Rotation 3 Fourth Year - Assessment STARES

Situation
A 72 year old man was admitted to the rehabilitation ward at Hollywood Hospital on the 25th of April 2010 with a decrease in mobility, an increasing number of falls and lethargy. According to his wife his memory was starting to fail and he was finding it harder and harder to cope at home. This in turn was putting an increasing amount of pressure on her and she could no longer manage on her own. His past medical history included a diagnosis of Parkinson’s disease in 2006 and ischaemic heart disease.

Task
I was set the task of performing a neurological assessment on this gentleman.

Action
In preparation for the assessment of the patient I read through his medical and bedside notes. There was very little mention of his Parkinson’s disease in the notes and, according to the drug chart, on the 27th of April he was taken off his Parkinson’s medication (Madopar). After this date the notes mentioned the diagnosis of progressive supranuclear palsy (PSP), however there was no clear time or indication that the diagnosis changed. I spoke to the registrar and the consultant but they too didn’t know where the diagnosis had come from, only that the medication was not effective so he was taken off it. I then decided that within the assessment I would include some tests that differentiated between PSP and Parkinson’s disease. These tests included observation of his posture in standing as in PSP the patient will lean backwards but in Parkinson’s disease the patient will have a flexed posture, testing of his eye movements, as vertical tracking and convergence decrease with PSP but remain normal in Parkinson’s disease, and lastly, observation for any resting tremor as this is present in Parkinson’s disease but absent in PSP.

On assessment the patient did show signs of bradykinesia, decreased cognition (MME 16), decreased balance (Berg 33) and a history of falls. These are all signs and symptoms of both Parkinson’s disease and PSP. There was no resting tremor, minor rigidity, no history of freezing or akinesia and he was not responsive to Levadopa, which are all signs of only Parkinson’s disease. Lastly, he had very minimal vertical tracking and convergence of his eyes and leant backwards in standing, all symptoms only present in PSP. Whist I couldn’t definitively say that the patient had PSP, clinically it appeared that it might be a possibility. I spoke to the registrar regarding my findings and she is now in the process of confirming a diagnosis.

As the assessment allowed me to construct a concise problem list, a definitive diagnosis did not affect my treatment of this patient. It does however guide the medical treatment, so it is an important finding from the registrar’s perspective. My problem list included decreased dynamic standing balance, decrease insight and attention and abnormal standing posture. I then treated the patient with exercises that focused on these problems, keeping in mind the patients discharge destination, low level care.

Result
My actions resulted in the patient having further investigations into their condition, therefore leading to a better diagnosis and hopefully better treatment. This however did not affect my treatment much except that with a clear diagnosis I have a better idea of how the disease is predicted to progress, the prognosis, the best treatments and what to look out for in the future.

Evaluation
Whilst I am happy with the outcome of the situation, I am quite aware that without the mention of PSP in the notes by another healthcare practitioner I would not have even considered it. It makes me realise the importance of knowing each condition in detail and the possible options for differential diagnosis. Even a basic knowledge of a condition and its differential diagnoses would allow the options to be known. I will definitely be revising my neurological conditions over this placement and ensuring that I know the other similar conditions out there. In this case it was not detrimental to the patient however in the future a lack of knowledge such as this with another condition could possibly result in a negative outcome.

Strategies
As stated above, knowledge of the various neurological conditions and their differential diagnoses would have ensured that this possible misdiagnosis was picked up. Also, thorough reading of the notes ensured that any miscommunication within the medical notes was picked up and that all health care practitioners are treating the same condition.