Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Follow-up for diagnosed Parkinson’s disease (monitoring response to
treatment, symptoms)
Evaluation of new or worsening motor symptoms (tremor, rigidity,
bradykinesia)
Assessment of non-motor symptoms (e.g., cognitive decline,
depression, sleep disturbances)
Medication review or adjustment
History of Present Illness:
Onset and duration of Parkinson’s disease symptoms.
Progression of motor symptoms (tremor, rigidity, bradykinesia)
since last visit.
Development of new or worsening non-motor symptoms (e.g., cognitive
decline, depression, sleep disturbances, constipation).
Response to current medications and any side effects experienced.
Past Medical History:
Underlying medical conditions (e.g., cardiovascular disease,
diabetes).
Previous surgeries (relevant surgeries on the brain).
Family History:
Family history of Parkinson’s disease (uncommon, but increases risk).
Social History:
Impact of Parkinson’s disease on daily activities (work,
hobbies, independence).
Social support system (important for coping with the disease).
Medications:
List of current Parkinson’s medications (e.g., levodopa,
carbidopa/levodopa, dopamine agonists, MAO-B inhibitors, COMT inhibitors).
Dosage and frequency of each medication.
Physical Examination:
General examination: Assess for signs of autonomic dysfunction
(e.g., orthostatic hypotension).
Neurological examination: Evaluate for cardinal features of
Parkinson’s disease (resting tremor, rigidity, bradykinesia, impaired postural
reflexes). Assess for gait and balance impairments. May also include
cognitive testing if indicated.
Assessment:
Parkinson’s disease: Confirmed diagnosis based on clinical
presentation (cardinal motor features) and course of the disease.
Stage of Parkinson’s disease: Consider using Hoehn and Yahr
staging system to classify the severity of motor symptoms.
Motor symptom response to treatment: Evaluate the effectiveness of
current medications in controlling tremors, rigidity, and bradykinesia.
Non-motor symptoms: Identify and assess the severity of
non-motor symptoms (cognitive decline, depression, sleep disturbances,
constipation).
Differential Diagnoses:
Consider other conditions that may mimic Parkinson’s disease:
Other movement disorders (e.g., essential tremor, Lewy body
dementia, progressive supranuclear palsy)
Drug-induced parkinsonism (side effect of certain medications)
Normal pressure hydrocephalus
Plan:
Treatment plan: May include adjustments to current medications,
addition of new medications, or referral for physical or occupational
therapy.
Medications: Adjust medication dosages or consider adding
different classes of medications to optimize motor symptom control
and manage non-motor symptoms. Consider potential side effects
of each medication.
Non-pharmacological therapy: Physical therapy and
occupational therapy can help improve gait, balance, and activities
of daily living. Speech therapy may be helpful for speech
difficulties.
Patient education: Educate the patient about Parkinson’s disease,
treatment options, and coping strategies.
Follow-up: Schedule regular follow-up visits to monitor symptoms,
adjust treatment as needed, and address any complications.
Consideration of specialist referral: Referral to a
movement disorders specialist may be necessary for complex cases or
consideration of advanced therapies (e.g., deep brain stimulation).
Prognosis:
Parkinson’s disease is a progressive neurodegenerative disorder,
but treatment can help manage symptoms and improve quality of life. Early diagnosis and intervention are crucial for optimal outcomes.