Chapter 69: Parkinson Disease: Slow and Shaky Level III

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Recognize motor and nonmotor symptoms of Parkinson disease (PD).

• Develop an optimal pharmacotherapeutic plan for a patient with PD progressing through different stages of the disease.

• Recommend alternative therapy for a patient experiencing adverse drug effects, drug–drug interactions, and drug–food interactions.

• Educate patients with PD about the disease, pharmacotherapeutic options, and nonpharmacologic treatments.

PATIENT PRESENTATION

Chief Complaint

“My work performance has declined because my tremor makes it difficult to type on the computer, and I am slower with most tasks.”

HPI

Lori Tanner is a 63-year-old, right-handed woman who presents to the neurology clinic because of a mild tremor in her right hand that has worsened over the past 6 months. It takes her longer to do things because it takes a little more effort to get movement started, and her muscles feel a little stiff. She also admits to difficulty falling asleep but has no issues staying asleep. The stiffness, slowness, tremor, and sleep problems have affected her job performance as a graphic designer, resulting in her contemplating early retirement. She also complains of constipation, depressed mood, lack of pleasure in her usual activities, and loss of sense of smell for about 2 years. Due to complaints of acid reflux, she is currently receiving treatment for it.

PMH

GERD × 1 month

Broken left wrist after fall 1 year ago

FH

Mother died at age 89 of complications associated with a hip fracture, osteoporosis, and Alzheimer disease (clinical diagnosis without postmortem confirmation); father died from an ischemic stroke at age 58; two daughters are in good health.

SH

(–) Alcohol, (–) tobacco, married for 23 years

ROS

No complaints other than those noted in the HPI. She denies any other symptoms of autonomic dysfunction such as problems with swallowing, urination, drooling, or dizziness. She admits to occasional crying spells and low mood but denies panic attacks, hallucinations, vivid dreams, and paranoia.

Meds

Pantoprazole 40 mg PO once daily 30 minutes before meals

Calcium carbonate 600 mg PO every morning and night

All

None

Physical Examination

Gen

The patient is a Caucasian woman who appears older than stated age.

VS

BP 118/74 mm Hg sitting, 116/70 mm Hg standing, P 70 bpm, RR 13; T 36.8°C; Wt 53 kg, ...