Case scenario
Phillip is an active semi-retired person, working part-time in the local specialty tea store. He is married to Klara with three adult children, all of whom live out of home:
Vanessa 35 years old-3 children under 10
Adam 33 years old-new born baby; and
Anton 30 years old with a 1 year-old child.
Each of the adult children is located interstate and has young family. Klara had previously participated in many outdoor activities with her husband and her hobbies include bushwalking, cryptic crosswords and gardening. Phillip and Klara have recently separated and are living separately.
Recently, Phillip has had a number of minor mishaps at work and has been increasingly dropping things. He has been experiencing a slight right-hand tremor and his gait has become unsteady. The tremor appears to worsen at night particularly when sitting down and when resting in bed. Phillip has been increasingly fatigued and forgetful. This was becoming more noticeable and problematic as the tremor did not subside and Phillip felt he was becoming clumsier.
Phillip has been increasingly concerned that he would fall asleep at work so has tried not to sit down unless he is at lunch. It is at work that the hand tremor is particularly troublesome. Two Phillip has also had two episodes of losing his balance and once fell over. Phillip also feels as if everything is spinning around and has numbness in his hands. He was also having difficulty speaking and slurring his words. Phillip managed to call an ambulance as he didn’t know what to do. Phillip was reviewed, admitted and seen by a medical officer, and referred to a neurologist for review.
Phillip spent two weeks in hospital and a provisional diagnosis of Parkinson’s disease was made. To rule out any other neurological conditions a series of investigations was conducted including an MRI and PET scan as part of the diagnostic screening process; no abnormalities were detected. Following these investigations and a thorough neurological exam, a firm diagnosis of Idiopathic Parkinson’s disease was made.
Phillip was discharged home, being collected by Klara. Klara indicated that she would not be able to be Phillip’s carer, Phillip was adamant that he would be fine at home on his own. You have been asked to see Phillip in the community as part of his discharge plan.
Symptoms experienced:
Intermittent fatigue for approximately 8 months.
Bradykinesia for approximately four months. Phillip has been increasingly dropping equipment and stock at work.
He has been unable to deal with hot water at work and was not able to make tea to serve as samples.
Increasing hand tremor for 4 months, most evident at rest.
Emotional lability for 4 months with out of proportion emotional reactions to small incidents.
Unsteady gait for approximately four months including stumbling without cause
Increasing levels of confusion;
Increasing drooling; Increasingly being told he is hard to hear;
Increasing nausea.
Discharge Summary Phillip Dillon is a 67-year-old male, recently separated from his wife. Admitted via A&E with a history of:
• Increasing upper limb tremor; more pronounced right side;
• Increasing global bradykinesia – shaking and slow response to requests
• C/O increasing fatigue and ‘sleepy’ episodes during the day when working; drooling;
• increasing hypophonia (hard to hear)
• Feeling ‘blue’ and sad on and off for the past 12 months.
Medical history
• High cholesterol Surgical history
• L knee arthroplasty – age 44
• Tonsillectomy and adenoidectomy as a child
• Other • semi-retired; works part time in Tea shop;
Recent admission to hospital for investigation of altered mobility;
• Neurological, musculoskeletal, cardiovascular assessment – no abnormalities detected
• Excluded neuro pathology – CT and PET scan – no abnormalities detected;
• Provisional diagnosis: Parkinson’s disease Discharged – yesterday Primary diagnosis of Parkinson’s disease
Medications
• Lipitor 25mg mane
• Dopamine releaser-Amantadine HCL – 100 mg daily
• Dopamine agonists – Carbergoline – 0.25mg BD
• Dopamine replacement – Levodopa 10mg TDS
• MAO-B inhibitors – Selegiline -25mg patch changed daily
• Maxolon for nausea 10mg prior to meals
• Paracetamol PRN
identify and discuss two PRIORITIES OF CARE and apply the clinical reasoning cycle to these as a means of justification