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A 68 yo right-handed retired business executive was referred to your
office because of tremor in his right hand. He had been in good health until
approximately 6 months before the office visit. Since then he has noticed
a tendency for his right hand to shake when he is not paying attention to
it. He has no trouble holding a cup of liquid or shaving with a razor, but
his hadwriting has become smaller and more difficult for him to produce.
He has also noticed trouble getting in and out of his car and in and out
of his favorite chair at home. He attributed this to "old age". Another
disturbing change has been the appearance of dandruff which has been resistant
to frequent shampooing with special shampoos.
His physical examination is unremarkable except for scaling of his oily,
skin expeially around the scalp. His gait is abnormal. He appears stiff
and has trouble turning. He tends to trun slowly with small steps. His
right arm does not swing. He can get up from a chair by using his hands
to pusch off. He cannot get up from a chair with hsi arms crossed in front
of his chest. There is a 3-5 Herz, resting tremor of the right hand which
the patient can suppress by holding his hand or soing some activity with
it. Tapping the space between his eyes results in a continued eyeblink
with no adaptive attentuation (Myerson's sign). There is cogwheeling present
in the right wrist and some increased tone in the right arm. He has full
strength, symmetrical 2+ deep tendon reflexes and normal appreciation
of all sensory modalities.
Questions:
- Name at least three causes of tremor in the elderly?
- Give at least five causes of Parkinson's Syndrome.
- Draw a diagram of the connections in the basal ganglia. Identify the
changes in these connections in Parkinson's Disease. Explain how this
leads to bradykinesia.
- Describe the current indications for treatment with each of the
following n Parkinson's Disease.
- Medications containing L-DOPA
- Dopamine agonist medication
- Ablative brain surgery
- Deep brain stimulation
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