A 70 year Old Man Comes In With Complaints Of Hand Tremors And Shakiness.

A 70 year old man presents to a neurologist accompanied by his wife. His wife says that she first noticed the tremors in her husband's hands 6 months ago., but it has gradually worsened since that time. The tremor seem to be present both at rest and during activity.The tremor nearly resolves while he is asleep. The patient has been unstable on his feet and has fallen on a couple of occasions. The patient tend to forget things easily and does not participate in activities he previously enjoyed.

Physical Examination:

• An old man with no acute distress.
• he shows little or no emotion during the history and physical examination.
• His face appears symmetric.
• he has a resting tremor in both the hands that consists of a regular beat of writ and finger flexion.
• He has an increased tone throughout his body , and it is difficult to passively range his extremities. 
• Sensation is grossly intact.
• When his gait is observed, he has difficulty initiating his first steps, walks in a shuffling pattern, and takes several extra steps when he tries to come to a stop. 

His photo taken in the office is shown below:

he was asked to write on a paper and he wrote like the pattern shown below;

the patient was diagnosed as a case of parkinson disease. 

Case Discussion:
Parkinson Disease is an idiopathic disease of dopamine depletion, loss of dopaminergic striated neurons in the substania nigra and Lewy body formation ( i.e eosinophillic cytoplasmic inclusions) in substania nigra neurons, leading to an abnormally increased inhibition of the thalamic cortical neural pathways.
Clinical features: include a history of memory loss, sleep disturbance, depression. On examination there is :

• resting tremor (i.e pill-rolling in the hands)
• bradykinesia (i.e decreased voluntary movement) with difficulty initiating movement.
• mask like face
• shuffling gait, involuntary gait acceleration following initiation
• cog wheel rigidity ( i.e increased tone of agonist and antagonist muscles)
• postural instability. 

Management: Diagnosis is clinical and there are no lab tests or imaging that is reliable for diagnosis.

1. Dopaminergic agnosist like levodopa, carbidopa, bromocriptine, and amantadide are used in treatment.

2. Other drugs inclde Monoamine oxidase B inhibitors (selegiline) and anticholinergic agents ( benztropine).

2. Initially a single drug is prescribed . later a second drug may be needed if symptoms cannot be controlled by monotherapy.