Clinical Case Study

Case 6 = 67 year old female with stiffness and tremor

Which, if any, of the symptoms or examination findings can be attributed to the normal aging process and why do you think that it is a possibility?

The joint stiffness/rigidity could be attributed to the normal aging process due to changes in the muscle cells and/or the joints. These changes may also contribute to the shuffling feet.

Muscle cells – The sarcomeres within the myofibrils are decreased, causing the muscle cells affected to shorten and reduces the distance of their movement, causing stiffness.

Joints – The increase of fibrous material in the synovial membrane may cause cartilage to form, making the membrane stiffer and less elastic. The membrane is also less able to produce and remove synovial fluid due to the loss of some blood vessels. Additionally, the joint capsule and ligaments become shorter, stiffer, and less able to stretch due to an increased formation of cross-links in the fibers.

What is the most likely diagnosis for this case and provide your rationale for picking that diagnosis? (Note: there can be more than 1 viable option for the case as long as the student can justify their choice).

The symptoms and exam findings point pretty easily to Parkinson’s disease. While tremors are usually linked to getting older, there are no specific physiological changes that are strictly age-related. It’s the specific nature of the tremor that leads me to this diagnosis (alongside the fact that she is not on any medication that could cause tremors) – the “pill rolling” motion, the pronounced presence when at rest, and disappearance when it is “given” a task (voluntary movement). The muscle stiffness, difficulty moving, shuffling feet, and diminished facial expressions are further signs of the disease’s progress. The depression others have noticed is also a regularly noted psychological effect of the disease.

Which special studies {blood tests, urinalysis, different imaging techniques} will confirm your diagnosis and why?

There are currently no standard diagnostic tests to diagnose PD. It is typically diagnosed based on medical history as well as a thorough neurological exam, to include the Unified Parkinson’s Disease Rating Scale (UPDRS). I could order a CT scan or MRI to rule out a stroke or tumor. A PET could possibly determine if there is a low level of dopamine (which would cause the tremors), but is experimental. There is also new progress in DaTscan™, an imaging scan that, using a radioactive drug, can determine dopamine levels as a way to confirm suspected diagnoses. As it is in its early stages, there is no long-term data for comparison to other imaging results. In this client’s case, since the symptoms seem to be in the more severe stage of PD, I’d strongly recommend a trial test of levodopa to boost dopamine production.

How do you think this patient should be managed (treated) and by whom (what type of provider {ex: neurologist, rheumatologist, cardiologist, acupuncturist, chiropractor, etc.})?

Parkinson’s treatment should be led by a neurologist. They would be able to best monitor the levodopa dosages as well