Case Files 55-60 (J)

Question 1

46yo female complains of hand tremor that is severe when trying to use a spoon or pen and goes away when she relaxes. In the office she struggles with the finger to nose test.

What is the most likely diagnosis?
What is the next diagnostic step?
What is the next step in treatment?

Answer 1

Most likely diagnosis is Essential tremor

The next diagnostic step is to investigate medications, alcohol, thyroid, and Wilson’s (if

Question 2

What is the most common movement disorder?

Answer 2

Essential tremor affects up to 5% of those >60

Parkinsons affects 1% of those >60

Question 3

What are the risk factors for Essential Tremor?

Answer 3

family history, EtOH, caffeine, smoking, stimulants.

Question 4

Whats the difference between chorea and hyperkinesia?

Answer 4

chorea is involuntary jerky movements

hyperkinesia is involuntary exaggeration of voluntary movements.

Question 5

an 82yo male presents with distal resting tremor, rigidity, bradykinesia, and postural instability that started on the left side and spread to the right (asymmetric onset).

What is the most likely diagnosis?
What is the cause?
What is the next step in treatment?

Answer 5

Most likely diagnosis is Parkinson Disease

The cause is depletion of dopamine in the substantia nigra and proliferation of lewy bodies (intracytoplasmic inclusions)

The next step in treatment is levadopa (with or without carbidopa), MOA-B inhibitors, and dopamine agonists (pramipexole and ropinirole)

Question 6

What is the most common neurodegenerative disorder?

Answer 6

Parkinson

Question 7

A 12yo male presents with his mother complaining of an increase in a tic that he has had since he was younger. He states that he can usually control them if he concentrates but that they get worse when he gets tired.

What is the most likely diagnosis?

What is the next step in treatment?

Answer 7

Most likely diagnosis is Tourette Syndrome

The next step in treatment is CBT and treating any comorbid ADD/ADHD/OCD. If that doesn’t work clonidine or haloperidol

Question 8

a 40yo man presents with slow onset of chorea. Family history is significant for a father and grandfather who died young.

What is the most likely diagnosis?
What is the cause?
What is the next step in treatment?

Answer 8

Most likely diagnosis is Huntington Disease

The cause is CAG repeats on Chr 4.

There is only palliative treatment.

Question 9

a 21yo male is given haloperidol for his tourette syndrome. He feels that it is not working and decided to double his dose. Within a week he had stooped posture and a shuffling gait with a resting tremor.

What is the most likely diagnosis?
What is the cause?
What is the next step in treatment?

Answer 9

Most likely diagnosis is neuroleptic effect causing parkinsonism

The cause is the haloperidol (a butyrophenone)

Treatment is to stop the haloperidol.

Question 10

a pt with parkinson is suffering from acute onset dyskinesia and dementia. What is the treatment?

Answer 10

decrease her carbi/levo

Question 11

A 19yo soldier presents to your office with a 3 month history of runny nose, itchy eyes, cough, and wheezing. He states that it is better on the weekends. He states that he was taking benadryl but its not working any longer. PE reveals hyperemic, boggy turbinates; prolonged I:E ratio and wheezing.

What is the most likely diagnosis?
What is the next diagnostic step?
What is the next step in treatment?

Answer 11

Most likely diagnosis is Allergic Asthma

The next diagnostic step is pre and post beta-agonist peak flows. Followed by PFTs, CXR, and allergy testing

The next step in treatment is:

• Short acting bronchodilator ie a beta2-agonist PRN (intermittent)
• above plus long acting bronchodilator ie a beta2-agonist or leukotriene inhibitor daily (Mild persistent)
• above plus inhaled corticosteroid daily (moderate persistent)
• above plus home O2 (severe)

Question 12

How do you classify asthma by how often symptoms wake you at night?

Answer 12

1x/week (moderate persistent)

nightly (severe)

Question 13

What is the 1st line treatment of an acute asthma exacerbation? 2nd line?

Answer 13

albuterol nubulizer

ORAL corticosteroids

Question 14

How do you classify asthma by how often the pt uses their short acting bronchodilator?

Question 15

How do you classify asthma by a patient’s FEV & FEV1/FVC:

Answer 15

> 80% & >85% (intermittent)

> 80% & >80% (Mild persistent)

60-80% & 75-85% (moderate persistent)

Question 16

a 45yo obese man presents to your office for fatigue. His wife says he snores.

Whats the most likely diagnosis?

Whats the next diagnostic step?

Whats the treatment?

Answer 16

Most likely diagnosis is Obstructive Sleep Apnea

The next diagnostic step is a sleep study

The treatment is CPAP and weight loss

Question 17

How do we classify OSA?

Answer 17

by their respiratory disturbance index (RDI) which is how many times per hour they stop breathing.

5-15 is mild
15-30 is moderate
>30 is severe

Question 18

a PT recently diagnosed with OSA and prescribed a CPAP comes in complaining of discomfort when they use it. What is the most likely cause of their discomfort?

Answer 18

Though it does take some adjusting to sleeping with the pressure, most discomfort stems from dry nasal membranes. Add some humidification.

Question 19

According to the USPSTF who should be screened for osteoporosis?

Answer 19

women >65yo and those with a 10year FRAX risk>9.3%

Question 20

What is the screening tool for osteoporosis?

Answer 20

DEXA scan

Question 21

What DEXA finding is diagnostic of osteoporosis?

Answer 21

T score of -2.5 or more in any one site

Question 22

What are the treatments for osteoporosis?

Answer 22

Bisphospohonates (alendronate)

SERMS

Calcitonin

Teriparatide

Question 23

What are the classic side effects to watch out for with bisphosphonates?

Answer 23

erosive esophagitis (this is why it should be taken with a full glass of water and >30min before bed) and osteonecrossis of the jaw (if received IV)