Parkinsonism

Parkinsonism is when there is a triad of bradykinesia, resting tremors and rigidity. There are many causes of parkinsonism. The most commonly seen parkinsonism in the  undergraduate medical final examinations would be Idiopathic Parkinson's disease. 

However, not everyone presenting with Parkinsonism signs have Idiopathic Parkinson's Disease. Therefore students should be wary and mindful about offering the diagnosis of Idiopathic Parkinson's disease upon encountering patients with the above triad. Remember, Idiopathic Parkinson's is a clinical diagnosis and its aetiology is idiopathic i.e. cause is uncertain. Although it is a clinical diagnosis and lab and radiological workup is not required to make the diagnosis, it is also important to consider other differentials causing Parkinsonism signs especially if the patient has risk factors. 

One key feature of Idiopathic Parkinson's Disease is that it is asymmetrical. In the early stages of the disease, parkinsonism can be seen affecting one side of the body. As shown in the video above, this patient has resting tremors affecting his right hand. 

The video below shows bradykinesia affecting the right hand of the same patient. 

As the disease progresses over the years, it may affect the contralateral side of the body as well. However, the key feature remains and Parkinsonism signs would still be asymmetrical. As shown in the next video below, this elderly gentleman has advanced Idiopathic Parkinson's disease as well but take note that the frequency of tremors affecting one arm is different from the other arm. 

Anything that causes damage to the basal ganglia can result in Parkinsonism. For example stroke (vascular), demyelinating diseases, brain tumors, drugs or even metabolic disorders like Wilson's disease. It is good to revise about Parkinsonism as it is a common appearance for the medical examinations. 

CCE. 

 

Chronic Tophaceous Gout

This would be a short case discussion. 

This case is a male patient with multiple joint swellings affecting both upper limbs. The swellings seem to affect the DIPJ, MCPJ as well as wrists. What is also strikingly noticeable is the presence of multiple tophi over the joint swellings. It is not difficult to reach a conclusion of tophaceous gout. 

Tophi are usually found occuring over distal joints or tissues where temperatures are relatively "cooler". This will enable cystallization to occur. This tophi are usually found over distal finger or toe joints, ear pinna. In severe cases, tophi can even be found ocurring almost anywhere on the body as depicted above. 

The next step would be to look for the possible aetiology. Look for psoriatic rashes, polycythemia, hepatosplenomegaly and lymphadenopathies to suggest hematological malignancies.

Then, last but not least, look for complications of the disease itself. Look for sallow coloured skin, dialysis catheters, arteriovenous fistulas to suggest chronic kidney or end stage kidney disease either as a result of obstructive uropathy or chronic NSAID intake for gouty pains. Examine the abdomen for enlarged ballotable kidneys to suggest obstructive uropathy due to urolithiasis. Also look for complications of chronic steroid therapy e.g. Cushing syndrome, hypertension, hyperglycemia (many GP clinics prescribe steroids and NSAIDs to control gouty arthritic pains). 

Remember to apply the triad of diagnosis - aetiology - complications for any case you encounter regardless of short or long case examination. This guide will serve you well and assist you in approaching any case as complete as possible. 

The image above shows central obesity with striation over the anterior abdomen suggesting a Cushingoid appearance. Take note also that there are multiple hyperpigmented scars over the peri-umbilical region suggesting repeated injections likely insulin therapy thus suggesting this patient may have concomitant diabetes mellitus. This will further strengthen the suspicion of Cushing's syndrome. Also notice that there are multiple tophi over the anterior abdominal wall as well. 

Therefore it can be concluded that this patient has been suffering from chronic tophaceous gout for which he has been treated with chronic steroid therapy resulting in secondary Cushing's syndrome. 

Should this case appear for the examinations, the case can be approached from the aspect of gout or can be approached from the aspect of Cushing's syndrome from which the diagnosis of gout is expected to be offered as the underlying main problem. So students should be ready for any possibilities. 

For the long case examination involving a patient with gout, it would be sensible to approach gout from this perspective: 

Gout is due to hyperuricemia.

Hyperuricemia can accumulate due to increased production or decreased clearance. 

For increased production, ask about dietary purine intake, ask about lifestyle (alcohol), ask about cell hemolysis (can be from polycythemia, can be from large solid tumours, can be from hemolytic anemia), ask about tissue damage (burns, surgery, trauma) and last but not least genetic factors (so ask about family history). 

For decreased clearance, ask about dehydration, ask about medications e.g. ACE inhibitors or ARBs or diuretics or aspirin which impedes uric acid excretion and ask about underlying kidney diseases.

Lastly remember to apply the triad of diagnosis - aetiology - complications as well to make your history complete. 

CCE.

Tackling A Case Of Stroke For The Long Case Examination

As an undergraduate, you are highly likely to encounter a case of stroke in the medical examinations either in the long case format or short case format.

Making a diagnosis of stroke is not difficult.

So, how do you suspect a patient has had a stroke?

From history taking, the patient may provide information regarding weakness affecting one side of the body i.e a hemiparesis or a single limb i.e. a monoparesis. The patient may also have cranial nerve involvement, presenting with diplopia, ptosis, facial asymmetry or slurred speech. It is uncommon to get a patient with dysphasia or aphasia for the undergraduate exams as this will impede history taking and physical examination. Nevertheless, you may still encounter a patient with aphasia or dysphasia if there is a shortage of neurological cases for the exams.

The student will be expected to take necessary detailed history pertaining to the right sided hemiparesis e.g. onset of weakness, progression of weakness, and severity. From history taking it is difficult to determine if the patient has had an ischemic stroke or a hemorrhagic stroke. However, in general, if the patient complained of a sudden severe headache preceding or occurring concurrently with the hemiparesis, it is always good to exclude hemorrhagic stroke first. In real life practice, there are many cases of hemorrhagic stroke where the patient presents with just sudden onset of limb weakness without any headaches. The severity of the hemiparesis is not a good indicator to suggest an ischemic event or a hemorrhagic event. There are cases of basal ganglia hypertensive hemorrhages where the patient only has a mild hemiparesis of 3-4/5 whereas there are cases of left middle cerebral artery territory infarctions with dense hemiparesis of 0-1/5.

Once you have decided that the patient has a hemiparesis, you can make a diagnosis of a stroke. If the student has already decided that this presenting complaint is likely due to an ischemic stroke, then a reasonable differential diagnosis would be hemorrhagic stroke. It is also applicable vice versa i.e. if the provisional diagnosis is a hemorrhagic stroke, then the differential would be an ischemic stroke. Only a CT brain can confirm the diagnoses.

Remember to explore other possible differentials as well. Ask about prolonged headaches, constitutional symptoms to suggest a brain tumour. Ask about stepwise deterioration of neurology e.g. history of facial asymmetry 10 years ago, then history of numbness affecting left leg 7 years ago, then history of bladder incontinence 3 years ago etc. This may suggest a possibility of a demyelinating condition such as multiple sclerosis. Also ask about recent head injury or trauma which may suggest a intracranial hemorrhage causing the stroke like symptoms. And also ask about fever, rashes, photophobia, neck stiffness or altered behaviour to suggest intracranial infection e.g. meningitis or cerebral abscess.

Once the student has established the diagnosis and its differentials, the next step should be to explore the aetiology. From history, ask about risk factors for the stroke i.e. hypertension and its BP control, diabetes and its glycemic control, dyslipidemia and its lipid control, history of ischemic heart disease, history of cigarette smoking or chronic alcohol consumption/ abuse, connective tissue disorders (especially if the patient is young, explore regarding anti phospholipid syndrome), medication history (compliance to medications as well as whether patient is on anti-platelet therapy or anti-coagulation therapy) and history of head injury. It is also good to get a detailed family history regarding cardiovascular risk factors as conditions like diabetes, dyslipidemia, hypertension may run in families. Also explore regarding dietary habits – fast food, oily food, high salt diet, lots of processed foods etc. These aetiologies are supporting a diagnosis of ischemic/ hemorrhagic stroke. Remember to get history regarding aetiologies for the other differentials too if relevant to your patient. 

Next step would be to explore complications that may arise from the stroke. Ask about headaches, blurred vision which could indicate raised intracranial pressure. Also ask about fever, cough, dyspnoea and choking episode to suggest that the patient may have aspirated. Ask about seizures as post stroke patients have tendency for seizures. Ask about falls and physical injuries due to the physical limitations as a result of the stroke. Ask about cognitive impairment or change in consciousness (very unlikely to get a demented or delirious or confused patient in the exam setting!).

Last but not least, explore about the patients social history in more detail than usual. As stroke affects the patient’s life very significantly, it is also good to know the patient’s baseline functionality e.g. right or left handedness, occupation, breadwinner or not, living at home with whom, hobbies, staying in what sort of house (single storey versus multi storey and whether there is lift facility). All this will give a rough idea on how the stroke may impact the patient’s life once he is discharged from the hospital. The information obtained will help you plan for long term management. For example if the patient is the sole breadwinner of his family and he is no longer able to work, then you may offer referral to social welfare for assistance. Another example would be if the patient is right hand dominant and is a typist and loves to play tennis using his right hand and he just suffered a stroke with right hemiparesis, then he will benefit from occupation therapist referral to get him to adapt and learn to adjust using his left hand while awaiting right hand to recover with rehab (if at all possible). 

Once the above mentioned has been settled, the student should go on to complete the other components of history taking to ensure a complete history is taken e.g. drug history, allergy history, surgical history, etc.

For physical examination (from head to toe), 

Head:

Examine the Glasgow Coma Scale (GCS) and also orientation to time, place, person. Look for cranial neuropathy if it is suggestive from the history taking. Example, if the patient complained of facial asymmetry and slurred speech, then it is probably worth examining the facial nerve and the cranial nerves 9,10,12 properly. If upon general inspection there is eye deviation or ptosis, then a proper examination of the cranial nerves 3,4 and 6 is warranted. Otherwise it is unnecessary to do a FULL cranial nerve examination. Time is the limiting factor here! If the student managed to complete history taking within a short time frame, then perhaps when there is ample time, the student may still do a concise but full cranial nerve examination (The olfactory nerve is probably the least examined cranial nerve as it rarely appears for exams. So be smart when choosing which cranial nerve to examine). Look for risk factors for stroke: xanthelasma, arcus senilis, acanthosis nigricans (darkening and velvety like skin over the neck and flexure area). Also assess speech and nystagmus if history suggests cerebellar involvement. 

UL:

Finger prick marks for diabetes mellitus. Nicotine stain over the finger nails. Tendon xanthomas. Upper motor neuron (UMN) signs affecting the weak arm: hypertonia, hyperreflexia. And also quantify the weakness using the MRC scale 0-5. Also check sensory deficits. Remember to check cerebellar signs as well if not yet done as part of the CN assessment. Important to check the blood pressure using sphygmomanometer as well. 

LL: 

Check for UMN signs affecting the weak leg: hypertonia, hyperreflexia, clonus, upgoing Babinski response. Quantify the weakness using MRC scale. And check for sensory deficits. Cerebellar assessment is also important if not yet done for UL or CN assessment. However if while assessing CN and UL and no cerebellar signs were detected, then it is not necessary to do cerebellar assessment for LL. Last but not least, ask the patient to walk to assess gait (do this only if the patient is able to walk. Do not cause a fall which may injure the patient). 

CCE.

Diabetes Mellitus - How to Approach a Patient with Diabetes Mellitus in the Long Case Examination (Physical Examination)

Once you have completed the history taking, you will know which system to examine more thoroughly i.e. the system that correlates with the primary or chief complaint. For example, if the chief complaint was numbness in the feet, then a thorough examination of the lower limbs would be the next logical step. 

For the purpose of this blog, I'll list out the things required for examination in general. You may tailor the examination requirement based on the patient you've clerked in the exam. 

General Examination:

1. GCS - always good to assess this. An alternative is the orientation to time/ place/ person assessment. The patient's mental state is an important first assessment for a diabetic patient as such patients are prone to cerebral ischemia, neuroglycopenia, hyperglycemic complications e.g. HHS and even vascular-related neurocognitive impairments. 

2. If the patient has trouble remembering many facts during history taking, you may want to offer to do a Mini Mental State Examination (MMSE) at the end of the presentation to identify presence of and severity of cognitive impairment or dementia at the end of the patient's examination (however, this will not be possible in the real exam setting due to time constraints). 

3. General appearance - Acromegaly, Cushingoid, thyrotoxicosis as these conditions may predispose to development of DM or aggravate DM control. Also look out for skin changes e.g. pallor or sallow coloured skin to suggest presence of chronic kidney disease and rashes that may suggest presence of connective tissue disorders e.g. systemic lupus, psoriasis, systemic sclerosis etc. Do take note of the peripheral joints as well especially the fingers, toes and ankle regions for any deformities to suggest a chronic inflammatory arthropathy or gout. The earlier mentioned conditions may all be treated with steroids for a prolonged period of time resulting in hyperglycemia or steroid induced diabetes mellitus.

4. Accessories - intravenous drips, insulin syringe pumps, intravenous antibiotics, oxygen support, orthoses (ankle splints for foot drop or limb prosthesis), customised shoes for Charcot foot or walking aids. Also improtant to take note of presence of arteriovenous fistulas and dialysis catheters (internal jugular or femoral dialysisc atheters)

5. Eyes - at least a visual acuity assessment using a portable modified Snellen's chart and RAPD assessment for any retinal or optic disc abnormality. If there is RAPD detected, then the next assessment would be funduscopy for diabetic retinopathy if time permits.

6. CVS - look for displaced apex with murmurs, raised JVP and bibasal crepitations to indicate heart failure (coronary artery disase is a complication of long standing and uncontrolled DM)

7. Respi - examination of this system should be selective. Look briefly for evidence of fluid overload e.g. basal crepitations to suggest pulmonary oedema or stony dullness percussion note with reduced vocal resonance to suggest pleural effusion. 

8. Peripheral pulses especially the distal pulses e.g. dorsalis pedis,/ posterior tibialis pulses. This would be more relevant if the patient reports claudication pain during history taking. Auscultation of the carotid arteries for any bruit to indicate stenosis is also important if time permits. Do take note that uncontrolled diabetes mellitus may accelerate atherosclerosis changes along major arteries. 

9. Neurological examination - particularly the lower limbs. You may limit the neurological examination to information obtained during history taking. For example if the patient reports that he has history of right sided leg weakness, then perhaps it is sufficient to focus your neurological examination to the lower limbs only, while briefly screen through neurological examination of the upper limbs and cranial nerves. Conducting a full neurological examination as a routine assessment during long case examination can be challenging due to time constraints. The earliest sign of diabetic peripheral neuropathy is loss of vibration sense and loss of proprioception in the distal joints e.g. interphalangeal joints in the toes. Also look out for diabetic foot ulcers, calluses over bony prominences and trophic changes affecting the skin over the lower limbs which may strongly suggest presence of peripheral neuropathy. 

10. Abdominal examination - look for signs of lipohypertrophy or lipoatrophy to suggest repeated insulin injections. This can usually be found at the periumbilical region. If found, it would be important to highlight this finding during the case presentation as it will impact treatment outcome. Patients that fail to rotate the insulin injection sites adequately will have the above changes occurring and this will impair optimal insulin absorption and affect adequacy of glucose control. Look for Tenchoff catheters over the anterior abdominal wall to suggest patient has ESRF and is undergoing CAPD. Also look renal transplantation scars to suggest a history of diabetic kidney disease (renal transplant scars are usually J shaped and located at either right iliac fossa or left iliac fossa regions). It is also possible that immunosuppressive therapy post organ transplant be the aetiology for diabetes mellitus in such a patient. Do consider palpating the abdomen for an abdominal aortic aneurysm as well. 

11. Lastly, do steal some time to screen the patient's body for any cutaneous infections like carbuncles, furuncles. Look also for tinea infections affecting the skin flexures e.g. axillary, infra-mammary, groin area. In uncontrolled diabetics, skin infections may be extensive. 

CCE