1)a)List and assess each one of the patients complaints.

The patient complains that she has stiffness on her right side over the
last 6 months.It takes her longer to do things because it takes more
effort to get movement started, and her muscles feel stiff.(rigidity)-motor symptoms
The patient feels that she does not think as quickly and it takes her
longer to remember things.bradyphrenia(slowness of thought process)-mental status changes
She also complains of constipation anddecreased libido for over a year.(autonomic ans sensory
symptoms)
The patient said it has become difficult to
read because the words occasionally look blurry. These symptoms
have affected her job performance as a high-school gym teacher,
resulting in her contemplating early retirement.(The vision loses sharpness as the disease progress)

1.b. Assess the potential problems observed in the physical examination

and laboratory findings.

Small amount of dry yellow scales in her eyebrows.(Changes in the skin are common
symptoms of Parkinsons disease)
Decreased volume of speech-hypophonia(reduce voice volume), decreased facial
expression-hypomimia(reduce facial animation), decreased eye blinking;
Mild rigidity in right arm. Decreased fine motor coordination on the right.
Mild trouble with dressingputting on nylon stockings and small buttons
(Mild problems with facial expression, rigidity in right limbs, rapid alternating
movements in right hand, and bradykinesia)
Handwriting sample: Somewhat slow and progressively smaller in size indicating signs
of micrographia.

1.c. List the cardinal motor and non-motor symptoms of PD, and
describe which signs and symptoms of PD are present in this
patient
cardinal motor=resting tremor,bradykinesia,rigidity,posture disability.
Patient have bradykinesia because she take longer to move.Patient have
rigidy because there is stiffness in right side for past six months.Patient
have no tremor and no problem in posture disability.
non motor =Sleep disturbances,Constipation,Bladder problems ,Sexual
problems, Excessive saliva,Weight loss or gain,Vision and dental
problems,Fatigue and loss of energy,Depression,Fear and anxiety,Skin
problems,Cognitive issues, such as memory difficulties, slowed thinking,
confusion and in some cases, dementia
Patient have constipationdecreased in libido,blurred vision,memory
difficulties and skin problem

1.d. According to the HoehnYahr Scale, what stage is the patients

disease?
Stage Two
In stage two of Parkinsons, the symptoms start getting worse. Tremor, rigidity and
other movement symptoms affect both sides of the body. Walking problems and poor
posture may become apparent. In this stage, the person is still able to live alone, but
completing day-to-day tasks becomes more difficult and may take longer.
The patient symptoms gets worse. There is stiffness for 6 months n other parkinson
disease symptoms shows for one year.These symptoms have affected her job
performance as a high-school gym teacher,
resulting in her contemplating early retiremen.So we believed this symptoms shows the
patient is in already stage two.

 2. Treatment goal
The goal in the management of IPD is to improve motor
and nonmotor symptoms so that patients are able to
maintain the best possible quality of life.
Main focus:
- correcting the shortage of dopamine (levodopa,
dopamine-agonists, inhibiting dopamine breakdown)
- blocking the relative excess of acetylcholine
- It is clearly definite which is the patients show two
symptoms of bradykinesia , rigidity which need to treat
antiparkinsonian therapy

3.a. Non- Pharmacogy alternatives

As we can see , the non pharmacologically alternatives we can use is

from the guide table which is :
Education
-The prospect of having a chronic and progressive neurologic disease is
frightening.
-Education is essential in order to provide the patient and family with
some understanding and control over the disorder.
Support
-The emotional and psychologic needs of the patient with PD and family
should be addressed.
Support for the caregiver is particularly important as he or she learns to
cope with the increasing needs of the spouse or parent, or more rarely, a
son or daughter

 3. Exercise
-Increase activity motor functions
-Learned to cope the problem which can increase the
quality of life of patients
4. Nutrition
-Make sure the patients eats well balanced nutrition to
balance with the lifestyle
-As the ageing , body loss many source of vitamins and
minerals

3.b Pharmocological Therapy viable

The therapy which include short term and long term
The first line therapy should introduce with a MAO- B
inhibitor as suggests by the table for short term therapy
As we can see , MAO can be use moderate to mild
symptoms of IPD
If the treatment failed , last options is to add with
Carbidopa/L-dopa for short term only to improve IPD
symptomatic
Other agents such amantadine , dopamine agonist ,
anticholinergic is contradict certain time due to blurry
vision and constipation complaints by patients

 Rasagiline 0.5- 1 mg
-Starting dose range 0.5, 1 mg for
Carbidopa/L-dopa 300-1000 mg
-Starting dose range 300 mg (short term intro and will be
discontinued when patient is improved )

Optimal Plan Therapy

Short Term Therapy (duration within 6 month)
MAO-B = Rasagiline 0.5 mg and 1 mg
Carbidopa/L-dopa 300 mg (discontinued after
improvement)
Improved patients disease such constipation and blurry
vision
Long Term Therapy (duration within 6 and more month)
Mao B = Rasagiline 0.5 mg and 1 mg
If treatment failed, add up with other second line
therapy
The treatment asses for Bradykinesia which suitable

5.Monitoring Parameters
For IPD evaluation , every months the patients is advisable to
do Micrographia test to check motor and cognitive test
The side effects of anticholinergic such vomitting,nausea .
Make sure the patients do not involve activity during
consumption of this drug
Neuroimaging test is good for the patients
Dopamine agonist can cause postural hypotension which the
patient must check the blood pressure frequently
Dopamine agonists also can cause hallucinations and
delusions , if this worsened into compulsive behaviours, must
be tackled by used antipsychotic medications
Monitor the sleep pattern because dopamine agonist can
cause sleep attacks

6.

What information should be provided to the patient to ensure

successful therapy, enhance compliance, and minimize adverse
effects?

Suitable combination therapy for a successful treatment

-Monoamine-oxidase-B inhibitors (MAO-BIs) - selegiline,
rasagiline.
-Oral or transdermal dopamine agonist. Pramipexole,
ropinirole and rotigotine are effective. Initial treatment
with an agonist is recommended in younger patients.
-Levodopa is the most effective symptomatic drug
-Amantadine or an anticholinergic.

-Speech and language therapy - improving loudness and

intelligibility of speech where possible, ensuring methods
of communication are available as the disease progresses
and to help with swallowing
Pharmacological approach
Ensure regular access to specialist care - for clinical
monitoring and medication adjustments.
The diagnosis should be regularly reviewed, particularly
if atypical symptoms or signs develop
Suggests specialist review every 6-12 months

 Suitable combination therapy for a successful treatment

-Monoamine-oxidase-B inhibitors (MAO-BIs) - selegiline,
rasagiline.
-Oral or transdermal dopamine agonist. Pramipexole,
ropinirole and rotigotine are effective. Initial treatment
with an agonist is recommended in younger patients.
-Levodopa is the most effective symptomatic drug
-Amantadine or an anticholinergic.

 Follow Up question (6 months)

1 . It is reasonable which is to introduce the patients
with Non L dopa treatments and the patients still young
age to proceed L dopa treatment
- MAO and Dopamine agonist can treat the patient in
scale of Moderate to mild IPD
2. The side effects from the therapy manifest by the
patients is blurred visions , buying duplicate things and
shopping excessively(compulsive behaviour) , the side
effects mostly coming from dopamine agonist therapy
3. Adjustment drug therapy is to substitute dopamine
agonist to amantadine (200-300 mg). The starting dose
is 100 mg and can be increased until 300 mg

 4. To ensure the successful of therapy is by counselling

the patients about this diseases and give guidelines
about to tackle this symptom. The medications should
be followed strictly to enable patient increase in quality
of life. Family supports is important to increase
motivation for this patient. Make sure patients is inform
the doctor about other supplement she take to avoid
interactions. For such other disease such blurred vision
that persistent, ask to consult with opthalmologist

 Follow up questions (10 years)

1. Patients problems such:
- Tremor , rigidity and stiffness reported with bilateral and
gait problems (dragging right foot)
- Slower and clumsier in any activities (bradykinesia
detected)
- Mild depressions , sleep problems and forgetfulness
- Motor fluctuations such as having off periods
- Unable to move from bed stiffness
- There is little improvement from the UPDSR test
- She is suspected positive is Myerson sign (resist
blinking from glabellar)

 2. Adjustment Of Therapy for the patients is needed as

the patients getting increasing in age and production of
dopamine getting decline. So the first step is to
substitute amantadine to Carbidopa/L dopa CR which is
controlled released. The side effects of L dopa such
wears of , delayed or no response and freezing can
be minimize by using MAO-B inhibitor
Therapy =
MAO- B
Rasagiline (0.5 , 1 mg)
Starting dose = 0.5 , 1mg
Carbidopa/L-dopa CR (400-1000 mg)
Starting dose=25/100,50/200