over the examination for Parkinsonism. One approach:
Vital signs: Postural drop (autonomic dysfunction)
Face/head and neck:
-lack of facial expression "mask"
-lack of blinking
-drooling (autonomic dysfunction)
-brow for seborrhea (autonomic dysfunction)
-speech (soft, monotonous)
-cognitive dysfunction, depression
Extraocular movements for progressive supranuclear palsy (upward, then downward gaze palsy)- a "Parkinson's plus" syndrome
Special test: Glabellar tap- tell pt to look straight ahead, tap firmly on mid-forehead outside of the patient's visual field. Expect blinking with each tap x 5-10, then blinking should stop
Standing, gait:
-difficulty initiating movement (akinesis, bradykinesia)
-shuffling gait
-difficulty walking heel to toe
-freezing
-festination (small steps, seeming to "hurry")
-retropulsion (tendency to fall back)
-'en bloc' turning
Upper extremities
-resting tremor with arms relaxed (4-7 hz)
-tremor diminishes on finger to nose (vs. essential tremor, which increases with movement)
-wrist tone for cogwheeling; may look for activated rigidity (movement of opposite hand brings out cogwheeling)
-tests for bradykinesia: finger pinching (progressively smaller), rotation of hands, opposing thumb sequentially with each finger (may add while rotating other hand)
-micrographia
Lower extremities
-foot tapping: low amplitude, progressively smaller (bradykinesia)
Evidence: From JAMA- Does this Patient Have Parkinson Disease?
Most sensitive tests:
Glabellar tap- negative likelihood ratio of 0.13
Difficulty with heel-toe walking: NLR 0.3
Most specific tests:
Tremor, rigidity and bradykinesia: PLR 2.2
Difficulty with heel-toe walking: PLR 2.9
Glabellar tap: PLR 4.5
Findings making Parkinson's disease very unlikely:
Cerebellar signs
Pyramidal signs
Cranial nerve palsies
Link:
TRAP, do you still use that acronym?
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