Physician's Assistant

Patient Details

Rapidreview (89 days ago 03:17)

Rapidreview Wed 07 January 2026 03:17

Last Modified: 89 days ago

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Medical ST5 Miller
Thanks for asking me to see this gentleman where there is a little diagnostic uncertainty.

Patient presents with neurological symptoms following recent medication changes. Reports significant mobility issues with legs feeling weak and unsteady, describing sensation of "being on a ship". Patient describes delayed motor responses where brain sends correct instructions but execution is impaired. Experiences difficulty with bed mobility and positioning, requiring assistance with basic movements.

Recent medication changes include switch from sertraline to mirtazapine and commencement of indapamide. Patient reports these symptoms began after medication changes.

Associated symptoms include urinary incontinence (new onset), weight loss, and generalised weakness. Previous GP, currently lives in Sydney near Macquarie Centre area.

EXAMINATION:
General appearance: Expressionless face, monotone voice
Neurological examination:
- Upper limbs: Lead pipe rigidity with very subtle cogwheeling on right arm, slightly increased tone on left arm. Power 5/5 throughout. Tiny resting tremor noted bilaterally. Reflexes slightly brisk throughout. Normal sensation. Slight dysdiadochokinesia bilaterally, no other cerebellar signs.
- Lower limbs: Power normal when tested supine, tone increased bilaterally, reflexes slightly brisk bilaterally, downgoing plantars, normal coordination when tested supine
- Gait: Unable to assess as patient feels like "on a ship", dizzy and unable to move legs effectively or lift feet when attempting to walk
- Cranial nerves: No significant abnormalities noted
- Vibration and proprioception: Intact

IMPRESSION:
Neuropsychiatric presentation with evidence of increased tone raising the possibility of parkinsonism. Requires further review by neurology team.

Differential diagnoses include:
1. Medication-induced parkinsonism (mirtazapine/indapamide related)
2. Idiopathic Parkinson's disease
3. Normal pressure hydrocephalus (less likely given normal-sized ventricles on recent CT head, but combination of neuropsychiatric symptoms, poor mobility and incontinence raises this possibility)

PLAN:
1. Neurology referral for further assessment of parkinsonian features
2. Psychiatry review to assess whether mirtazapine could contribute to current presentation
3. Physiotherapy assessment for mobility and rehabilitation
4. Continue monitoring symptoms and functional status

No evidence of hydrocephalus with normal-sized ventricles on recent CT head, making normal pressure hydrocephalus less likely in this context.

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Refined ultra rapid review (89 days ago 03:27)

Refined ultra rapid review Wed 07 January 2026 03:27

Last Modified: 89 days ago

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Medical ST5 Miller Review
Thank you for asking me to see this gentleman Dr Kayko.

Neuropsychiatric presentation with mobility issues, incontinence, and recent medication changes. Patient reports feeling like "on a ship" with unsteady gait and weakness.

History:
Patient reports mobility issues with difficulty coordinating movement and following instructions. New onset urinary incontinence. Recent medication switch from sertraline to mirtazapine, also on indapamide. Patient describes feeling weak, particularly in arms, with difficulty with fine motor tasks. Reports feeling unsteady and like "on a ship" when standing.

Retired GP.

Examination:
General appearance: Expressionless face, monotone voice
Neurological examination:
- Upper limbs: Lead pipe rigidity with very subtle cogwheeling on right arm, slightly increased tone in left arm. Power 5/5 throughout. Very subtle resting tremor noted bilaterally. Slight dysdiadochokinesia bilaterally. Normal sensation.
- Lower limbs: Power normal, tone increased bilaterally. Unable to stand independently or assess gait due to patient feeling dizzy and unsteady like "on a ship".
- Reflexes: Slightly brisk throughout
- Plantars: Downgoing
- Coordination: Finger-nose testing normal, heel-shin normal, but overall coordination affected by tremor and rigidity

Impression:
Neuropsychiatric presentation with evidence of increased tone raising possibility of parkinsonism. Differential diagnoses include:
1. Medication-induced parkinsonism (mirtazapine)
2. Idiopathic Parkinson's disease
3. Normal pressure hydrocephalus (less likely given normal-sized ventricles on recent CT head)
4. Reaction to recent medication changes

Plan:
1. Neurology referral for assessment of possible parkinsonism
2. Psychiatry review regarding medication changes and potential causative role of mirtazapine
3. Physiotherapy assessment for mobility and rehabilitation
4. Consider medication review if symptoms medication-related

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Refined rapid review (89 days ago 03:30)

Refined rapid review Wed 07 January 2026 03:30

Last Modified: 89 days ago

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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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