Clinical Skills

Question 1

Before you begin

Answer 1

• Walk your patient in
• Sit to stand
• Gait
• Walking aid
• Arm swing
• Posture
• Facial expression
• Speech
• Confusion
• Re-emergent tremor
• General appearance

Question 2

History taking

Answer 2

• Open vs closed questions
• Why are you here? allow them to open up
• What has changed in the last year
• Are there things you used to do that you have stopped now
• Timeline: PD usually months to a year or 2 years. If many years think ET

Question 3

Bradykinesia

What might a patient tell you

Answer 3

• Slowness of movement
• Everything is slow- asking them for examples (e.g. ADLs), particularly around movement/gait
• Fine motor tasks may be more difficult (Button + Zips)
• Handwriting has changed
• Voice may be quite

Question 4

Examining for bradykinesia

Answer 4

• Tell them your going to examine
• With one hand copy me (open and close thumb and index finger) for 20 seconds
• Can do pronation/superation
• Complete one hand than the other
• For lower limbs can use foot taps
• You want to see decreiment
• You also want to observe: Spontaneous movement, blink frequency and facial expression
• Gait

Question 5

Tremor- Hx

Answer 5

• Unilateral vs Bilateral- Onset, when does it happen, progressive (EtOH can make it better for essential tremor. For PD it may be due to relaxation)
• Stops me doing things….
• Embarrasing
• I have had it for months vs years

Question 6

Examination of tremor

Answer 6

• In PD a resting tremor is key. This tremor occurs when the body is completly at rest against gravity and ceases during active movement
• Sit with arms in your laps, close their eyes and ask them to do a task (Serial subtraction)- assessing for resting tremor
• Complete with arms outstretched with fingers stretched- postural tremor
• Purposeful (intention) tremor
• Chin/Jaw- Not head
• Cerebellar features- atypical PD
• Archimedes spiral- essential tremor tends to be large and zigzaged, PD tends to be small spirals

Question 7

Differential diagnosis- Essential tremor

Answer 7

• Frequency of 5-10 Hz
• Kinetic tremor
• Postural tremor (without latency, unlike PD)
• Improves with rest and often involves the head and neck

Question 8

Differential diagnosis- dystonic tremor

Answer 8

• Irregular
• Asymmetrical
• Kinetic tremor (common)
• Postural tremor (position-dependent)
• Variable frequency depending on the position of the affected body part
• Worsened by specific motor tasks
• Thumb extension is frequently involved

Question 9

Rigidity

Answer 9

• My arm doesn’t move
• Shoes scuff
• Frozen shoulder that does not improve

Question 10

Examination of rigidity

Answer 10

• Ask about pain
• Move their arm- expecting increased tone throughout the movement
• Cogwheeling- can occur with essential tremor as well as PD

Question 11

Other things to do

Answer 11

• Full neurological exam
• Eye signs
• Risk factors and Fhx
• Pre-motor/predictive factors- constipation, Anosmia, mood
• Differential diagnosis- vascular risk factors, head injury, drugs
• Non-motor Sx