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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 59 OF 100
A 58-year-old man presents for evaluation of tremors and falls for the past 18 months. The tremor always has been severe in the left hand but has been noticeable in the right hand for the past 12 months. The tremors are most bothersome when he is sitting in a chair and not as prominent when he is moving around. He states he started falling about the same time the tremor began but denies experiencing lightheadedness or vertigo prior to a fall. He has no other explanation except that he “just trips.” Examination reveals a 4-Hz rest tremor in both hands, with much higher in amplitude on the left, and rigidity in both arms that is worse when he performs repetitive tasks with the contralateral hand. The patient was previously diagnosed with Parkinson’s disease yet has not responded to dopaminergic therapy. Thus, atypical parkinsonism is considered based on his lack of treatment response, in addition to which of the following atypical clinical features?
A. Asymmetry of tremors
B. Patient age at onset
C. History of early and frequent falls **
D. Worsening rigidity with contralateral movement
E. Improvement of tremors with activity
** = Your answer
Atypical parkinsonian syndromes often are similar in presentation to idiopathic Parkinson’s disease; therefore, it is important to identify signs and symptoms more suggestive of these conditions. Examples include early gait instability or falls, rapid progression of symptoms, and a poor response to levodopa therapy. Experiencing a fall at the onset of tremors is concerning in this patient and is not typical in Parkinson’s disease. The other clinical characteristics listed are common in Parkinson’s disease, and although they also may be present in an atypical parkinsonian syndrome, their presence would not necessarily point toward one.
* McFarland N. Diagnostic approach to atypical parkinsonian syndromes. Continuum Lifelong Learning Neurol. 2016;22(4):1117-1142.