Case Presentation Parkinson Disease

Case Presentation
Parkinson Disease
o Patient database worksheet

Preceptor name: Zeinab Abbass
Student name: Mariam Aydin
Rotation: IM
o Patient Information
Patient’s Initials: JM
Age: 58 years old
Gender: Female
o Case Presentation: Subjective and Objective:

JM, 58 years old women presented to the
neurology clinic because of stiffness on her right
side over the last 6 months.
She also mentioned that it takes her longer to do
things because it takes more effort to get
movement started and also her muscles feel stiff.
She also feels that she doesn’t think as quickly
and it takes her longer to remember things.
In addition to that, she complains of constipation
and decreased libido for over a year.
And recently it has become difficult to read
because the words look blurry, so these
symptoms affected her job performance resulting
in her contemplating early retirement.
She denies any symptoms of autonomic
dysfunction and any psychological problems.
No past medication history was mentioned, and
recently she is not taking any medication too.
o Family history:
Her Mother died at age 94 of complications
associated with Alzheimer’s disease.
Her father died of colon cancer.
Her two daughters and husband are alive and in
good health.
o Social History
She is nonalcoholic, nonsmoker, and married for
25 years
o Physical Examination:
 Blood pressure is normal 118/76 mmHg
 Normal Pulse 70 beats/min
 Normal Respiratory rate 13 breath/min
 Normal Temperature 36.8°C
 Weight 55 kg & height 160 cm, so she has a
normal BMI 21.5
 While examining the skin a small amount of dry
yellow scale in her eyebrows are present
 Upon head, eyes, ears, nose and throat
examination a decreased volume of speech,
decreased facial expression & decreased eye
blinking was noticed.
 Lungs are clear
 Normal heart rate and rhythm with no
murmurs
 The abdomen is soft and nontender
 Musculoskeletal and Extremities examination
shows mild rigidity in right arm, decreased fine
motor coordination on the right side with
normal peripheral pulses and postural stability.
o Neurological Findings:
1. Folstein or MMSE which is a mini mental
state examination used for screening
cognitive function scores 30/30 which means
she has normal cognition.
2. Hamilton depression scale 4/21 measures
factors that might be related to depression
3. Unified Parkinson disease rating scale
Part 1: scores 0/16
Part 2: which measures activities of daily living
scores 3/52
Part 3: motor exam scores 10/108 as mild
problems with facial expression, rigidity, rapid
alternating movements in right hand, and
bradykinesia
o Laboratory findings:
All are within normal ranges, except
homocysteine is slightly high (>15)
o Diagnosis:
JM is diagnosed with early, mild Parkinson’s
disease based on the findings as bradykinesia,
stiffness, mild rigidity, craniofacial motor features
as hypomimia, decreased spontaneous eye blink
rate, visual disturbances as blurred vision,
musculoskeletal symptoms as micrographia and
autonomic dysfunction as constipation and
sexual dysfunction.
o Goal of Treatment:
Our goal is to slow the progression of the disease
and to treat symptoms associated with it, since
there is no cure for Parkinson’s disease.
o Non pharmacological Treatment:

JM should do exercises and physical therapy to
strengthen and stretch the muscles.
Her diet should include fiber since she is
complaining of constipation.
o Pharmacological Treatment:
Because motor symptoms of Parkinson’s disease
begin to interfere with daily function and quality
of life as JM’s symptoms have affected her job
performance, and since her age is less the 65
years old, so either levodopa dopamine agonists
is indicated. The major factors that influence the
choice of therapy are age and severity of
symptoms.
It might be reasonable to start with dopamine
agonist because symptoms are mild and since
dopamine agonist have a lower risk of motor
complications than levodopa, so patients with
early Parkinson’s disease can be treated with
dopamine agonist for several years before they
require levodopa, this would reduce the
exposure to levodopa and therefore minimizes
the impacts of side effects.
Also in a meta-analysis randomized trial
published in Pubmed in 2008, which is a study
aims to quantify more reliably the benefits and
risks of dopamine agonists compared to levodopa
in early Parkinson’s disease. This meta-analysis
confirms that motor complications are reduced
with dopamine agonists compared to levodopa.
Also dopamine agonists have longer half-life,
reducing the need of multiple dosing compared
to levodopa.
However dopamine agonists are subdivided into

ergoline and non-ergoline agonists. Currently
ergoline derivatives are not preferred for first line
treatment because they are associated with higher
risk of cardiac problems such as fibrotic cardiac
valvulopathy.
The FDA approved four non-ergoline dopamine
agonists to treat Parkinson’s disease, two of
them can be given orally as Pramipexole and
Ropinirole. Ritogotine available as patch and
apomorphine available as subcutaneous
injection. However there are few studies that
have compared the efficacy of various dopamine
agonists with each other have found either no
significant difference of only mild superiority of
one agent over another.
I choose to go for pramipexole IR.
Dosing: started at 0.125 mg 3 times daily. The
dose should be increased gradually by 0.125
mg/dose every 5-7 days.
Most patients can be managed on total daily
doses of 1.5-4.5 mg.
o Adverse Effects:
Nausea, vomiting, confusion, hallucination,
hypersexuality, peripheral edema common with
chronic use of dopamine agonists. But most of
the adverse events of dopamine agonists can be
avoided by initiating treatment with very small
doses and titrating to therapeutic levels slowly
over several weeks.
o According to NICE Guideline: when starting

dopamine agonists therapy, patient and their
family members should be given verbal and
written information about the following:
o The different types of impulse control disorder
such as hypersexuality, binge eating, obsessive
shopping. And who to contact if impulse
control disorder develops
o The possibility that if problematic impulse
control disorder develops, dopamine agonists
therapy will be reviewed and may be reduced
or discontinued.
o Concerning other symptoms such as blurred

vision, it can be treated with ana eye emollient.
Constipation can be treated either by changing
her diet by increasing fiber and fluid intake,
increased physical activity can be beneficial or
giving Polyethylene glycol solution (macrogol)
is recommended.
o Monitoring:
People with PD should have regular access to the
following:
• Clinical monitoring and medication adjustment
• A continuing point of contact for support,
including home visits, when appropriate
• A reliable source of information about clinical
and social matters of concern to people with PD
and their caregivers, which may be provided by a
PD nurse specialist.
o Guidelines used:
1. NICE GUIDELINE PARKINSON’S DISEASE IN

ADULTS PUBLISHED DATE 19 JULY 20171
2. Canadian guideline for Parkinson disease
Published in 2019 September

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Case Presentation

o Patient database worksheet

o Case Presentation: Subjective and Objective:

o Non pharmacological Treatment:

However dopamine agonists are subdivided into

o According to NICE Guideline: when starting

o Concerning other symptoms such as blurred

1. NICE GUIDELINE PARKINSON’S DISEASE IN

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