Case 4

Setting: OPD

“My walking is getting really slow.”

HPI

A 74-year-old man with progressive inability to walk over the past year comes to your office. He also has a hard time getting up from a seated position and he becomes lightheaded when he tries.

PMHX

ostearthritis

Medications

acetaminophen

General: immobile, seems very “grim-faced”
**Neurological:**
Tremor at rest at 3 cycles/second, cogwheeling present
Slow gait; significant retropulsion. He cannot easily turn.

Orders

MRI of head
Basic Metabolic Panel

The patient’s diagnosis of Parkinson disease (PD) is obvious on examination. There is no test to specifically diagnose PD.

Which should be tested for on examination?

Hyperreflexia➜ Orthostatic hypotension➜ Spasticity of muscles➜ Decreased papillary reflexes➜

The patient has orthostasis on examination as well as decreased facial movements (hypomimia). The main thing that bothers him is slow gait and general immobility. He is not as bothered by the tremor because it stops when he reaches for something.

Started on

Benztropine

Instead of the previously scheduled 2-week follow-up appointment, the patient is brought back in 4 days by his wife. He has abdominal pain, dry mouth, and urine retention.

Which of the following should you also ask about or examine for?

Bradycardia➜ Memory Difficulty➜ Diarrhoea➜ Constricted pupils➜

You stop the benztropine and start amantadine. When you see the patient again in 2 weeks, there is no significant improvement. You take the case to your senior.
Your senior asks, what is the next step to try?

Catechol-O-methyltransferase (COMT) inhibitor (tolcapone, entacapone)➜ Ropinirole or pramipexole➜ Bromocriptine➜ Selegiline➜

Your senior asks you to start ropinirole and see the patient again in 2 weeks. He has modest improvement in mobility and orthostasis. Over the next year, he is stable then begins to deteriorate again.
What is the next step to try?

Catechol-O-methyltransferase (COMT) inhibitor (tolcapone, entacapone)➜ L-Dopa and carbidopa➜ Bromocriptine➜

Catechol-O-methyltransferase (COMT) inhibitor (tolcapone, entacapone)➜ Nothing more can be done.➜ Order deep brain stimulation➜

Your senior tells you to start the patient on tolcapone.
After a few days on the new medications, the good news is, the patient has much better mobility. The bad news is, he has started to develop visual hallucinations and sees bugs coming out of the walls.
What to do now?

Start Haloperidol➜ Start Quentiapine➜ Order deep brain stimulation➜ Risperidone➜

The treatment is quetiapine, which is an antipsychotic medication with the lowest amount of parkinsonian adverse effects.
Reference- Internal Medicine- Correlationa and Clinical Scenarios

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