Extrapyramidal OSCE

Question 1

Core features of parkinsonism

Answer 1

TRAP

• Tremor
• Rigidity
• Akinesia (more accurately bradykinesia)
• Postural instability

Question 2

Causes of parkinsonism

Answer 2

idiopathic Parkinson’s Disease
drugs
- lithium
- penothiazine antipsychotics
- atypical antipsychotics (less so)
- metoclopramide
Parkinson’s plus syndrome
- Shy Drager syndrome (autonomic failure)
- Multisystem atrophy (cerebellar and pyramidal features)
- Progressive supranuclear palsy (opthalmoplegia, especially downgaze)
Atherosclerotic pseudoparkinsonism (legs only, less tremor)
Dementia pugilistica
- Parkinsonism secondary to repeated head trauma associated with boxing eg Mohammed Ali

Question 3

Treatments used in Parkinsons Disease

Answer 3

• L-Dopa
• Dopamine agonists eg ropinerole, apomorphine SC infusion,
• anticholinergics eg procyclidine, orphenadrine
• COMT inhibitors eg entacapone
• MAO-B inhibitors eg selegiline
• glutamate antagonists eg amantadine

Question 4

Conditions with similar presentation to Parkinson’s Disease

Answer 4

1) Benign essential tremor

2) Wilson’s tremor
- tremor
- dyskinesias
- psychiatric illness
- hepatotoxicity
- Kaiser-Fleishcer rings in eyes

Question 5

Long term complications of L-Dopa therapy

Answer 5

• Increasingly severe Parkinsonism
• Autonomic neuropathy
• Dysphagia
• Dementia
• Dyskinesias
• Motor fluctuations (on-off / end of dose)

Question 6

DDx of tremor

Answer 6

• Resting: Parkinsonism
• Flapping: hepatic failure (encephalopathy), respiratory failure, renal failure
• Intention: cerebellar lesion
• Postural: benign essential tremor, physiological tremor

Question 7

Benign essential tremor vs exaggerated physiological tremor

• aetiology
• examination
• management
• other info

Answer 7

Benign essential:

• aetiology: unknown, genetic component likely (family hx in 50%)
• exam: mild assymetry common, slower (~7Hz), titubation in 50%, postural & action
• Mx: beta-blockers, gabapentin if contraindicated
• Other info: improvement with alcohol, progressive

Exaggerated physiological

• aetiology: fever, hyperthyroidism, anxiety states, medication-induced (eg salbutamol)
• exam: usually symmetrical, faster (~5Hz), no titubation, usually purely postural (abolished on action)
• Mx: treat/remove cause if possible, beta-blockers (or gabapentin) sometimes needed.
• Other info: non-progressive