Physical Exam Tapas

Today we saw some great cases:

• Erythema Nodosum: discussed here. Secondary to sarcoid? TB?


• CREST syndrome: discussed here.


• Pulmonary Hypertension: discussed here. Secondary to Ebstein's anomaly.

Parkinson's Disease

Today we saw a gentleman with Parkinson's Disease. A few features to watch for on the physical exam.

• Head and Neck: Look for a masked facies, seborrhea, absence of blinking, and possibly drooling. In addition, the glabellar tap maneuver is often positive, but not a very nice exam to perform.
• Listen: Speech is often soft, slow, and monotonous.
• Tremor: This is at rest, and initially starts unilaterally. Often described as a 'pill rolling' tremor with 4-6 cycles per second. It will eventually move bilaterally.
• Tone: Classically with 'cogwheel' vs lead pipe rigidity. We felt a good example of cogwheeling today.
• Bradykinesia: Slower movements. You can bring this out by having them pretend to play the piano, heel tapping, etc.
• Gait: Watch for a stooped posture ('simian posture'), with a shuffling ('festinating') gait. It appears as if their center of gravity is just in front of them. Watch closely when turning around - this often requires multiple little steps rather than just one or two steps.
• Other: Watch for micrographia (small writing), difficulty opening jars, difficulty turning in bed, difficulty going from a sit-to-stand.

Here is an excellent JAMA article on the clinical evaluation of Parkinson's Disease.