Parkinson's Disease Examination

- Festinating gait (slow and shuffling movements when walking)
- Decreased arm swing
- Difficulty turning and initiating movements (patients may use a walking stick to 'poke' their feet to get them to move). Lines or markings on the floor can sometimes help.
- Stooping posture

- Postural instability

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Inspection

Look for:

- Hypomimia (decreased facial expression)
- Blepharoclonus (fine eyelid tremor)
- Resting tremor (brought out by distraction - such as conversation)
- Tardive dyskinesia (chewing movements of the mouth - drug treatment side effect)

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Face

Look for:

- glabellar tap (keep blinking - normally adjust)
- normal eye movements but abnormal vertical gaze + VOR
(in supranuclear palsy) - speech ? monotonous voice

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Trunk

Test:

- Axial rigidity (found in the 'supranuclear palsy' form of Parkinson's disease)

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Arms

Look and test for:

- Tremor ('pill rolling', more pronounced at rest - as opposed to cerebellar tremors that are more pronounced upon initiation of movement)
- Normal muscle bulk / reflexes / power
- Increased tone - leadpipe rigidity (move whole arm around elbow joint) & cog-wheel rigidity (support forearm and flex/extend the flat palm at the wrist - cogwheeling is the jerky 'stepwise' movement that is felt due to tremor superimposed upon rigidity) ? these features are enhanced by asking the patient to move the other arm up and down as a 'distractor' or 'reinforcer'
- Bradykinesia (slowness of movement - observed when patient is asked to flap arms up and down)
- Finger-nose pointing (tremor decreases)

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Extras

For a few bonus points, you can test/mention the following:

- Micrographia (small writing)
- Examine the observations chart for a postural BP drop (in the 'multisystem atrophy' form of Parkinson's)
- Examine the drug chart (is this perhaps a drug-induced 'Parkinsonism' - caused by anti-dopaminergic drugs such as metoclopromide)
- Examine the cerebellar system's function (also affected in 'multisystem atrophy')

To complete: Thank the patient.

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