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The Parkinson's Exam General Inspection The lack of facial expression leads to a mask-like facies, hypomimia. They may drool and the tremor may be very obvious. In true idiopathic Parkinson's Disease the findings are almost always asymmetrical. Watch throughout for the restless movements of akithisia. Are there any mobility aids?
Gait The posture is characteristically flexed, fixed as a forwards stoop, and there are few spontaneous movements (hypokinesia). They may have difficulty initiating the standing up movement at the beginning of the exam and have an unstable posture. Watch for freezing and hesitation of initiating movements during the next stages.
Ask the patient to walk, turn quickly, stop and restart. They may turn 'en bloc'. Bradykinesia - it will take them a long, slow time for each movement, unless they are festinating. Shuffling gait - small steps with feet hardly lifted from the ground. Often difficulty in initiating the movement. Festination - once the movement is initiated the patient hurries and has difficulty stopping, looking like he might fall over at the end, trying to catch up with his centre of gravity No normal arm swinging (akinesia) Still standing - test propulsion and retropulsion if it is safe to do so. This is the same theory as the 'pull test': a gentle tug towards you demonstrating an inability to catch balance and the need for several steps forwards. Propulsion is pushing from behind, retropulsion from in front. They may fall over. Kinesia paradoxica - the striking phenomenon of being able to initiate movement upon an external cue, of something that they could not previously do. These are often rapid movements and they cannot do slow ones. E.g. they may run down the stairs or start to ride a bike, even though they can only walk with difficulty. When they start to run down the stairs they may not be able to stop in time.
Back on the couch. Face: titubation (nodding of the head) is a type of tremor. Mouth hypokinesia may be seen as drooling. There may be an absence of blinking or slow blinking. Hypomimia. Test the glabellar tap. Tap over the middle of the forehead in a non-threatening way. The sign is positive if the patient continues to blink as long as there are taps. Normal people stop after a few taps. Assess speech: monotonic and hypotonic speech = one tone, quiet, hoarse, and lacks intonation. Sometimes palilalia is present: repeating at the end of a word. Speech may also have a rapid festinating pattern. There may be dysarthria.
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