tremor stiffness slowness balance problems gait disturbance in question stem --- most likely diagnosis?
Parkinson disease
symptoms of Parkinson disease
Bradykinesia - / hypokinesia/ akinesia
- limb bradykinesia
- loss of facial expression
- loss of arm swing
- difficulty with fine movement, “micrographia”
Rigidity (stiffness)
- cogwheeling
Tremor
- resting tremor 4-6Hz, suppressed by initiating movement
Trouble turning in bed Trouble opening jars Shuffling gate Trouble rasing from a chair Glabellar Tap difficulty walking heel-to-toe
Late symptoms of Parkinson disease
- Postural instability (e.g. pull test)/ frequent falls
- cognitive impairment / dementia/ psychotic symptoms/ depression
- sleep disturbance - daytime hypersomnolence + nocturnal akinesia
- autonomic dysfunction (GI, orthostatic hypotension, excessive sweating)
DDx of tremor
- essential tremor
- hyperthyroidism
- drug induced (e.g. beta agonist)
- cerebellar disorder
DDx of Parkinsonian syndrome
- Alzheimer’s
- Multiple cerebral infarcts
- drug induced (e.g. metaclopramide, antipsychotics, lithium)
- multiple system atrophy
- progressive supranuclear palsy
MDS clinical diagnosis of Parkinsonism
bradykinesia plus rest tremor or rigidity
clinical criteria of clinically established PD
All of the 3:
1 ) No absolute exclusion criteria
2) = or > 2 supportive criteria
3) No red flags
Clinically Probable PD diagnostic criteria
- Absence of absolute exclusion criteria
2. Presence of red flags counterbalanced by supportive criteria
Absolute exclusion criteria of PD
- Cerebellar sign
- Supranuclear gaze palsy
- Established diagnosis of behavioural variant fronto-temporal dementia
- Parkinsonism restricted to the lower limbs only for >3 yrs
- Tx with an antidepaminergic or w/ dopamine-depletion agent
- Absence of response to levodopa
- Sensory-cortical loss
- No evidence for dopaminergic deficiency on functional imaging
- Other parkinsonism-inducing condition
If using ergot-dopamine agonists, what regular investigations are needed?
Annually
- Cr
- ESR
- CXR
what are the risks of quick withdrawal of sudden fail of PD medical treatment?
- risk of acute akinesia
- neuroleptic malignant syndrome
What are the symptoms of neuroleptic malignant syndrome?
> > Muscular rigidity (typically, “lead pipe” rigidity)
Shuffling gait
Tremor
Dysphagia
> > Hyperthermia (temperature >38°C)
>> Autonomic dysregulation Diaphoresis Pallor Tachycardia Dyspnea Incontinence
> > Changes in the level of consciousness
Psychomotor agitation
Delirium progressing to lethargy, stupor, coma
Management of neuroleptic malignant syndrome ?
- discontinue all neuroleptic agents
- mainly supportive, monitoring and management in an ICU suggested
- controlling the rigidity and hyperthermia and preventing complications (eg, respiratory failure, rhabdomyolysis, renal failure)
- trial of dantrolene and bromocriptine to hasten clinical response
- amantadine, lorazepam, and electroconvulsive therapy
classes of PD medications
First-line
1 ) Levodopa
2) dopamine agonist
3) MAOB inhibitors
2nd line
- Anticholinergics
- Beta adrenergics for postural tremor
- Amantadine
- selective and reversible inhibitor of the enzyme catechol-O-methyltransferase (COMT) - Entacapone (for late Parkinson’s)
symptoms of dopamine dysregulation syndrome
on dopaminergic medications, associated with
- impulse control disorder
- abnormal behavior
- hypersexuality
- pathological gambling
Non-pharmacological treatment for PD
- deep brain stimulation of the STN
- GPi
- unilateral pallidotomy
- refer to PT/OT/SLP
- consider most of daily protein in last meal ( NO decrease total protein) if on levodopa AND having motor fluctuations
- take vitamin D
list common cormorbid illness with PD
- depression: do not treat psychotic symptoms, only consider quetiapine or clozapine
- dementia
- sleep disorder
- drooling/ salivation
- urinary urgency/ incontinence
- constipation
- orthostatic hypotension
- erectile dysfunction
Migraine prophylaxis - classes of meds
- beta blocker (metoprololor/ propranolol)
- anticonvulsants (topiramate or valproic acid - teratogenic)
- tricyclic antidepressants (amitriptyline)
- calcium channel blocker (Verapamil)
- ACE inhibitor or ARB (Candesartan)
- Gabapentin
First line Rx of moderate - severe migraine
Triptan +/- NSAIDs (triptan at onset of pain)
contraindication of using triptans
- CVD (CVA, TIA, MI, PVD, coronary spasm, Prinzmetal angina)
- WPW
- pregnancy
- basilar migraines
- ergotamine in previous 24 hours
Migraine diagnosis criteria
A) At least 5 attacks fulfilling criteria B, C, and D
B) Attack lasting 4 to 72 hours (untreated or unsuccessfully treated)
C) Having at least two of these characteristics:
- aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
- moderate or severe pain intensity
- pulsating quality
- unilateral location
D) Having at least one of these conditions during the headache:
- nausea and/or vomiting
- phonophobia or photophobia
conditions when NO CT needed to diagnose migraine
4 of 5 POUND
- pulsatile
- duration 4-72 hours
- unilateral
- nausea
- disabling
Red flags of headache (SNOOP) - needs CT
S - systemic (HTN, fever, wt loss, myalgia, scalp tenderness)
N - neuro symptoms, focal neuro deficits, LOC, visual field defect, CN asymmetry
O - onset: sudden, abrupt, split second
O - older: new or progressive > 50 y/o
P - previous hx: 1st? new/ different, change nature/ severity
S - 2nd risk factors: HIV, CA, ***precipitated by Valsalva (cough, sneeze, bending over)
Nonpharmacologic therapies for migraine prophylaxis
- Relaxation training
- Thermal biofeedback combined with relaxation training
- Electromyographic feedback
- Cognitive behavior therapy (CBT)
-
Respi51
-
Psychiatry31
-
Cardio/Hema16
-
Rheuma14
-
GYNE28
-
Gastro57
-
periodic health and screening36
-
Infectious Disease37
-
OB55
-
Neurology31
-
old questions49
-
pediatrics18
-
endocrine12
-
GU/ nephrology26
-
Old SAMPS32
-
Ortho & MSK17
-
FM Vital 52
-
SAMP FMRC 2018 - Sept3089
-
SAM 201990
-
SAM 202039
-
cfpc self-learning5
