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INSTRUCTIONS FOR THE DOCTOR

This is a long case.

Please take a history, examine this patient appropriately and discuss with her a management plan.

Scenario

A 65-year-old woman, Sybil Clarke, has booked a long appointment. She has noticed a tremor and her family have told her that they can no longer read her writing.

The following information is on her summary sheet:

  • Past medical history

  • Glaucoma, sees ophthalmologist regularly

  • Vaginal hysterectomy eight years ago for prolapse

  • First child, Terry, now aged 42

  • Second child, Malcolm, now aged 39

  • Medication

  • Timolol 0.25% 1 drop bd

  • Allergies

  • Nil

  • Immunisations

  • Up-to-date

  • Social history

  • Retired school secretary

  • Husband—retired credit union manager

  • Non-smoker

  • Alcohol intake—nil.

INSTRUCTIONS FOR THE PATIENT, SYBIL CLARKE

You are a 65-year-old retired school secretary. You have always been a very meticulous sort of person. Much to your embarrassment you now have a shake. You have made the appointment because your family said that they could not read your writing on the Christmas card that you sent them.

The shake has been getting worse gradually over the last couple of years, but it’s now at a point that it is making it hard to complete day-to-day tasks such as doing up buttons. Your writing has deteriorated, becoming smaller and harder to read. You are finding it harder to move, and sometimes it can take a bit longer to get out of a chair. You are often fatigued. You had put this down to getting older but are starting to worry that you’re getting older much quicker than your friends. You haven’t had any falls. If asked, your voice has become softer and your family have complained they can’t hear you when you’re talking on the phone. You have had no issues with dribbling but do occasionally find it a little tricky to swallow foods like steak and bread. You are mostly continent of urine but have noticed some increased urgency over time. There have been no changes in your bowels.

You are mostly managing at home with cooking, cleaning, shopping and so forth, but are noticing that things take a bit more of a toll on you than in the past.

You have no mood symptoms or excessive anxiety, but you are worried about the cause of your tremor and deteriorating health.

Clinical examination findings

Please try to display a resting pill-rolling tremor, an expressionless face, persistent blinking on glabellar tap, cogwheel rigidity, a shuffling gait with a lack of arm swing, micrographia, poor balance and slow, stiff movements.

The following information is on your medical record:

  • Past medical history

  • Glaucoma, sees ophthalmologist regularly

  • Vaginal hysterectomy eight years ago for prolapse

  • First child, Terry, now aged 42

  • Second child, Malcolm, now aged 39

  • Medication...

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