Presenting Complaint

• You are concerned about your right hand shaking. It is bothersome and you are self-conscious about others noticing and pointing it out.

History of Presenting Complaint

• Site: Involuntary shaking mainly in the right hand but sometimes also occurs in the left hand
• Onset: Noticed it 8 months ago.
• Character: Shaking is small and slow but not jittery or big that you hit a person. 
• Timing: Only occurs whenever you are sitting or watching TV. (Only if asked specifically) unsure if symptoms have worsened since onset.
• Associated Symptoms: Have had difficulty sleeping recently and feeling low in mood. Never had incontinence or loss of consciousness. Feel memory is unaffected. (Only if specifically asked) have difficulty walking, feel you have slowed down and take smaller than normal strides.
• Exacerbating/Relieving factors: Shaking particularly worse when relaxing but goes away when you are aware of it or you move the hand. It never occurs on movement. 

Systems Review

• Neurological: No focal sensory or motor deficits but difficulty with walking
• Cardiorespiratory: Nil
• Gastrointestinal: Nil
• Genitourinary: Nil
• Otherwise well, no other problems
• Red flags: as below
  • Feel more tired
  • No night sweats, unintended weight loss, change in appetite, fevers or recent infection

Previous Medical History

• Osteoarthritis
• Hypertension

Drug History

• Ibuprofen and omeprazole for osteoarthritis,
• Felodipine and enalapril for hypertension

Allergies

• NKDA

Social History

• Never smoked cigarettes
• Drink alcohol on social occasions only.
• Never taken recreational drugs.
• Retired but used to work as an accountant.
• Lives alone as husband died 4 years ago.
• Have 2 children who lives close by and visit regularly.

Family History

• Father has Alzheimer’s and Prostate Cancer
• Mother had Osteoarthritis

ICE

• Expectations: Want to know the diagnosis and if there are any medication to treat it

• Ideas: Worsening of arthritis.

• Concerns: Worried if it is not treatable as you are self-conscious of the symptoms.

Vitals

• HR: 76 bpm
• Blood pressure: 136/88 mmHg
• SpO₂: 98%
• Temperature: 36.6℃
• Respiratory Rate: 14 breaths per minute

Hand Examination

• Tremor does not worsen on movement of the hand or maintaining posture
• Heberden’s and Bouchard’s nodes present bilaterally consistent with osteoarthritis of the hand.
• Low frequency tremor of the right hand at rest.

(Image source: https://commons.wikimedia.org/wiki/File:Heberden-Arthrose.JPG (accessed 21/4/24) from Wikimedia Commons. Author: Drahreg01. Link to licence: https://creativecommons.org/licenses/by-sa/3.0/deed.en)

1. What is the most likely diagnosis and explain why?

• Idiopathic Parkinson’s disease (IPD). Unilateral, low frequency resting tremor, low mood, bradykinesia, shuffling gait (smaller strides) are characteristic features of IPD. Further information on tremors and other abnormal movement disorders can be found on our abnormal movement history guide.

2. What is the underlying aetiology of Parkinson’s disease?

• Loss of dopaminergic neurons of nigrostriatal pathway (mainly substantia nigra) due to intraneuronal α-synuclein aggregates forming Lewy bodies

3. List 3 secondary causes of parkinsonism

• Antidopaminergic drugs e.g. antipsychotics
• Stroke, traumatic brain injury i.e. vascular 
• Multiple system atrophy – Parkinson’s predominant
• Progressive supranuclear palsy
• Corticobasal degeneration

4. What imaging can be used to distinguish between primary and secondary parkinsonism?

• Dopamine transporter imaging scan. In primary parkinsonism, there is reduced dopamine uptake appearing as a “dot” in the scan. Other causes will have normal dopamine uptake appearing as a “comma” in the scan.

5. Following a diagnosis of Idiopathic PD, what steps should the GP take?

• Review patient at least every 6-12 months.
• Consider MDT input from physiotherapy, occupational therapy, adult social care, community nursing, bladder and bowel continence team, mental health services, as necessary.
• Advise the person and their family/carers about sources of information and support, such as national Parkinson’s UK charity and leaflets entailing their diagnosis and management.
• Notify the Driver and Vehicle Licensing Agency (DVLA).
• Opportunities for advance care planning e.g. LPA

6. What drug treatment is indicated for motor symptoms?

• MAO-B or COMT inhibitors are 3rd line therapies

• Co-careldopa (levodopa + carbidopa) is 1st line

• Dopamine agonists e.g. bromocriptine is 2nd line