Chief Complaint (CC)

Progressive resting tremor of the right hand with slowness of movement, stiffness, and impaired dexterity over the past 18 months.‍‍

History of Present Illness

Anni Lloyd is a 67-year-old right-handed female who presents for evaluation of progressive tremor and slowing of movement. Approximately 18 months ago, she first noticed an intermittent resting tremor involving her right hand that gradually became more frequent and noticeable. Over the past year, she has developed increasing stiffness of the right arm, reduced manual dexterity, and generalized slowness affecting activities such as handwriting, buttoning clothing, and food preparation. Her husband has also observed reduced facial expression, softer speech, and decreased right arm swing while walking. She reports that her handwriting has become progressively smaller and more cramped.

She denies falls but describes occasional imbalance when turning quickly and difficulty rising from low chairs. She also reports constipation, diminished sense of smell for several years, and occasional vivid dreams with dream enactment behaviors reported by her husband. She denies hallucinations, significant cognitive decline, orthostatic syncope, or urinary incontinence. There is no history of exposure to dopamine-blocking medications, prior stroke, significant head trauma, or toxin exposure. Symptoms have gradually progressed and are beginning to interfere with daily activities, prompting neurological evaluation.

Past Medical History

• Hypertension
• Hyperlipidemia
• Osteoarthritis
• Chronic constipation

Current Medications

• Amlodipine 5 mg daily
• Atorvastatin 20 mg nightly
• Polyethylene glycol as needed
• Vitamin D3 1000 IU daily

Past Surgical History

• Left total knee arthroplasty (2021)
• Cholecystectomy (2014)

Family History

• Father diagnosed with Parkinson's disease in his seventies
• Mother with hypertension
• No family history of essential tremor or atypical parkinsonian disorders

Social History

Anni Lloyd is a retired librarian who lives with her husband. She has never smoked, drinks alcohol occasionally, and denies illicit drug use. She remains physically active with daily walks but has reduced participation in gardening because of worsening hand dexterity.

Functional Status

Activities of Daily Living (ADLs):

• Independent with bathing, dressing, toileting, and feeding
• Requires additional time for dressing and grooming because of bradykinesia

Instrumental Activities of Daily Living (IADLs):

• Independent with finances and medication management
• Difficulty with handwriting, meal preparation, and fine motor tasks
• Continues to drive without difficulty
• Reduced endurance for household chores

Review of Systems (ROS)

General: Mild fatigue. No fever or weight loss.

Respiratory: No cough or dyspnea.

Cardiovascular: No chest pain, palpitations, or syncope.

GI: Chronic constipation. No nausea, vomiting, or abdominal pain.

GU: No urinary urgency or incontinence.

Psychiatric: Reports occasional dream enactment behavior during sleep. No depression, hallucinations, or anxiety.

Musculoskeletal: Progressive stiffness involving the right upper extremity.

Neurological: Resting tremor of the right hand, generalized slowness of movement, rigidity, impaired dexterity, reduced facial expression, and mild gait slowing. No seizures, focal weakness, sensory loss, or episodes of loss of consciousness.‍

Vitals

BP: 134/78 mmHg

Pulse: 70 bpm

Temp: 98.1°F

Height: 165 cm

Weight: 69 kg

BMI: 25.3 kg/m²‍

Examination

General:

Pleasant female in no acute distress.

Mental Status Exam:

Appearance: Well groomed

Behavior: Cooperative

Mood: Euthymic

Affect: Mildly reduced facial expression (hypomimia)

Thought Process: Logical and goal-directed

Interactions: Appropriate with preserved insight and judgment

Neurological:

Mental Status: Alert and fully oriented to person, place, time, and situation. Speech mildly hypophonic but fluent. Attention, language, memory, and comprehension are intact.

Cranial Nerves: Cranial nerves II-XII intact. Mild facial hypomimia. Extraocular movements full without supranuclear gaze limitation. Pupils equal and reactive. Facial sensation intact.

Motor: Mild resting tremor involving the right upper extremity, increasing with distraction and decreasing during voluntary movement. Mild to moderate cogwheel rigidity involving the right wrist and elbow with mild rigidity on the left. Bradykinesia demonstrated during finger tapping, hand opening-closing, and rapid alternating movements, greater on the right. Strength 5/5 throughout without pyramidal weakness.

Reflexes: 2+ and symmetric throughout. Plantar responses flexor bilaterally.

Coordination: Finger-to-nose intact without dysmetria. No intention tremor.

Sensory: Intact to light touch, pinprick, vibration, and proprioception throughout.

Gait and Station: Mildly stooped posture with decreased right arm swing, shortened stride length, and mild en bloc turning. Pull test demonstrates mild postural instability with recovery in two steps. No freezing of gait observed.‍

Labs and Imaging

Laboratory Tests (June 2026):

CBC and comprehensive metabolic panel within normal limits. TSH 2.16 uIU/mL. Vitamin B12 518 pg/mL. No metabolic abnormalities contributing to parkinsonism.

MRI Brain (July 2026):

Mild generalized cerebral volume loss consistent with age. No acute infarction, intracranial mass, hydrocephalus, or structural abnormality to explain parkinsonian symptoms. Mild chronic microvascular white matter changes.‍

Assessment

1. Idiopathic Parkinson's disease, early stage
2. Bradykinesia, rigidity, and resting tremor affecting dominant upper extremity
3. Mild gait impairment without falls
4. Non-motor symptoms including constipation, hyposmia, and probable REM sleep behavior disorder

Plan

1. Idiopathic Parkinson's Disease

The patient demonstrates asymmetric resting tremor, bradykinesia, rigidity, and characteristic gait changes consistent with idiopathic Parkinson's disease. The gradual onset, asymmetric presentation, associated non-motor symptoms, and absence of atypical neurological features support the diagnosis. Symptoms are beginning to interfere with daily activities, and initiation of dopaminergic therapy is appropriate.

• Initiate carbidopa-levodopa 25/100 mg one tablet three times daily
• Review expected benefits, potential adverse effects, and gradual dose titration
• Encourage regular aerobic exercise and participation in Parkinson's disease-specific physical therapy

2. Motor Symptoms

Bradykinesia and rigidity are contributing to impaired dexterity and slowing of daily activities.

• Refer to physical therapy for gait, balance, and mobility training
• Refer to occupational therapy for fine motor rehabilitation and adaptive strategies
• Encourage daily stretching and flexibility exercises

3. Non-Motor Symptoms

Constipation and probable REM sleep behavior disorder are common non-motor manifestations of Parkinson's disease.

• Continue bowel regimen with adequate hydration and dietary fiber
• Consider melatonin if dream enactment behaviors become more frequent or disruptive
• Continue monitoring for autonomic symptoms, mood changes, cognitive impairment, and sleep disturbances

4. Long-Term Disease Management

Parkinson's disease is a chronic progressive neurodegenerative disorder requiring ongoing symptom monitoring and medication adjustment.

• Educate the patient regarding disease progression and treatment expectations
• Encourage participation in regular exercise and community support programs
• Reassess motor response and medication tolerance after initiation of levodopa therapy

Ordered

Medications:

• Carbidopa-levodopa 25/100 mg three times daily

Referrals:

• Physical therapy
• Occupational therapy

Follow Up

Follow-up is scheduled in six weeks to assess symptomatic response to carbidopa-levodopa, evaluate medication tolerance, and determine whether dose adjustment is needed. The patient was instructed to report any worsening balance, frequent falls, hallucinations, significant orthostatic symptoms, or new neurological changes before the scheduled follow-up.

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