Physical Examination

Key Facts

Conduct a full neurological examination.
Rule out other conditions before diagnosing PD.
Sensory examination is usually unremarkable in PD.
Confirmatory diagnosis by a neurologist or movement disorders specialist is recommended.
Examine skin, given increased risk of melanoma.

Clinical Best Practices

Perform a full medical evaluation with a thorough neurological examination.
Confirmatory diagnosis by a neurologist or movement disorder specialist is recommended.

Many of the signs of PD are readily visible to the examiner in the majority of patients. The 4 cardinal symptoms including tremor, rigidity, akinesia/bradykinesia and postural instability should be evaluated. However, it is important to ask for and evaluate non-motor symptoms which are harder to identify and may not be specific.

Examination Component	Findings and what they may mean
Mental status	Cognitive impairment on the MMSE or MoCA may indicate cognitive impairment and/or dementia If visual hallucinations and dementia are present before or within a year on parkinsonism onset, then consider the diagnosis of dementia with Lewy Bodies (DLB) Depression, apathy and anxiety are common but not exclusive of PD
Cranial nerves	Impaired vertical eye movements would make one suspicious of progressive supranuclear palsy (PSP) Check for hyposmia-it is usually an early marker of PD. You can use the UPSITⁱ test Masked face is typical in PD PD patients may have a soft voice and /or mumbled or fast speech
Motor Examination	Asymmetric resting tremor with bradykinesia on one side is very typical of PD PD tremors may occur in the tongue, jaw, lower lip, hand, or in the leg/foot PD tremor worsens with distracting the patient with mental tasks, etc Cogwheel rigidity is typical of PD Many patients have drooling due to reduced spontaneous swallowing of saliva Diminished gesturing is common in PD Micrographia is typical of PD
Sensory examination	Impaired position sense in the toes may indicate that the patient has a sensory ataxia on top of PD gait problems Sensory examination is usually unremarkable
Coordination examination	Conduct a dexterity test. Ask patient to finger tap. Finger taps should have not only a maintained speed over 10-15 seconds but a maintained amplitude as well; slowing of speed, decrement of amplitude, and pauses/arrests in finger and foot taps are consistent with bradykinesia Ataxia would make one concerned about the possibility of multiple system atrophy (MSA)
Deep tendon reflexes	Asymmetry of reflexes and up going plantar responses (Babinski sign) may indicate prior strokes/brain infarcts and vascular parkinsonism; or an up going toe would be suggestive of MSA
Gait and balance	Gait dysfunction is frequently multifactorial, and not just related to parkinsonism Freezing of gait is related to PD A PD patient may have difficulties in rising from the chair A PD patient may have difficulties in taking the first step A PD patient may have limitations in turning Reduced arm swing is common in PD Postural instability is common. It can be measured with the Pull Testⁱ. PD patients may have problems maintaining their balance Timed Up and Go (TUG) test can be helpful for evaluation
Other	Check for skin changes-melanoma