CASE PRESENTATION ON PARKINSON’S

DISEASE

PRESENTED BY:
T.AVINASH
VIth PHARM D
Y13PHD0721
 A 83 yrs of
male patient admitted in the hospital with
the chief complaint of unable to talk,
generalised wakness not responding
commands since afternoon. He has the
history of parkinsonism since 8 (syndopa 125
mg), type 2 dibetes mellitus since 5 years
(glyciphase) and hypertension since 6 years
(Telma H 40).
 PATIENT DEMOGRAPHIC DETAILS

AGE: 83years SEX: male WEIGHT/Kg: 63

DOA: 30/07/2018 DOD:04/08/2018 I.P. No.:10824

CHIEF COMPLAINTS:

K/C/O unable to talk, generalised wakness not responding commands since

afternoon.

HISTORY OF PRESENT ILLNESS:

now came with h/o unable to talk, generalised wakness not responding
commands since afternoon.
 SUBJECTIVE EVIDENCE

HISTORY OF PAST ILLNESS:-

MEDICAL HISTORY:
parkinsonism since 8yrs

Hypertension since 6yrs

Diabetis mellitus since 5yrs

SURGICAL HISTORY:- NILL

TREATMENT HISTORY:-

DIABETES:- Glyciphase HYPERTENSION:- Telma H40 CAD:- NO CVA:- NO

ASTHMA:-NO TUBERCULOSIS:- NO HORMONAL:- NO
CHEMO/RADIATION:- NO BLOOD TRANSFUSION:- NO

OTHER DETAILS:- parkinsonism since 8yrs syndopa 125 mg PERSONAL

HISTORY: Employee FOOD HABBIT:- Non- vegtarian

FAMILY HISTORY:- NIL

ALLERGIES: NIL
 OBJECTIVE EVIDENCE

PHYSICAL EXAMINATION:
o BP: 170/90 mmhg
o PULSE: 88 beats/min
o RR: 20 cycles/ min
o TEMPERATURE:- 98.4 F

SYSTEMIC EXAMINATION:
o CVS: S1, S2 (+) no murmur.
o Respiratory system: NVBS(+).
o Abdominal system: Soft, no tenderness.
o CNS: Drowsy.
o Speech: Slurred
PLAN TO CARE:-
o To treat the symptoms of parkinsonism.
EXTERNAL INJURIES:- NIL
PROVISIONAL DIAGNOSIS:- PARKINSONISM
PLAN OF THE TREATMENT:-
o INJ.FLUCOLOXANCILLIN 1gm IV TID
o INJ.PIRACETAM 15ml IV OD with 25ml NS
o INJ. ENOXAPARIN 40mg S/C OD
o TAB. PANTOPRAZOLE 40mg OD
o TAB. LEVODOPA(1OOmg)+ CARBIDOPA (25mg)
AVD. INVESTIGATION:-Serum electrolytes, haemoglobin, platelet count .
DESIRED OUT COME:- Relieving from the symptoms of parkinsonism .
 OBJECTIVE EVIDENCE

Lab Report:-
Parameter Normal range Day1 Day2 Day3 Day4 Day5 Remarks

HB 13-18gm/dl 13.9 14.1 - - - Normal

TC 4000-11000/ul 7000 - - - - Normal

Platelets 150,000 to 2,06,000 2,60,000 - - - Normal

450,000/cumm
polymorphs 45-75% 60 70 - - - Normal
Lymphocyte 20-40% 31 34 - - - Normal
Eosinophils 0-6% 04 03 - - - Normal
MONOCYTES 0-4% 03 04 - - - Normal
BASOPHILS 0-1% 00 00 - - - Normal
PCV 42-52vol% 43.2 43.6 - - - Normal
 OBJECTIVE EVIDENCE
Lab Report:-
Parameter Normal range Day1 Day2 Day3 Day4 Day5 Remarks

MCH 27-32pg 28.4 23.4 - - - Normal

MCHC 31 to 35 g/dl 32.2 33.0 - - - Normal

MCV 80 to 96 fl 80.8 84.8 - - - Normal

Na 135-145 mEq/L 136 140 - - - Normal

k 3.5-5.0 mEq/L 4.6 4.4 - - - Normal

Occult stool positive - - - - - Normal

Creatinine 0.7-1.4/dl 0.8 0.7 - - - Normal

Albumin Serum 3.5-5.0g/dl 3.0 - - - - Normal

Ureic acid 10-40mg/dl 30 35 37 - - Normal

 OBJECTIVE EVIDENCE
Lab Report:-

Urine Analysis:-
Parameter Result Remarks

Pus cells 8-10 (0-4) UTI

RBCs Nil (0-4 RBCs per high power field ) Normal.

Epithelial cells occasional (0-4)

bacteria nil (none)

Dipstick test: Normal

glucose

Bilirubin, ketone, protein, -ve

urobilinogen

pH 8 (4.6-8)
 ASSESSMENT

FINAL DIAGNOSIS/ ASSESSMENT OF THE PROBLEM:

• PARKINSONISM
• HYPERTENSION
• TYPE 2 DIABETES MELLITUS
 PLANNING

THERAPEUTIC GOALS:-
o Treating he acute symptoms of parkinsonism.
o achieving remission (the absence of symptoms)
o Getting the blood sugar level & blood pressure getting to normal.
 Treatment Chart
DAY & TIME
NAME OF MEDICATION DOSE & INDICATION
(GENERIC NAME) ROUTE,
FREQ. D1 D2 D3 D4 D5

INJ. FLUCLOXACILLIN 1gm,IV, 9am- 9am- 9am-3pm- 9am-3pm- 9am- Urinary tract Infection
TID
3pm-9pm 3pm-9pm 9pm 9pm 3pm-9pm
INJ. PIRACETAM 15ml with 3pm 3pm 3pm 3pm 3pm Visuomotor skills,
25ml NS,IV, cognetive deficts
OD
INJ. GLUTAMINE 50ml,IV, 2pm 2pm - - - Parkinson’s disease
OD
INJ. ENOXAPARIN 40mg,S/C, 2pm 2pm 2pm 2pm 2pm Anticoagulant
OD
T. PANTOPRAZOLE 40mg,RT, - - 6am 6am 6am Gastric irritation
OD
T. AMLODIPINE 5mg,RT, - - 8am-9pm 8am-9pm 8am-9pm Hypertension
BD
T. ALLOPURINOL 100mg,RT, 1pm 1pm 1pm 1pm 1pm Uric acid
OD
 Treatment Chart
DAY & TIME
NAME OF MEDICATION DOSE & INDICATION
(GENERIC NAME) ROUTE,
FREQ. D1 D2 D3 D4 D5

T. OLANZAPINE 5gm,RT, - - 9pm 9pm 9pm Antipsychotic

HS
T. LEVODOPA+CARBIDOPA 100mg+25m - - 6am-10am- 6am-10am- 6am-10am- Parkinson’s disease
g,RT,QID
2pm-10pm 2pm-10pm 2pm-10pm
T. LEVODOPA+CARBIDOPA 200mg+50m - - 10pm 10pm 10pm Parkinson’s disease
g,RT,OD
T.ASPIRIN 150mg,RT, - - 2pm 2pm 2pm Antiplatelet
OD
POWDER FRESUBIN-DM 6SPOONS IN - - 6am-10am- 6am-10am- 6am-10am- Meal replacement
200ml,RT,
QID
2pm-10pm 2pm-10pm 2pm-10pm
Syp. Lactulose 15ml,RT, - - 9pm 9pm 9pm Constipation
HS
 PLANNING
THERAPEUTIC INTERVENTION:-
Patient is receiving both aspirin and enoxaparin,
by taking these medications leads to increases the risk of bleeding.
MONITORING PARAMETERS:-
patient should be monitored for every 24 hours by
checking the bleeding time and clotting time.
DRUG-DRUG INTERACTION:-
Levodopa - Amlodipine:-
Concurrent use of these medication leads to hypotension.
Monitor: The hypotensive effects of levodopa and amlodipine agents may be
additive. Hemodynamic response should be monitored.
Resolution:- The above interaction should require the dose adjustment of
amlodipine for first few weeks.
 Discharge Medication[FOR 5 DAYS]
NAME OF MEDICATION DOSE &
(GENERIC NAME) ROUTE, INDICATION
FREQUENCY

T. LEVODOPA+CARBIDOPA 100mg+25mg,RT,QID, 6am- PARKINSON’S DISEASE

10am-2pm-10pm
T. AMLODIPINE 5mg,RT, HYPERTENSION
BD,8am-9pm
T. PANTOPRAZOLE 40mg,RT, GASTRIC IRRITATION.
OD,6am
T. PIRACETAM 500mg,RT, VISUOMOTOR SKILLS, COGNETIVE
BD, 7am-7pm DEFICTS
T.ASPIRIN 150mg,RT, ANTIPLATELET
OD
T. CEFPODOXIME 200mg,RT, URINARY TRACT INFECTION
BD, 7am-7pm
Syp. Lactulose 15ml,RT, CONSTIPATION
SOS
 PATIENT COUNSELLING
DISEASE SPECIFIC:
• Parkinson’s disease is a neurological disorder in which there is a gradual loss of brain
cells that make and store dopamine. Dopamine is a chemical in the brain, known as a
neurotransmitter, which sends messages that control movement. As Parkinson’s
disease progresses, more dopamine neurons in the brain are lost.
MOVEMENT/MOTOR-RELATED SYMPTOMS
 Bradykinesia:- slowing down and loss of spontaneous and voluntary movement .
 Rigidity:- unusual stiffness in a limb or other body part .
 Resting Tremor:- an uncontrollable movement that affects a limb when it is at rest
and usually stops for the duration of a voluntary movement.
 Postural Instability:- problems with standing or walking, or impaired balance and
coordination, which can lead to falls .
 Dystonia:- involuntary movement with a muscle contraction, such as a cramp.
 Reduced facial expression:- “mask-like” face due to bradykinesia Speech and
swallowing problems.
 Speech and swallowing problems.
NON-MOVEMENT/ NON-MOTOR-RELATED SYMPTOMS
 Cognitive Impairment :decline in ability to multi-task and/or concentrate; potential
decline in intellectual functioning and onset of psychosis .
 Mood Changes :can include depression, apathy or anxiety.
 Sleep disorders :for example, REM sleep behavior disorder, where individuals act out
their dreams .
 Hyposmia : loss of sense of smell.
 Fatigue .
 Constipation .
 Bladder Problems :a sudden need to urinate or incontinence .
 Orthostatic Hypotension: low blood pressure upon standing .
 Pain :central pain other than pain caused by posture problems or dystonia.
Stage 01: Symptoms on one side only.
Stage 02: Symptoms on both sides without balance impairment.
Stage 03: Mild to moderate disease, some postural instability, physically independent.
Stage 04: Severe disease, able to walk or stand unassisted.
Stage 05:Wheel chair bound or bedridden unless assisted.
 PATIENT COUNSELLING
DRUG SPECIFIC:
• Carbidopa/levadopa helps to restore levels of dopamine, a chemical
messenger in the brain responsible for smooth coordinated movement and
other motor functions. Carbidopa works to prevent levadopa from being
broken down before it reaches the brain and to prevent nausea. There are
multiple forms available.
TREATMENT-RELATED SYMPTOMS
• Dyskinesia / involuntary, twisting/turning, jerky movements that can result
from long-term use of medications that treat Parkinson’s disease
• Impulse Control / inability to resist an impulse that is harmful to self or others
that can result from use of medications that treat Parkinson’s disease
 Amlodipine is used to treat the hypertension and it may include the side
effects of tiredness, stomach pain,nausea,dizziness, flushing, arrhythmia,
palpitations.
 PATIENT COUNSELLING
DIET SPECIFIC:
 The medication levodopa (Sinemet) is a protein building block so it competes
for absorption with other proteins. Eating a very proteinic meal reduces the
likelihood of effectively absorbing levodopa, so you may want to leave meat,
fish and cheese for dinner and eat more carbohydrates and vegetables during
the day.
 Taking medication on an empty stomach 30 minutes before or 60 minutes
after a meal allows the drug to reach the small intestine and absorb faster.
 Increased fluid and fiber consumption can help maintain regularity. Aim to
drink six to eight 8 ounce glasses of water per day. Warm liquids, especially in
the morning, can stimulate bowel movements. Dietary sources of fiber consist
of fruits (with the peel), vegetables, legumes, whole grain breads and
cereals. Most of these are high in antioxidants as well.
 Diet high in antioxidants may offset oxidative stress and cellular damage.
 PATIENT COUNSELLING
Antioxidants are present in:
 vegetables: artichokes, okra, kale, bell peppers, potatoes
 fruits: berries, pears, apples, grapes
 grains
 eggs
 legumes: kidney beans, edamame, lentils
 nuts: pecans, walnuts, hazelnuts
 dark chocolate
 some beverages such as red wine, coffee and tea
THANK YOU