1) A 56-year-old male presented with a history of decreased consciousness and parkinsonism symptoms including shaking of his right hand, difficulty walking, and falling. 2) His symptoms began in 2013 and have progressively worsened over time, with additional symptoms of forgetfulness, difficulty calculating and reading, slowed movement, and hallucinations. 3) His neurological examination was inconsistent at times but showed signs of parkinsonism including rigidity, tremor, and decreased motor function as well as decreased gag reflex.

1. JOIN CASE
NEUROLOGY-PSYCHIATRY
PARKINSONISM
PUZZLE

2. Patient’s Identity
• Name : Mr. X
• Age : 56 years old
• Sex : Male
• Address : Surabaya
• Race : Javanese / Indonesia
• Religion : Muslim
• Education : SMP
• Occupation : Unemployee
• Marrital status : Married
2

3. History of Present Illness (Heteroanamnesis)
• Decreased of consciousness occurred abruptly a day before
admission, patient could not be woken up from sleep. It happened
after he had breakfast and took medicine. No specific symptoms/
sign before.
• His eyes were closed and gaze upward. Stiffness of the body/ jaw
clenching / bitten tongue/ drooling (-)
• About an hour later, he started to respond, disoriented (He said
that he had just visited his home in Solo), gradually returned to
normal.
• Headache/ nausea/ vomit/ fever/ seizure/ trauma (-)
• Asymmetric face/ slurred speech/ half body weakness/ numbness/
tingling/ hearing disturbance/ smelling disturbance/ dizziness (-)
• Patient was referred from X Hospital with susp.syncope dd seizure.
Chief complain: History of decreased consciousness
3

4. • His illness began in December 2013. His right hand shaking
during activity (ie. hanging clothes), followed by his right leg
and left extremities within a month. He easily fall when he
walk/stand. He often complain fatigue/body discomfort
(“pegal-pegal”) and difficult to initiate sleeping. When he
cannot sleep, he walk around the house and grumble
unclearly (“ngomel-ngomel”). He easily cry with unclear
reason.
• In March 2014, patient was suddenly slow in response &
slurred in speech, consulted to Neurologist and Psychiatrist,
with diagnosis of stroke, he received medication but did not
take it routinely.
• About six months before admission (August 2014), patient
became forgetful and experienced difficulty in calculating &
reading. He also became slower in walking and easier to fall.
4

5. • Early December 2014, patient was hospitalized in X Hospital
because he felt “confuse”. He did not want to eat or doing
other activity. He also hear voices and see shadows and
flashes of light.
• After hospitalized, he could not walk, choked when
eating/drinking .
5
• Family problem since 8 years ago.
• Patient had a garment kiosk in traditional market, stop
working 1 year ago. Patient only lying in bed & doing daily
activity at home.
• History of smoking 2 packs/day for >10 years, had stopped
smoking 10 years ago.
• Alcohol/coffee consumption (-)
Psychosocial history

6. History of family illness
6
• Stroke (March & December 2014), CT scan?, Tx ?
• Uncontrolled hypertension since 5 years ago
• He routinely attend follow up in X Hospital this last 6 months.
Last 2-3 weeks Tx: ASA 1x80mg, Amlodipine 1x5mg, HCT
1x12.5mg, Stalevo (Carbidopa+Levodopa+Entacapone) 3x1tab,
Haloperidol 3x1.5mg, Fluoxetine 1x20mg, Alprazolam 3x0.5mg,
Lorazepam 1x1tab
• His right knee was swelling and painful, got therapy from
Orthopaedic
• Head trauma/seizure/ infection/DM/Tumor/Heart
disease/chronic cough/Lung disease (-)
History of past illness
• Patient’s sister had hypertension, diabetes, and forgetfulness
• Stiffness/ stroke/ seizure (-)

7. General Examination
VS BP 130/80 HR 90 x/m reg RR 20 x/m t 37.2 C
H/N a-/i-/c-/d-
Carotid bruit (-) mass (-) lymph node enlargement (-)
Th. Symmetric, ret(-), mass (-)
C: S1S2 single, m(-), g (-)
P: ves/ves, rh ---/--- , wh ---/---
Abd. Soufle, bowel sound +, mass -
Ext. normal perfusion, no edema
7
Note: Patient refused / discontinued the examination for several times because tired or sleepy.
Complete and detail history taking & physical-neurological examination was difficult to be
performed

8. Neurological Examination
GCS 456
MS Neck rigidity (+) Brudzinsky (-) Lasseque (-)
Cranial nerves I: -
II, III: pupil round 3/3, light refl. +/+
III, IV, VI: ocular motility normal
V: RK +/+, sensoric normal
VII: mask face, slight left facial palsy central
type (normal variation?)
VIII: nystagmus -
IX, X: gag reflex ↓/↓ normal, dysphagia (-)
XI: -
XII: lingual palsy -
8

9. Motoric 5/4  5/5
4/4  5/5 (inconsistent*)
Cogwheel rigidity  improved
Tremor +/+ resting, kinetic, postural  tremor
kinetic & postural
Sensoric Normal
Physiological reflex BPR +3/+3 KPR +2/+2
TPR +3/+3 APR +2/+2
Pathological reflex Babinski -/- Chaddock -/-
Varians -/- Hoffman/Tromner +/+
Primitive reflex Palmomental +/+ Grasp -/-
Cerebellar sign Dismetria -/-, intention tremor -/-, Ataxia -
Disdiadochokinesia -/dte  +/+  -/-
(inconsistent)*
CV / ANS Urine inkontinence  normal
MMSE 20
*inconsistent normal/abnormal inter-examiner or from time to time, during follow up period 9

10. Imaging & Lab
• Head CT : normal
• Head MRI : normal
• Blood work : normal
10

11. Let’s help this patient! 11