As discussed in the first article in this three series, neurologists faced with potential Parkinson's patients are not being scanned, do not have blood tests, or are based on the diagnosis of the spinal cord There is no definitive inspection, such as a faucet. Parkinson's disease is what is called "clinical diagnosis". This means that a decision on whether or not the patient really suffers from Parkinson's disease requires a strong face to interact with a neurologist. The meeting usually requires a thorough historical perspective, an interview and a comprehensive physical examination. Videography and other aids are used very frequently, but the diagnosis is completely dependent on neurologist clinical insight by investigating what the patient presents in the language and examination.
To summarize this approach very briefly, while interviewing and examining a patient, the neurologist creates a viable and feasible list in the head. This list, Differential diagnosis, It is often said that "I do not know well". It is very similar to a good detective and is a neurologist who is adjusting the differentiation as if it were a list of problems. Redirect the line of questions and the focus of physical examination is based on allegations of judgment and denial.
Each of these findings helps the neurologist to continually reconfigure the differences and change their priorities. Since the list is confined to a few possibilities, we ask further questions and refine the exam. Thereafter, the patient is sent for an examination that may eliminate other possibilities. For example, the patient obtains brain CT or MRI without diagnosing Parkinson's disease, but eliminates larger structural causes that can mimic Parkinson's syndrome such as brain tumor or multiple sclerosis. Frequently, measurement of the electrical stimulation and the neural response of the affected limb called EMG (electromyogram) is done to eliminate local nerve damage as another cause.
If everything points to Parkinson's disease, the patient undergoes a test of a drug that duplicates or mimics dopamine. If the patient shows improvement, everyone can be pretty sure of it. Parkinson's disease
The point is that there is no single protocol or textbook path to conduct a diagnosis. The neurologist has a formal structure covering all so - called bases, but the details of that path depend heavily on the discovery on the way to the next step in the structure.
Early parkinsonism is presented differently to all patients and is often easily resolved as a mild one such as small persistent convulsions, drowsiness, minor tremor and even depression or anxiety attacks, It can be difficult.
A typical story asked if anyone had experienced is that one or two of the ten general early warning symptoms (part 1) are tracing a pinky finger at the neurologist's first visit (Case of Michael J. Fox), or on their own new sunset depression, they are dismissed or treated symptomatically. I was administered antidepressant medicine, and when trembling occurred it was dismissed as a side effect of the antidepressant. It was not until I was overly difficult to write, both completely from the severe slowdown of my right hand, and I was completely trained to play the piano entirely impossible.
Neither myself nor Mr. Fox never made a mistake nor missed something important in either case. For example, any one or two of 10 warning signs may be interpreted by other causes, which is usually the case.
Review of early symptoms:
- Tremor or big run out on one side
- Small handwriting
- Loss of smell
- can not sleep
- Trouble / stiffness of movement and walking
- constipation
- Soft voice or low voice
- Loss of expression, "masked face"
- Dizziness and syncope
- Stop and hit
I added two to this list:
- EDS (excessive daytime sleepiness) or fatigue
- New onset psychiatric disorder (usually depression or anxiety attack)
PD is suspected, it is necessary to exclude it taking into consideration many other diseases and symptoms. That is the place that contains the so-called "differential diagnosis" list. Each difference list is somewhat different depending on what the patient presents to the neurologist and is specialized in neurology. These lists may be quite large initially. To exclude all other causes of the list before the PD reaches the top, you need practical knowledge about each list item and its diagnostic method.
Although other laboratory tests and scans are used to exclude other causes, Parkinson's disease is a clinical diagnosis, the most important 'examination' is the first old face to face dialogue, the neurology Doctor.
An example :
A 42-year-old woman, a cello player of the local symphony orchestra, complains neurologists with difficulties in manipulating the bow while trembling with his right hand. Sadly she is carefully asked to "take a break" from her work at the symphony until it is properly appreciated. She also fell a lot in the incident. She does not sweep strings quickly as she trembles disappear when you actually play, but the bow feels like "being drawn to something", so you can not sweep the strings quickly.
Here is a sample that starts the differential diagnosis of a person who has a persistent tremor on the right hand. The tremor occurs at rest and in addition to the fact that the movement disappears, especially on the right side, PD is raised to the first place.
Samples of differential diagnosis list of Parkinson's disease (Neurologists need extensive knowledge on how these are presented):
- Parkinson's disease
- Essential tremor (not undefined nonspecific tremor, does not get worse)
- Brain tumor: She needs to undergo CT scan or MRI scan of the brain
- Damage to the nerve of the affected arm by trauma or multiple sclerosis (MS). She is more likely to undergo EMG nerve evaluation of her right arm.
- Other degenerative neurological diseases, long sublists, please skip the details:
- Benign familial tremor
- Dominant SCA (spinocerebellar ataxia)
- Cerebellar ataxia
- Olive bridge cerebellar degeneration
- Familial basal ganglion calcification (Far syndrome)
- Alzheimer's syndrome
- Amyotrophic lateral sclerosis
- Dementia, Lewy body type
- Parkinsonism - dementia complex
- Progressive supranuclear palsy
- Cerebellar degeneration
- Shy · Drager syndrome
- Ankylosing spinal degeneration
- Corticobasal degeneration
- Frontotemporal dementia
- Lesions of the basal ganglia where the brain controls stroke / bleeding exercise
- Lyme disease
- Drug (her main doctor put her in Northern subtilin for depression)
- Antipsychotics
- Antidepressant
- Lithium
- Amphetamine
- Cocaine
- MPTP (a by-product of a bad habit of making ecstasy like Parkinsonian syndrome after a single dose)
- Alcohol or drug withdrawal
- Alcoholic brain degeneration
After doing directional interviews and examinations, her neurologist did not think that he used the funds of his knowledge and experience to show the characteristics of other degenerative diseases.
By physical examination and observation, he noticed that he was not swinging his right arm when walking in the corridor. She slightly pulled her right leg.
He copied some sentences from medical writing. It took her a long time and writing was very small.
When he moved with his arm to the wrist and elbow, I felt a ratchet feeling more than a smooth passive movement (classical PD symptoms called "gear").
She denies the history of drugs and rarely drinks.
The deer tick carrying the lime is her in San Diego who is not thriving.
There was no brain tumor, stroke, stroke, bleeding, no defect suggesting MS, so the MRI scan of the brain was normal. Parkinson's disease usually results in a very normal brain scan. Several research techniques using radioactive dopamine-like compounds have shown that they are not generally available but can reveal defects, and that it is possible to perform diagnostics exceptionally without it in this document It is unnecessary.
Her EMG nerve examination showed normal neurological function to the affected arm.
Finally, very important in establishing Parkinson's disease as her diagnosis, he imitated dopamine and examined her a week later. She did not show the drug most of what was discovered last time in her second visit in a week.
At that time, the neurologist was convinced that it was PD and gently broke the news to her.
