Physician's Assistant

Refined rapid review Wed 07 January 2026 03:30

Last Modified: 89 days ago

MRN:

Content:

ST5 Miller Clinical Review Note

Reason for review:
Neuropsychiatric presentation with mobility issues

Background:
Patient is a GP from Sydney (Macquarie Centre area). Recently switched from sertraline to mirtazapine and started on indapamide. Experiencing new-onset mobility difficulties and incontinence.

History:
Patient reports difficulty with movement coordination - feels like his body is not responding properly to instructions from his brain. Describes delayed responses and wrong movements. New onset urinary incontinence. Significant weakness in arms and difficulty with fine motor tasks like bringing thumb to little finger. Reports feeling like he's "on a ship" with unsteadiness and room movement sensation. Symptoms developed after medication changes from sertraline to mirtazapine, with concurrent indapamide therapy. Recent hyponatraemia has since normalised.

Examination:
Neurological examination reveals:
Upper limbs: Lead pipe rigidity and very subtle cogwheeling on right arm with slightly increased tone in left arm. Power 5/5 throughout. Reflexes slightly brisk throughout. Normal sensation. Slight dysdiadochokinesia bilaterally. No other cerebellar signs.
Lower limbs: Power normal, tone increased bilaterally, reflexes slightly brisk bilaterally throughout, downgoing plantars, normal coordination.
Gait: Unable to stand independently or assess gait as patient feels dizzy like "on a ship" and unable to move legs effectively.
General appearance: Expressionless face and monotone voice noted.

Investigations:
CT Head (recent): Normal sized ventricles, no evidence of hydrocephalus

Impression:
Neuropsychiatric presentation with evidence of increased tone raising possibility of parkinsonism. Differential includes medication-induced symptoms from recent mirtazapine switch. Normal pressure hydrocephalus less likely given normal CT head, though combination of neuropsychiatric symptoms, poor mobility and incontinence raises this possibility.

Plan:
1. Neurology team review for further assessment of possible parkinsonism
2. Psychiatry team review to assess whether mirtazapine could cause this clinical picture
3. Physiotherapy assessment for full mobility evaluation
4. Focus on rehabilitation management
5. Consider dopaminergic assessment given subtle resting tremor and rigidity

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Summary:

Investigations:

Refined rapid review Wed 07 January 2026 03:30

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