Diagnosis of Parkinson's Disease
Parkinson's Disease Diagnosis: Book Excerpts
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TREMOR:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- When does the tremor occur? Intention tremor, which means that the tremor occurs on movement, would suggest that the patient is suffering from a familial or senile tremor or multiple sclerosis, Wilson's disease, or hereditary familial ataxia. It also may suggest alcoholism. Nothing is more dramatic than the intention tremor of alcohol withdrawal. A tremor occurring at rest would suggest Parkinson's disease or manganese poisoning. A fine tremor of the outstretched hands, which is sometimes described as tension tremor, would suggest hyperthyroidism.
- The next question to ask is whether there are associated neurologic findings. A tremor with long tract findings, such as hyperactive reflexes or Babinski's sign, would suggest multiple sclerosis, whereas a fairly symmetrical tremor with no long tract signs or other neurologic findings would suggest a familial senile tremor. A tremor with mental deterioration would suggest Wilson's disease.
- Are there associated systemic findings? If the patient has tachycardia and an enlarged thyroid, one should consider hyperthyroidism. However, simply tachycardia alone might indicate that the patient is very sensitive to caffeine. Kayser-Fleischer ring and enlarged liver would suggest Wilson's disease. An enlarged liver alone would suggest alcoholism.
DIAGNOSTIC WORKUP
Certainly a thyroid profile should be done on all cases that present with a tremor alone. In addition, blood tests for serum copper and ceruloplasmin should be done when Wilson's disease is suspected. A drug and alcohol screen should be done also. If multiple sclerosis, Wilson's disease, or a cerebellar tumor is suspected, a CT scan or MRI of the brain should be done. When there is doubt as to whether the tremor is a resting or active tremor, an EMG may be done to separate the two. Most patients presenting with a mild intention tremor that is symmetrical and not associated with other neurologic findings will probably have familial or senile tremor, and the response to beta-blockers can be determined.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Tremor:
Differential Diagnosis
(In a Page: Signs and Symptoms)
Resting tremors
-
Parkinson's disease
–“Pill-rolling” appearance
–Associated cog-wheel rigidity, shuffling
gait, akinesis, and/or depression
-
Benign familial or essential tremor
–Especially common with head tremor (e.g., actress Katherine Hepburn)
–Positive family history
–No other neurologic findings
Drug or toxin-induced tremors (e.g., MPTP)
Postural tremors: Elicited when a limb is held up against gravity; caused by metabolic conditions (e.g., thyrotoxicosis)
Voluntary movement (hyperkinetic) tremors
Wilson's disease
Stroke
Cerebellar disease
Movement tremors
Intentional tremor: Occurs with movement toward a target; associated with a cerebellar deficit which would inhibit (e.g., multiple sclerosis, midbrain injury or stroke)
Workup and Diagnosis
-
Evaluation of tremors includes a complete history and physical examination with attention to the onset and other characteristics of the tremor; medication history; a limited general physical examination and a comprehensive neurologic examination
-
CT or MRI of head to rule out mass lesions, CVA, and normal pressure hydrocephalus
-
Initial labs may include TSH, T4, CBC, vitamin B12 and folate, RPR, and a comprehensive metabolic panel (electrolytes, calcium, glucose, BUN/creatinine, liver function tests, and albumin)
-
Essential or familial tremor is diagnosed by excluding other etiologies and by a positive response to propranolol
-
Parkinson's disease is diagnosed by the characteristic constellation of symptoms and response to treatment (Parkinson's is often diagnosed and treated before tremor develops)
-
Toxicology screen to rule out drug ingestion
-
The following types of movement may be confused with
tremor, but are actually separate entities
–Tics are usually unifocal and slower and are not tremors
–Chorea causes jerky irregular movements
–Myoclonus is rapid and irregular
–Athetosis and dystonia are slow movements
–Asterixis results from inhibition of muscle contractions
due to hepatic encephalopathy
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
TREMOR AND OTHER INVOLUNTARY MOVEMENTS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of tremor and other involuntary movements involves most of all a good history. The neurologic exam is important as it will determine the type of tremor. Rapid fine tremors (8–20/s) are suggestive of hyperthyroidism and emotional disorders. Coarser tremors at rest suggest parkinsonism, whereas a flapping tremor of 4 to 8 per second suggests Wilson disease. The association of other neurologic signs helps pin down the diagnosis. Spasms of pain suggest a thalamic syndrome, whereas ataxia suggests Friedreich ataxia and loss of memory suggests manganese toxicity. Laboratory tests will be useful in selected cases. Blood lead, manganese, copper, and ceruloplasmin levels may be necessary. A T3, T4, and FT4 index will confirm the diagnosis of Graves disease. Other tests that may be helpful may be found in the Appendix or listed below.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Tremors:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin the patient history by asking the patient about the tremor’s onset (sudden or gradual) and about its duration, progression, and any aggravating or alleviating factors. Does the tremor interfere with the patient’s normal activities? Does he have other symptoms? Ask the patient and his family and friends about behavioral changes or memory loss.
Explore the patient’s personal and family medical history for a neurologic (especially seizures), endocrine, or metabolic disorder. Obtain a complete drug history, noting especially the use of phenothiazines. Also, ask about alcohol use.
Assess the patient’s overall appearance and demeanor, noting mental status. Test range of motion and strength in all major muscle groups while observing for chorea, athetosis, dystonia, and other involuntary movements. Check deep tendon reflexes and, if possible, observe the patient’s gait.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Parkinson's disease:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Generally, laboratory data are of little value in identifying Parkinson’s disease; consequently, diagnosis is based on the patient’s age, history, and characteristic clinical picture.
Conclusive diagnosis is possible only after ruling out other causes of tremor, involutional depression, cerebral arteriosclerosis and, in patients younger than age 30, intracranial tumors, Wilson’s disease, or phenothiazine or other drug toxicity.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Tremors:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin the patient history by asking the patient about the tremor’s onset (sudden or gradual) and about its duration, progression, and any aggravating or alleviating factors. Does the tremor interfere with the patient’s normal activities? Does he have other symptoms? Has he noticed any behavioral changes or memory loss? (The patient’s family or friends may provide more accurate information on this.)
Explore the patient’s personal and family medical history for a neurologic (especially seizures), endocrine, or metabolic disorder. Obtain a complete drug history, noting especially the use of phenothiazines. Also, ask about alcohol use.
Assess the patient’s overall appearance and demeanor, noting mental status. Test range of motion and strength in all major muscle groups while observing for chorea, athetosis, dystonia, and other involuntary movements. Check deep tendon reflexes and, if possible, observe the patient’s gait.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Tremor:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Tremor characteristics. Does the tremor occur at rest, with goal-directed movement, or with maintenance of a specific posture? Parkinsonian tremor is a classic resting tremor, whereas essential tremor occurs or increases with maintenance of a posture. Drug-induced, drug withdrawal, and psychogenic tremors can occur at rest, with postural maintenance, or with movement.
B. What worsens the tremor? Parkinsonian tremor increases during mental stress or with movement of other body parts. Observation, stress, anxiety, fatigue, and certain drugs exacerbate essential tremor. Exposure to cold, fear, pain, caffeine, emotional loss, and stressful situations can initiate and promote physiologic tremors. A complete alcohol and medication history will further elicit possible secondary causes of tremor. Some known tremor-precipitating agents include antidepressants, lithium, neuroleptics, dopamine blocking agents, sympathomimetics, pseudoephedrine, theophylline, caffeine, methylphenidate, and withdrawal of alcohol (1,2).
C. What inhibits the tremor? Sleep stops all tremors. Whereas essential tremors increase with movement, Parkinsonian tremors diminish with goal-directed actions of the affected body part. Alcohol ingestion decreases tremor in 75% of patients with essential tremor (3). Physiologic and secondary tremors usually remit with removal of the precipitator or correction of the underlying disorder.
D. How has the tremor changed over time? Essential tremor slowly progresses. It can advance to cause social embarrassment, loss of function, and disability. Parkinsonian tremor and secondary tremors parallel the course and treatment of the underlying disease.
E. Family history. Only a slight familial relationship is seen with Parkinson’s disease, whereas at least 60% of essential tremor patients have a relative with tremor (3).
F. Onset and progression. When did the tremor begin? How has the tremor affected your life, your job, and your relationships? Parkinsonian and essential tremors usually occur after the fifth decade. Both can progress to cause decreased function, social embarrassment and isolation, disability, and loss of livelihood. Physiologic and psychogenic tremors rapidly occur and regress.
Physical examination.
A general search for signs of central nervous system involvement, drug use or withdrawal, and peripheral neuropathy may uncover secondary tremor causes. A focused examination of affected body parts, including provocative tests, may distinguish among the tremor types. Essential tremor is usually bilateral, symmetric, and increases with observed provocative testing such as maintaining a posture against gravity, pouring water, or drawing. It most commonly involves the hands and arms. It can also involve the head and voice. In advanced stages, leg and feet involvement can occur.
Parkinsonian tremor, the classic “pill rolling” resting tremor, remits with movement. It can herald the onset of Parkinson’s disease, or develop concurrently with rigidity, bradykinesia, and postural instability. Psychogenic tremors appear and remit suddenly, can exhibit unusual combinations of rest and intention tremors, occur in the presence of other unrelated neurologic signs, and diminish with distraction.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Tremor/InvoluntaryMovements:
Differential Overview
(Field Guide to Bedside Diagnosis)
Tremor
❑ Anxiety
❑ Physiologic tremor
❑ Essential tremor
❑ Parkinson disease
❑ Cerebellar disease
❑ Hyperthyroidism
❑ Opiate withdrawal
❑ Myoclonus
❑ Multiple sclerosis
❑ Amyotrophic lateral sclerosis
Involuntary Movements
❑ Tics
❑ Drugs
❑ Systemic lupus erythematosus
❑ Rheumatic fever
❑ Huntington disease
❑ Tourette syndrome
❑ Wilson disease
Diagnostic Approach
A postural tremor is characterized by fine regular movement of the fingers or hands with the arms outstretched. It is not present at complete rest. Anxiety, benign essential tremor, hyperthyroidism, or medications (alcohol, caffeine, lithium, beta agonists, or phenytoin) may cause it. Proximal postural tremors involving the shoulder, pelvis, and neck are due to cerebellar lesions.
An intention or action tremor, characterized by irregular jerking brought out by movement, can be caused by cerebellar disorders such as multiple sclerosis and alcoholic or paraneoplastic cerebellar degeneration (lung or ovarian cancer). Hereditary ataxias also follow this pattern.
A rest tremor is evident with the affected part supported and at rest and dampened during voluntary activity, fluctuating in amplitude. It is activated during walking, and interferes with use of eating utensils and with writing. It occurs with Parkinson disease, phenothiazines, severe essential tremor, Wilson disease, mercury poisoning, general paresis, and with midbrain lesions (stroke or demyelinating disease).
Choreiform movements are brief, irregular, jerky, nonrhythmic muscle contractions. Ballismus is a large amplitude jerk that produces flinging of the limb. It is commonly unilateral (hemiballismus). Athetosis is a continuous, sinuous, writhing movement of the digits, limbs, trunk, face, or tongue. Dystonia is a slow, involuntary twisting spasm. Tics are patterned coordinated movements that appear suddenly and intermittently.
Writing or drawing may demonstrate the large, tremulous, angulated loops of essential tremor or the micrographia of Parkinsonism. Horizontal or vertical head tremor is associated with essential tremor, cervical dystonia, or midline cerebellar syndromes, while face, lip, and jaw tremors are seen in Parkinsonism.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Parkinson's disease:
Diagnosis
(Handbook of Diseases)
Generally, laboratory data are of little value in identifying Parkinson’s disease; diagnosis is based on the patient’s age and history and on the characteristic clinical picture. However, urinalysis may support the diagnosis by revealing decreased dopamine levels.
A conclusive diagnosis is possible only after ruling out other causes of tremor, involutional depression, cerebral arteriosclerosis and, in patients younger than age 30, intracranial tumors, Wilson’s disease, or phenothiazine or other drug toxicity.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Tremors:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the patient history by asking the patient about the tremor’s onset. Was onset sudden or gradual? Also, ask about the tremor’s duration, progression, and any aggravating or alleviating factors. Does the tremor interfere with the patient’s normal activities? Does he have other symptoms? Has he noticed any behavioral changes or memory loss? (The patient’s family or friends may provide more accurate information on this.)
Explore the patient’s personal and family medical history for a neurologic (especially seizures), endocrine, or metabolic disorder. Obtain a complete drug history, noting especially the use of phenothiazines. Also, ask about alcohol use.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Tremors:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin the patient history by asking the patient about the tremor's onset (sudden or gradual) and about its duration, progression, and any aggravating or alleviating factors. Does the tremor interfere with the patient's normal activities? Does he have other symptoms? Ask the patient and his family and friends about behavioral changes or memory loss.
Explore the patient's personal and family medical history for a neurologic (especially seizures), endocrine, or metabolic disorder. Obtain a complete drug history, noting especially the use of phenothiazines. Also, ask about alcohol use.
Assess the patient's overall appearance and demeanor, noting mental status. Test range of motion and strength in all major muscle groups while observing for chorea, athetosis, dystonia, and other involuntary movements. Check deep tendon reflexes and, if possible, observe the patient's gait.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Asterixis [Liver flap, flapping tremor]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
To elicit asterixis, have the patient extend his arms, dorsiflex his wrists, and spread his fingers (or do this for him if necessary). Briefly observe him for asterixis. Alternatively, if the patient has a decreased level of consciousness (LOC) but can follow verbal commands, ask him to squeeze two of your fingers. Consider rapid clutching and unclutching indications of asterixis, or elevate the patient's leg off the bed and dorsiflex the foot. Briefly check for asterixis in the ankle. If the patient can tightly close his eyes and mouth, watch for irregular tremulous movements of the eyelids and corners of the mouth. If he can stick out his tongue, observe the patient for continuous quivering. (See Recognizing asterixis.)
Action stat!
Because asterixis may signal serious metabolic deterioration, quickly evaluate the patient's neurologic status and vital signs. Compare this data with baseline measurements, and watch carefully for acute changes. Continue to closely monitor his neurologic status, vital signs, and urine output.
If the patient has hepatic disease, assess him for early indications of hemorrhage, including restlessness, tachypnea, and cool, moist, pale skin. If the patient is jaundiced, check for pallor in the conjunctiva and mucous membranes of the mouth.
It's important to recognize that hypotension, oliguria, hematemesis, and melena are late signs of hemorrhage. Prepare to insert a large-bore I.V. catheter for fluid and blood replacement. Position the patient flat in bed with his legs elevated 20 degrees. Begin or continue to administer oxygen.
If the patient has renal disease, briefly review the therapy he has received. If he's on dialysis, ask about the frequency of treatments to help gauge the severity of disease. Question a family member if the patient's LOC is significantly decreased.
Then assess the patient for hyperkalemia and metabolic acidosis. Look for tachycardia, nausea, diarrhea, abdominal cramps, muscle weakness, hyperreflexia, and Kussmaul's respirations. Prepare to administer sodium bicarbonate, calcium gluconate, dextrose, insulin, or sodium polystyrene sulfonate.
If the patient has pulmonary disease, check for labored respirations, tachypnea, accessory muscle use, and cyanosis, which are critical signs. Prepare to provide oxygen via nasal cannula, mask, or intubation and mechanical ventilation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
TREMOR AND OTHER INVOLUNTARY MOVEMENTS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of tremor and other involuntary movements involves most of
all a good history. A family history may identify familial tremor. Look for
exposure to lead, manganese, and various drugs. The neurologic examination
is important as it will determine the type of tremor. Rapid fine tremors
(8–20/s) are suggestive of hyperthyroidism and emotional disorders. Coarser
tremors at rest suggest Parkinsonism, whereas a flapping tremor of 4 to 8
per second suggests Wilson disease. The association of other neurologic
signs helps to pin down the diagnosis. Spasms of pain suggest a thalamic
syndrome, ataxia suggests Friedreich ataxia, and loss of memory suggests
manganese toxicity. Laboratory tests will be useful in selected cases. Blood
lead, manganese, copper, and ceruloplasmin levels may be necessary. A
triiodothyronine (T3), thyroxine (T4), and free T4
index will confirm the diagnosis of
Graves disease. Other tests that may be helpful may be found in Appendix A
or listed below.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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