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For your information.



Clinical Manifestations

Cardinal features of Parkinson's disease include

1. Resting tremor generally of one hand or foot, often unilateral, which ceases with movement. Tremor also may be noted in the lips, chin, and tongue.

2. Rigidity, manifested by increased resistance to passive range of motion. Cog-wheel rigidity often can be elicited in the wrists and elbows.

3. Akinesia and bradykinesia.

4. Disturbances of gait. Festination is a quickened gait with the body propelled forward.

Patients with Parkinson's disease also may have

1. Loss of righting reflexes

2. Postural changes

3. Masked facial expressions and delayed ability to demonstrate facial expressions (hypomimia)

4. Decreased blinking

5. Hypophonia/dysarthria

6. Micrographia

7. Depression

8. Dementia

9. Constipation

10. Seborrhea

11. Impotence

12. Urinary incontinence

13. Myalgia

14. Sleep disturbances (Kennedy-Malone & Loftus-Fader, in press).



Diagnostic Evaluation

1. Diagnosis requires finding two of the three cardinal signs: bradykinesia, resting tremor, or rigidity.

2. There are no histologic indicators for Parkinson's disease.

3. Magnetic resonance imaging (MRI) may be ordered to rule out suspected brain lesions or abnormalities such as normal pressure hydrocephalus.

4. A clinical response to carbidopa/levodopa provides a strong indication of Parkinson's disease.

5. Positron emission tomography (PET) scanning has been used in the evaluation of levodopa uptake and conversion to dopamine in the corpus striatum. Clinicians use PET scans to confirm the diagnosis of Parkinson's disease before surgery.



Differential Diagnosis

1. Essential benign familial tremor is characterized by involuntary rhythmic shaking or tremor, usually involving the hands, head, voice, or other body parts. Essential tremor, which is 10 to 20 times more prevalent than Parkinson's disease, is an action tremor. It can be postural or kinetic in nature. This tremor is more prominent with voluntary movement such as eating or drinking.

2. Huntington's disease is clearly genetic in origin. It is an autosomal dominant inherited neuropsychiatric disorder that presents in adult life (usually in patients younger than 40 years). Symptoms include personality and mood changes, chorea, clumsiness, and cognitive decline. Apathy, irritability, and depression are common. Huntington's disease is a deteriorating illness that ultimately results in death after a 15- to 20-year duration of the disease.

3. Shy-Drager syndrome is a neurodegenerative disorder characterized by bradykinesia, rigidity, minimal tremor, and poor response to dopamine. Shy-Drager displays early and prominent autonomic nervous system dysfunction.

4. Progressive supranuclear palsy signs and symptoms include early gait disturbances characterized by falls and axial rigidity, with nuchal dystopia, facial spasticity, and supranuclear gaze abnormalities. Cognitive and behavioral abnormalities are present.

5. Creutzfeldt-Jakob disease is a rare neurodegenerative disease. In 10% of the cases, it is inherited in an autosomal dominant fashion. Creutzfeldt-Jakob disease has been transmitted by accidental inoculation through contaminated corneal transplants, dural grafts, intracerebral electrodes, and human growth hormone preparations. Symptoms include malaise, impaired sleep, altered eating patterns, and rapid progressive syndrome of mental deterioration associated with extrapyramidal, pyramidal, cerebellar, visual changes, lead-pipe rigidity, and myoclonus. The cognitive deficits in Creutzfeldt-Jakob disease present as cortical dementia with aphasia, agnosia, amnesia, apraxia, hallucinations, and delusions.

6. Normal-pressure hydrocephalus, also known as symptomatic hydrocephalus, presents with gait apraxia, urinary incontinence, and dementia (Aminoff, 1997).



(¥H¤WºK¦ÛLippincott's Primary Care Practice Vol.3(2)1999 pp 169-173)



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