Medical Emergencies · patient case with 3 questions
The tremor that came before the toothache
demo: 74-year-old male, brought by his daughter
chief: Broken lower molar and difficulty maintaining oral hygiene.
history: Parkinson disease diagnosed six years ago. He now lives with his daughter and rarely leaves the house; she manages his transport and his brushing. Two weeks ago he had his annual influenza vaccination, and since then she reports he has become noticeably weaker in both legs, though he has no fever.
meds: Carbidopa-levodopa. No anticoagulants.
findings: Masked facies with reduced blink rate. Pill-rolling tremor of the right hand at rest that settles when he reaches for an object. Generalised plaque accumulation and drooling. Symmetrical ascending weakness of the lower limbs with absent ankle reflexes.
Question 1
All of the following are features of Parkinson disease EXCEPT:
Show answer and explanation
Correct answer: A. Loss of vision
- A. Correct, and this is the exception. Blindness is not a feature. Reduced blink rate causes dry, irritated eyes and some patients report blurring, but the visual pathway itself is not affected by the loss of dopaminergic neurons in the substantia nigra.
- B. Bradykinesia, the slowing and progressive decrement of movement, is required for the diagnosis. It underlies micrographia and the shuffling gait.
- C. A resting pill-rolling tremor that diminishes on purposeful movement is the classic sign. The mnemonic TRAP covers tremor, rigidity, akinesia and postural instability.
- D. Akinesia, meaning difficulty initiating movement, is a core feature. It produces the hesitation at doorways and the freezing of gait these patients describe.
Question 2
What is the most likely explanation for the new symmetrical ascending weakness two weeks after his influenza vaccination?
Show answer and explanation
Correct answer: D. Guillain-Barre syndrome
- A. Parkinson disease causes rigidity and bradykinesia, not flaccid weakness with areflexia, and it does not deteriorate abruptly over two weeks in this pattern.
- B. Myasthenia gravis causes fatigable weakness that worsens through the day, characteristically affecting extraocular and bulbar muscles first with ptosis and diplopia, and it preserves reflexes.
- C. Amyotrophic lateral sclerosis is slowly progressive over months, is typically asymmetrical, and mixes upper motor neuron signs such as hyperreflexia and spasticity with lower motor neuron wasting and fasciculations. Its reflexes are usually brisk, not absent.
- D. Correct. Guillain-Barre syndrome is an acute inflammatory demyelinating polyradiculoneuropathy that follows an immunological trigger, classically Campylobacter infection but also vaccination, by one to three weeks. It gives symmetrical ascending weakness with loss of deep tendon reflexes and little or no fever. It is a medical emergency because it can ascend to the respiratory muscles.
Question 3
The daughter mentions that many of her father's friends are also housebound. Which statement about homebound patients is correct?
Show answer and explanation
Correct answer: B. They represent an underserved population that is growing in number
- A. The reverse is true. Reduced access, dependence on carers for daily hygiene, polypharmacy causing xerostomia and high-frequency soft diets all combine to increase disease.
- B. Correct. Homebound and long-term care residents are a recognised underserved group, and their numbers are rising as the population ages and more people live longer with chronic disease. Access is limited by transport, mobility, cognition and cost, and their rates of untreated disease exceed the general population.
- C. No federal statute requires an individual dentist to make domiciliary visits. Portable and mobile dentistry is voluntary, and the resulting access gap is exactly the problem.
- D. Traditional Medicare Part A and B exclude routine dental care. Some Medicare Advantage plans add limited dental benefits, but coverage is far from comprehensive.