Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 56-year-old woman is evaluated for a 1-year history of tremor. The tremor is more prominent on the right side. She also reports increasing problems with balance and numerous falls, especially when arising from a chair or turning. The patient does not have any significant cognitive symptoms. She has occasional urinary incontinence, intermittent constipation, and a history of acting out of dreams during sleep.
On physical examination, blood pressure is 115/75 mm Hg sitting and 85/70 mm Hg standing, pulse rate is 65/min sitting and 75/min standing, and respiration rate is 22/min. Bruises over the upper and lower extremities secondary to falls are present. On cranial nerve examination, dysmetric saccades, decreased facial expression, and hypophonic speech are noted. Vertical eye movements are normal. A low-amplitude tremor at rest that is more prominent on the right side is present. Repetitive finger tapping movements are bradykinetic. On finger-to-nose testing, mild dysmetria is present. Gait is ataxic with a wide base and frequent veering to both sides; she is unsteady on turning. Gait speed is normal, but arm swing is decreased. A pull test confirms postural instability. No sensory deficits are noted.
Which of the following is the most likely diagnosis?
A. Multiple system atrophy
B. Parkinson disease
C. Progressive supranuclear palsy
D. Vascular parkinsonism
Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.
