CASE III-3 Right-Sided Tremor,
Rigidity, Slowness and Gait
Difficulties
CHIEF COMPLAINT
A 73 year old right handed woman was
referred to a tertiary care center due to
worsening right-greater-than-left
bradykinesia, tremor, rigidity, and
unsteady gait. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties HISTORY
Sixteen years previously, the patient first noticed mild
difficulty using her right hand, and decreased right
arm swing when walking. She later developed
shaking of her right arm and then right leg. The
patient was evaluated by a neurologist who diagnosed
her with Parkinson’s disease. Over the years, her
shaking and slowed movements became gradually
worse, to the point where recently she has had
difficulty writing, dressing with buttons, cooking,
and cutting food. She also has become more
unsteady, with two falls in the past year, fracturing
her right arm on one occasion. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties HISTORY (cont’d)
Tremor and stiffness have become so severe that it
is difficult for her to sleep at night. Initially treatment
with levodopa plus carbidopa (Sinemet) provided
excellent benefit, but this has become less effective
over time despite increasing doses (see also below).
She did not tolerate treatment with anticholinergic
agents or dopaminergic agonists due to side effects.
She has a family history of Parkinson's disease in her
mother. The patient has no history of use of
dopaminergic antagonist medications, toxin exposure,
strokes, or encephalitis. CT and MRI scans were
normal. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION
Vital signs: T = 98.1˚F, P = 88, BP = 130/82, R = 18
Neck: Supple.
Lungs: Clear.
Heart: Regular rate, no murmurs.
Abdomen: Normal bowel sounds, soft, non-tender.
Extremities: No edema. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION (cont’d)
Neurologic exam (2 hours after her last Sinemet dose,
and just before her next dose):
MENTAL STATUS: Alert and oriented x 3. Normal
language. Recalled 3/3 words after 5 min. Copied
shapes correctly, but slowly. Wrote a sentence with
tremulous, micrographic handwriting.
CRANIAL NERVES: Normal, except for mild
“hypomimia” (decreased facial expressiveness). CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION (cont’d)
MOTOR: Moderate general bradykinesia (slowing of
movements), for example with finger tapping, worse
on the right side. Constant 3–4 Hz tremor of the
right upper and lower extremities, worse at rest.
Mild cogwheel rigidity, especially of the right arm.
No pronator drift. Power 5/5 throughout.
REFLEXES: 1+ symmetrical throughout, with bilateral
downgoing plantar responses.
COORDINATION: Finger–nose and heel–shin slow,
but no dysmetria. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION (cont’d)
GAIT: Stooped, slow gait, lurching forward with few
steps, and decreased right arm swing. Turned
slowly without twisting body (“en bloc” turning). Took
several rapid steps to correct herself and prevent a fall
when gently pulled (“anteropulsion, retropulsion”).
SENSORY: Intact light touch, pin prick, and
graphesthesia. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties LOCALIZATION AND DIFFERENTIAL DIAGNOSIS
DISCUSSION QUESTIONS
1. Based on the symptoms and signs shown in bold
on the previous slides, is this patient more likely to
have typical idiopathic Parkinson's disease, or atypical
parkinsonism?
2. Degeneration of neurons in which structure is
primarily responsible for idiopathic Parkinson's
disease? What is the main neurotransmitter of these
neurons (Review Figure 16.7, p. 750 in Neuroanatomy
through Clinical Cases, 2nd Ed.)? How does loss of
these neurons result in a hypokinetic movement
disorder? CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties HISTORY (cont’d)

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