Parkinsonism

Question 1

List the four main symptoms of parkinsons

Answer 1

Tremor (4-6 hrz in resting limb)
Rigidity
Akinesia
Postural instability

Will see limb bradykinesia (slowness in movements and decreased amplitude)
Loss of facial expression
Shuffling gait
Difficulty with small movement or opening jars
Difficulty with transitions like moving in bed or rising from a chair
Micrographia

Question 2

List three important questions to ask on history for tremor

Answer 2

1. Medications-Long term antipsychotics? Extrapyramidal?
2. Alcohol-During withdrawl, better with alcholhol-Essential
3. When do they have the tremor-At rest? Probably parkinsons

Question 3

What is a physical exam finding that can point to cerebellar cause of tremor

Answer 3

Past pointing and dysdiadochokinesia

Question 4

What Blood work should you get for tremor

Answer 4

TSH
NA
MG
Ca
B12 
A1C

Question 5

DDX for parkinsons

Answer 5

Essential tremor-Intention tremor better with alcohol
Hyperthyroidism
Drug induced
Cerebellar disorder-Past-pointing (MS, Stroke, tumor)
Dementia
Progressive supranuclear palsy-Slow vertical gaze, falls
Multiple system atrophy-No improvement with Leva dopa

Question 6

When would you warn someone they may have a more rapid course of parkinsons

Answer 6

Older
Rigidity or hypokinesia as initial symptom (vs tremor)
Early autonomic and cognitive changes

Question 7

List three reasons you could NOT diagnose someone with parkinsons

Answer 7

Cerebellar signs
Supranuclear gaze palsy
No response to levadopa

Question 8

List five red flags for tremor

Answer 8

Rapid deterioration of gait
Resp dysfunction
Early severe autonomic failure
Bilateral, symmetric presentation (Usually unilateral and progresses to bilateral)

Question 9

First line treatment and how effective is it and how effective at confirming diagnosis

Answer 9

Leva dopa
30% don’t respond
20% who respond have other dx

Question 10

Other than leva dopa, name three other treatment options

Answer 10

Dopamine Agnoists (pramipexole)
MAOB inhibitors (rasagiline) 
Deep Brain stimulation 

2nd line:
Anticholinergics
Apomorphine infusions-Warn for impulse control and motor complications

Question 11

List four non tremor symptoms you should watch for and treat to improve quality of live

Answer 11

Constipation
Drooling
Erectile Dysfunction 
Hypotension
Depression 
Sleep issues
Incontinence

Question 12

If you are going to start a parkinsons patient on Antipsychotics which should you choose

Answer 12

Quetiapine and clozapine

Question 13

List five non pharm treatments

Answer 13

One large meal at the end of the day (protein) 
Decrease alcohol 
Increased salt intake
Telt bed
Compression stockings 
Referrals: 
Movement disorder
Palliative
Dietitian 
SLP
PT
OT
Neurology

Question 14

What pharm can you use to treat hypotension

Answer 14

Midodrine (alpha 1 agonist)

Fludrocortisone (steroid)