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Neurology: tremor

Mr Green is a 75 year old man known to suffer with Parkinson’s disease. Which of the following make up the classical triad of signs?

Describe the gait you might expect to see in Mr Green.

What is the cause of Parkinson’s disease?

Degeneration of dopaminergic neurons affecting the nigrostriatal tract occurs in Parkinson’s disease, but what are the other 3 dopaminergic pathways?

When Mr Green first presented 3 years ago he complained of a shaking in his left hand that was getting worse. He had not noticed any tremor on the right side. His GP referred him to a neurologist who took a detailed history in order to try and rule out some of the other causes of Parkinsonism. Which of the following may cause Parkinsonism?

Although Mr Green had recently been taking haloperidol the doctor did not believe this was the cause of his symptoms. Based on the information you have been given so far what is the most likely reason for this conclusion?

Treatment of Parkinson’s disease involves a multidisciplinary team. Drug therapies tend to be delayed as limited medications are available (i.e. few alternative treatment options when maximum dose reached), and increased doses are more commonly associated with side effects. Mr Green, after discussion with his neurologist, has decided that his symptoms are bothersome enough that medication should be started. His neurologist suggests that they start with a dopamine agonist to delay the need for levodopa. Which of the following belong to this class of drug?

Before prescribing the new medication (ropinirole) the neurologist checks Mr Green for cardiovascular risk factors – in particular he asks when his blood pressure was last checked. Why is this?


 
Mr Green starts with the Ropinirole and manages to control his symptom well, and restore his quality of life.
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Parkinsonian gait before and after treatment.



Parkinsons brain

Areas of the brain. Peter Lavelle ©.



Dopamine pathway

The role of dopamine in Parkinson's disease. Aging Sciences ©.










Pin-rolling tremor, a typical tremor of Parkinson's dsease.














Tardive dyskinesia is a side effect of dopaminergic treatment which may be irreversible.