Examination findings

• The patient exhibited pill-rolling unilateral tremor in the left arm.
• She also had cogwheeling rigidity at the left wrist.
• Body stooping was evident, with reduced arm swing bilaterally on walking.
• The pull test was positive, and leg tone increased bilaterally.
• Dopaminergic therapy trials were carried out
  - Co-beneldopa (benserazide hydrochloride and levodopa) 125 bd was given which led to
  dizziness and worsened her tremor
  - Ropinirole was tolerated only to 1mg tid but with no observable benefit
  - Selegiline 5mg bd was tolerated but with minimal benefit.
• Levodopa was then re-instituted as Sinemet Plus with domperidone cover, titrated slowly to 400mg.
• Her tremor was minimally responsive, with improved mobility.
• In the light of the minimal, uncertain benefit of dopaminergic therapy and history of intolerance, the clinician wanted to confirm the patient had Parkinson’s disease before continuing with increased dose.

DaTSCAN imaging