Medical Emergencies · patient case question
All of the following are features of Parkinson disease EXCEPT:
Patient case: 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.
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.
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