Listen to the patient: He is teaching the students

“Sure thing. Teaching at 2:45pm, I’ll find an interesting case.”

It was 2:10pm by the time I finished clerking a new arrival and I still needed to have lunch. How was I going to find a case and prepare for it?

I then remembered a patient I had seen earlier on a ward round. He was an elective admission for an angio of the right leg because of 3 weeks of worsening claudication. He had no accompanying medical notes at the time. I had to clerk him fully, which turned out to be a blessing for the medical students.

The patient turned out to have some incredible, rare conditions. Each condition deserves a separate blog post, so for now I’d like to focus on his Parkinson’s disease for 5 years, managed on co-beneldopa and entacapone.

I initially planned to go through a Parkinson’s examination with the students in an OSCE format. Most of medical education on Parkinson’s makes it seem like this exotic disease with unique signs that you must exhibit, nod sagely as you demonstrate them before moving straight into a discussion with the examiner about the complications of long term levodopa. Unless we are working in neurology or care of the elderly, maybe its hard to appreciate what a day in the life of a patient with significant parkinsonism entails. I wanted to find out.

“How does the Parkinson’s affect you?”

“Well I can’t sign cheques for the business anymore, that’s for the missus now.”

Micrographia must be horrible. Hearing it from people unable to do their normal business as a result made me appreciate the significance of this. Imagine having a great idea and being unable to jot it down. I could really sense some of the frustration when I read about it in these forum posts.

“And I had this episode where I was walking along, and got completely stuck. I was there for a few minutes. It was weird. In my head I kept telling myself to move but I just wouldn’t. You feel like something’s very wrong and you wonder what you’ve done to cause it.”

The patient was describing the freezing phenomenon. Classically, the feet are rooted to the ground but everything above the waist works just as normal. You could even make a cup of tea if the table were close enough. The Parkinson’s UK guide for patients on freezing is so helpful. I remember being taught that patients with Parkinson’s may freeze when they get to an obstacle e.g. a narrow doorway but could follow a tape across the same obstacle. The principle is that in Parkinson’s, there seems to be a problem synchronising all the complex movements we have subconsciously mastered since we learnt to walk. Anything that stresses the mind or adds to the challenge of walking can leave a patient with Parkinson’s unable to just walk. However, if you can break up the task of walking into a sequence of smaller goals, this seems to get around the problem.

I had always thought that the reason people fall in Parkinson’s disease was because of a loss of postural reflexes and the gait disturbances. It seems it’s a multifactorial and sadly synergistic cocktail of problems, of which the freezing phenomenon is quite important. Again, the patient information leaflet on why people fall in Parkinson’s is a great read, and complements the freezing leaflet.

“The doctor told me to use the smallest dose of levodopa to make it last longer. I wish I could take more, but I know it’s for the best. It sorts everything out in about 30 minutes.”

It must be a daily struggle requiring a little bit of Zen to choose to not give yourself a medication that you know can take away the symptoms so effectively.

“What was the first symptom you noticed?”

“I had drooling right from the beginning.”

A recent paper suggests that the non-motor symptoms of Parkinson’s disease may predate the motor symptoms by years. In particular, “excess saliva, forgetfulness, urinary urgency, hyposmia, and constipation” are potential early symptoms. Drooling occurs in about half of all patients with PD.

I sense there may be a shift from seeing Parkinson’s disease as an isolated lesion of the dopamingeric neurons in the substantia nigra affecting extrapyramidal movements to a more holistic view of a neurological disease with a wide range of clinical manifestations. The non-motor questionnaire helps draw attention to these symptoms.

Medical students and MRCP candidates will probably have to churn out a Parkinson’s examination at some stage. I’ve made 3 things for this:

  1. A Parkinson’s OSCE/PACES examination crib sheet.
  2. A video of the patient’s tremor (with consent of course)
  3. A podcast on the management of Parkinson’s disease, designed to nullify any attempted grilling from your examiner

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