Polly Cystic
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You are the F2 on your GP placement. You have been asked to see Polly, a 67 year old lady who has started to feel like she is walking more slowly. Please take a focussed history of the patient’s presenting complaint and perform a relevant examination.
You are Polly, a 67 year old lady who has reluctantly come to see her GP because you think your walking has become slower.
HPC: You feel like you have been “slowing down” over the past year. You can’t keep up with your friends when you’re walking any more, and you get very tired when you’re walking your cocker spaniel Cookie. Your husband has noticed that you are slower about the house too. You do feel stiff in your joints, especially in your left hand, which is bothersome as you are left handed. If asked: - No, you have not noticed a tremor - Yes, your handwriting has got smaller, you think because your hand feels stiff. - Yes, you think you can’t smell things like you used to. - Yes, you’ve been having vivid dreams. Your husband says you’ve been moving around a lot in your sleep. - Yes, you’ve been feeling a bit down recently, but we’ve had rubbish weather. You are not convinced that you are depressed - Yes, you did fall about 3 weeks ago when out shopping with your daughter. You did not hurt yourself / hit your head / lose consciousness or any other questions asked. As far as you are concerned it was a simple trip, probably over something on the floor you did not see. PMH: You were diagnosed with COPD 5 years ago, and had a peptic ulcer 10 years ago. Medications: You take omeprazole once daily, one of the “brown inhalers” twice a day, and have a salbutamol inhaler for when you need it, but you rarely need to use it and haven’t used it all in the last few months. FH: Your mother died of a heart attack when she was 72. Your father died of prostate cancer at 85. Your eldest brother has osteoarthritis. SH: You live at home with your husband in a 3 bed house. Your daughter lives nearby, and your son lives in London. You are originally from Jamaica, having moved to the UK 20 years ago. You don’t smoke now, but used to for 5 years in your 20s. You drink a few glasses of wine a week. You feel guilty that you should do more exercise, but as your coordination has got worse, you avoid the gym as you think people are staring at you. ICE: You wonder if this is osteoarthritis, like your brother has. He started to slow down and get stiff joints too. You’re worried that without this you might lose your independence, which you’re very scared of, and that people may judge you.
This potentially a challenging scenario as there are multiple lines of questioning to explore. A good candidate will establish whether the patient has any symptoms of Parkinson’s disease, and upon hearing stiff joints will screen for inflammatory symptoms. Candidates could perform neurological or joint examination. Gait should be included. The positive findings are increased tone in the limbs, but no tremor; micrographia (if tested); a slightly stooped posture and shuffling gait, with difficulty turning corners. Students should identify the common and the more concerning differentials. These should include Parkinson’s disease and arthritis, as above. Questions you may wish to ask could include: • How would you differentiate between osteoarthritis and rheumatoid arthritis? • What symptoms of Parkinson’s are present in this case? • What are some subtypes of Parkinson’s and how can you differentiate them clinically? (e.g. PSP, MSA, vascular aspect) • If you were to be suspicious of Parkinson’s disease, how would you investigate and manage this patient?
