A 58-year-old man comes to the office due to tremor in his right hand. The patient first noticed the tremor a year ago, and it has progressively worsened to the point that he has difficulty writing. He often becomes self-conscious and feels embarrassed in social situations. The patient has had no headache, vision impairment, difficulty speaking or swallowing, sleep disturbances, bowel or bladder incontinence, extremity weakness or numbness, or memory loss. He has a history of hypertension for which he takes lisinopril. The patient is an attorney and does not use tobacco, alcohol, or illicit drugs. Family history is unremarkable.
Neurologic examination shows a Mini-Mental State Examination score of 29/30. A low-frequency tremor is noted in the right hand when resting the arm on a chair. The tremor is exacerbated by mental distraction such as counting backward and becomes less prominent with voluntary activity such as reaching for a pen. When the patient writes, his words become progressively smaller and illegible. There is mild rigidity of the bilateral upper extremities with decreased arm swing during ambulation. The remainder of the neurologic examination shows no other abnormalities.
Blood cell counts, serum chemistry studies, and thyroid function tests are within normal limits. MRI of the brain shows no abnormalities.
Which of the following is the most appropriate next step in management of this patient?

Question

A 58-year-old man comes to the office due to tremor in his right hand.  The patient first noticed the tremor a year ago, and it has progressively worsened to the point that he has difficulty writing.  He often becomes self-conscious and feels embarrassed in social situations.  The patient has had no headache, vision impairment, difficulty speaking or swallowing, sleep disturbances, bowel or bladder incontinence, extremity weakness or numbness, or memory loss.  He has a history of hypertension for which he takes lisinopril.  The patient is an attorney and does not use tobacco, alcohol, or illicit drugs.  Family history is unremarkable.
Neurologic examination shows a Mini-Mental State Examination score of 29/30.  A low-frequency tremor is noted in the right hand when resting the arm on a chair.  The tremor is exacerbated by mental distraction such as counting backward and becomes less prominent with voluntary activity such as reaching for a pen.  When the patient writes, his words become progressively smaller and illegible.  There is mild rigidity of the bilateral upper extremities with decreased arm swing during ambulation.  The remainder of the neurologic examination shows no other abnormalities.
Blood cell counts, serum chemistry studies, and thyroid function tests are within normal limits.  MRI of the brain shows no abnormalities.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9872_2ec9_853d_89bb14872937_MD0002_00 This patient has tremor-predominant idiopathic Parkinson disease (PD), a slowly progressive neurodegenerative disorder characterized by bradykinesia, cogwheel rigidity, and resting tremor. His symptoms are significant and debilitating to him as a high-functioning professional. Carbidopa/levodopa is the most effective medication for the treatment of the motor symptoms of idiopathic PD; however, in mild to moderate disease and patients age <65, dopamine agonists (eg, bromocriptine, pramipexole, ropinirole) are generally preferred as they are associated with fewer motor fluctuations. (Choice A) Deep-brain stimulation is considered in patients who have medically refractory resting tremor, levodopa-induced dyskinesias, or significant motor fluctuations. (Choice B) Donepezil is an acetylcholinesterase inhibitor used to increase acetylcholine levels in the frontal lobes of patients with dementia. This patient's Mini-Mental Status Examination score is 29/30, making dementia unlikely. (Choice D) Propranolol is used for treatment of an essential tremor. Essential tremors are typically symmetric, high frequency, and worsen with action, as opposed to parkinsonian tremors, which are asymmetric, low frequency, and worsen with rest. In addition, bradykinesia and rigidity are not commonly noted with essential tremors. (Choice E) Trihexyphenidyl is an anticholinergic agent that can be used as monotherapy or adjunct therapy for the treatment of resting tremor in idiopathic PD. Pramipexole is a better choice for this patient as trihexyphenidyl will not improve his other motor symptoms of PD (ie, bradykinesia and rigidity). Educational objective: Parkinson disease is a progressive neurodegenerative disorder characterized by bradykinesia, cogwheel rigidity, and resting tremor. Carbidopa/levodopa is the most effective medication for treatment of motor symptoms; however, in mild to moderate disease and patients age <65, dopamine agonists are generally preferred as they are associated with fewer motor fluctuations. __________ References: Diagnosis and therapy of idiopathic Parkinson's disease. (http://www.ncbi.nlm.nih.gov/pubmed/20104716) Pharmacological treatment of Parkinson disease: a review. (http://www.ncbi.nlm.nih.gov/pubmed/24756517)

A 58-Year-Old Man Comes to the Office Due to Tremor