Parkinson (BST & CBD 5)

Arihta Johana Wulandari Ginting

1215172
Preceptor : dr. Yenni Limyati, Sp.KFR
 General Information

Name : Mr. MH
Sex : Male
Age : 66 years old
Address : Bandung
Occupation : Enterpreneur
Marital Status : Married
Religion : Islam
Date of examination : May, 25th 2016
 Anamnesis
Autoanamnesis
Chief Complaint : Shakes in the Hand
Spesific History :
Patient presented Shakes in the Hand since 3 months ago. The shakes felt when
he is in relaxed position. His handwriting has become messy, small and difficult to
read. Patient said that complaints has worsened over these 3 months. even the
foot tends to have the shakes. Patient said he felt more rigid to walking and
standing, like short or shuffling steps but still have a balance. Sometimes, patient
feel hard and slow to make a movement or do a fast action.
Patient do not fall or have a head injury. Patient did not feel memory loss,
decreasing in cognition function, any kind usages of antidepression & antianxiety
drugs, any others guilty feeling, lack in motivation or insomnia
Past medical history : no similar experience, hipertention, DM, or history of trauma .
Family medical history : no particular history
Treatment : no history
Allergies : no history
 Physical Examination
Vital Sign
Heart rate : 88x/minute
Respiration rate : 22
x/minute
Blood pressure : 130/80
mmHg
Temperature : 37,1 C

Nutritional
Weight : 61 kg
Height : 168 cm
BMI : 21.61 kg/m2 (normal)
GENERAL EXAMINATION

Conciousness : Compos Mentis

Head : within normal limits
Neck : within normal limits
Thorax : within normal limits
Abdomen : within normal limits
Extremity : within normal limits
Blood vessel : within normal limits
Neurological Examination

Appearance :
Head : normal size and shape
Collumna vertebralis : skoliosis -, kifosis -,
lordosis -, gibus -
Meningeal signs :
Nuchal rigidity :-
Brudzinsky I :-
Brudzinsky II :-
Brudzinsky III :-
Kernig : -
Laseque : -
 Cranial Nerves

N I : normosmia NV:
N II :
Visual acuity : good Sensory of
Confrontation : good ophtalmic : +/+
Funduscopy : not
performed maxillary : +/+
N III/IV/VI
Ptosis : - mandibular : +/+
Pupil : round, isochors,
d=3 mm Motoric : good
Light reflex : D +/+, I +/+
Eye orientation : central
Eye movements : good,
nystagmus
 N VII :
Eyebrow movement :
symmetrical
Eye closure : symmetrical

Nasolabial plica : symmetrical

Facial movement : symmetric,

masked face (+)
2/3 anterior tasting : not
performed

N VIII :
Hearing : good
Balance : not performed
N IX/X :
Voice : dysphonia -
Swallowing : dysphagia -
Pharyngeal arched : symmetrical
Uvula : central N XII :
Palatal contraction : symmetrical No tongue deviation
Pharyngeal Reflex : not performed Atrophy : -
1/3 posterior tasting : not Fasiculations : -
performed

N XI :
Shoulder lift : symmetrical
Left and right head movements :
within normal limits
Motoric
Upper Extremities : 5/5
Lower extremities: 5/5
Normotone, atrophy , fasiculation
Involuntary movement : resting tremor (+/+)
Gait : March a petite pas (-) Propulsi (-)
Retropulsi (-) Lateropulsi (-)
Sensory
Upper limbs : within normal limit
Trunk : within normal limit
Lower limbs : +/+

Coordination test
not performed
Physiological relfexes :
Biceps : +/+ Pathological relfexes
Triceps : +/+ Hofman trommer : -/-
Babinsky : -/-
Radius : +/+
Chaddock : -/-
Ulna : +/+ Oppenheim : -/-
KPR: +/+ Gordon : -/-
Schaeffer : -/-
APR:+/+
Epigastric : not performed
Clonus : -
Mesogastric : not performed
Hypogastric : not performed Primitive relfexes
Chremaster : not performed Glabella : -
Snout : -
Palmo mental : -
Cognitive Examination

Psychological connection :
good
Aphasia :
Motoric : -
Sensory: -
Memory :
Short memory term : good
Long memory term : good
Calculation ability : good
 Resume
A Man, 66 years old, presented bilateral hand tremor since 3 months
ago. Resting Tremor (+), micrographia (+). Patient said that complaints
has worsened over these 3 months. even the foot tends to have the
shakes. Rigidity (+) Postural Reflexes still good. Bradikinesia (+)
Patient do not fall or have a head injury. Patient did not feel memory
loss, decreasing in cognition function, any kind usages of antidepression
& antianxiety drugs, any others guilty feeling, lack in motivation or
insomnia
Past medical history : no similar experience, hipertention, DM, or history of trauma ..
Family medical history : no particular history
Treatment : no history
Allergies : no history
 Physical Examination

Vital Sign
Heart rate : 88x/minute
Respiration rate : 22 x/minute
Blood pressure : 130/80 mmHg
Temperature : 37,1 C
Nutritional
BMI : 21.61 kg/m2 (normal)
General Examination :
Within normal limits
 Neurological Examination

Meningeal signs : (-)

Cranial nerves : N.VII (masked face (+))
Motoric :
Involuntary movement : resting tremor (+/+)
Gait : March a petite pas (-) Propulsi (-) Retropulsi (-)
Lateropulsi (-)
Sensory : within normal limit
Coordination: not performed
Physiological relfexes : +/+
Pathological relfexes : -/-
Cognitive test : good
 Status fungsional (ADL Barthel)
I: Sebelum sakit; II: Saat MRS; III: Minggu I perawatan; IV: Minggu II
perawatan

Jenis kegiatan I II III IV

Mengendalikan rangsang pembuangan tinja 2 2
Mengendalikan rangsang berkemih 2 2
Membersihkan diri 1 1
Menggunakan jamban 2 2 Nilai ADL :
20 = mandiri
Makan 2 2
12-19 =
Berubah sikap dari berbaring ke duduk 3 3 Ketergantungan
Berpindah/berjalan 3 3 ringan
Memakai baju 2 2 9-11 =
Naik turun tangga 2 2 Ketergantungan
sedang
Mandi 1 1
5-8 =
Total 20 20 Ketergantungan
(man (mandi
diri) ri) berat
0-4 =
Ketergantungan
MINI MENTAL STATE EXAMINATION (MMSE) Max Nilai
Sekarang hari, tanggal, bulan, musim, tahun apa? 5 5
Kita berada dimana? Negara, provinsi, RS, lantai/kamar 5 5
Sebutkan tiga objek : tiap 1 detik pasien disuruh mengulangi (bola, 3 3
kursi, sepatu)
Pengurangan 100 dengan 7 (hentikan setelah lima jawaban) 5 5
93,86,79,72,65
Responden disuruh menyebut kembali ketiga nama objek diatas tadi 3 3
Responden disuruh menyebut pensil, buku 2 2
Responden disuruh mengulang kata namun, tanpa, bila 1 1
Responden disuruh melakukan perintah : ambil kertas itu dengan 3 3
tangan anda, lipatlah menjadi dua bagian dan letakkan di lantai

Responden disuruh membaca kalimat kemudian melakukan perintah 1 1

kalimat pejamkan mata
Responden disuruh menulis dengan spontan 1 1
Responden disuruh menggambar bentuk di bawah ini 1 1
Jumlah 30 30
 Diagnosis

Clinic : Parkinson Syndrome (stage II)

Location : Bilateral Tremor
Ethiology : Idiopathic
DD : Essential Tremor
Drug Induced Tremor
 Functional Diagnosis

Disease : Parkinson
Impairment : -
Body structure : -
Body functional : bilateral hand tremor,
masked face
Activity limitation : rigidity and bradikinesia,
postural reflexes still good.
Participation restriction : -
Enviromental factor : -
Personal factor : -
 Management

Non pharmalogical :
- education
- medical rehabilitation

Pharmalogical :
Madopar dispersible tablet 125 mg 3x1 tab
(combination levodopa and carbidopa)
Antikolinergik : Trihexyphenidil 2mg (2x1/2 tab)
 Physical or Remedial Therapy
Six domains are distinguished:
1. transfers (e.g. standing up from a chair and rolling out of bed)
2. body posture
3. reaching and gripping
4. balance
5. walking
6. physical capacity (i.e. muscular strength, joint mobility, general condition)

Recommendation :
1) the use of cueing strategies to improve walking; 2) cognitive movement
strategies to improve the performance of transfers; 3) specific exercises to
improve balance;4) training joint mobility and strength (to improve physical
capacity).
 disease progression

This is divided into three phases:

In the early phase (Hoehn & Yahr 1-2.5), the aim is to prevent
inactivity, fear of moving and fear of falling and to maintain
and/or improve stamina.
In the middle phase (Hoehn & Yahr 2-4) is to maintain or
encourage activities in the aforementioned domains. It is
particularly in this phase that cooperation with an
occupational therapist can be indicated.
In the late phase (Hoehn & Yahr 5) is to maintain vital
functions and prevent complications, such as pressure sores
and contractures.
 Speech and Language therapy

In Parkinsons disease, the speech and language

pathologist focuses on three domains:
1) speech problems (dysarthria and
communicative blocks),
2) oropharyngeal swallowing disorders and
3) loss of saliva, and the limitations and
participation problems which can result from
this.
The aim of the dysarthria is to improve intelligibility
and the communication.
Lee Silverman Voice Treatment (LSVT), do three to
four times a week in four weeksf : increasing the
loudness of the voice, which simultaneously
activates breathing, voice quality and articulation,
making the patient easier to understand.
(Pitch Limiting Voice Treatment, or PLVT) : Speak in
a lower pitch in order to prevent the voice going
higher when talking louder , feel more relaxed &
improved voicing
 Medical Rehabilitation

Flexibility/stretching and strengthening exercises

Fitness (aerobic) activities
Strategies to improve mobility: walking, freezing,
standing up from chairs, reduce risk of falls
Strategies to improve self-care activities
Handwriting
Stress management
Instruction in cognitive strategies
Speech training in swallowing as well as rate, control,
respiration and phonation
Prognosis
Ad vitam : ad bonam
Ad fungsionam : dubia ad bonam
Ad sanationam : dubia ad malam
Appendices