During the morning rounds, a second year resident presents a patient as "a 58-year-old female who suffers from rigidity and tremors. She has been diagnosed with a neurodegenerative disease involving the depigmentation of substantia nigra and loss of dopaminergic input to basal ganglia."
What is the disease in question?
Correct Answer B:
Parkinson’s disease involves rigidity and tremors followed by akinesia. It is a neurodegenerative disease involving the the depigmentation of substantia nigra and loss of dopaminergic input to basal ganglia. Lack of dopamine levels results in over excitation of muscles, manifested in the form of rigidity and tremors.
→ Epilepsy (choice A) involves loss of consciousness with muscular movements.
→ Mood disorder (choice C) occurs due to the decreased production of not only dopamine but also nor-epinephrine and serotonin.
→ Schizophrenia (choice D) is due to the excess production of dopamine, nor-epinephrine and serotonin.
→ The most striking neuropathology in Huntington disease (choice E) occurs within the neostriatum, in which gross atrophy of the caudate nucleus and putamen is accompanied by selective neuronal loss and astrogliosis.
Regarding treatment of this patient, which of the following statements is true?
This patient suffers from Parkinson’s disease. Levodopa is the most efficacious symptomatic medication with few short term side effects (choice B - true), but its chronic use is associated with the development of fluctuations and dyskinesias. Once fluctuations and dyskinesias become problematic, they are difficult to resolve.
→ Studies demonstrate that a patient's quality of life deteriorates quickly if treatment is not instituted at or shortly after diagnosis (choice A - false).
→ Dopamine agonists provide moderate symptomatic benefit and rarely cause fluctuations and dyskinesias by themselves, but they have more side effects than levodopa (choice D - false), including sleepiness and impulse control disorders. However, these side effects resolve upon lowering the dose or discontinuing the medication.
→ Dopamine agonists and levodopa are started at a low dose, escalated slowly, and titrated to control symptoms (choice C - false).
→ For patients who have disability due to tremor that is not adequately controlled with dopaminergic medication, an anticholinergic agent can be used. Anticholinergic medications provide good tremor relief in approximately 50% of patients but do not meaningfully improve bradykinesia or rigidity (choice E - false).
A 73-year-old male sees you for evaluation of a tremor. Based on the history and examination, you suspect Parkinson’s disease.
Which one of the following would be most helpful for confirming the diagnosis?
Correct Answer C: Patients with Parkinson's disease should respond to an adequate therapeutic challenge of levodopa or a dopamine agonist. The diagnosis of idiopathic Parkinson's disease is clinical, not radiographic. Cardinal signs of Parkinson's disease include an asymmetric tremor onset and a distal resting tremor of 3-6 Hz.
A teenage girl was raped and she was given a prophylactic drug to prevent gonorrhea.
What is the most appropriate treatment of choice?
Correct Answer A:
Treatment for suspected gonorrhea is with Ceftriaxone, which can be given 250mg IM.
> Chlamydia is usually treated with either doxycycline or azithromycin.
> Metronidazole is a treatment for bacterial vaginosis and trichomonis.
> Syphilis is treated with penicillin usually.
Which one of the following is appropriate and effective treatment for genitourinary gonorrhea in a 20-year-old male with a purulent urethral discharge?
Correct Answer C:
Not only has the incidence of gonorrhea increased since 2002, but the rate of quinolone-resistant infection has also increased. Ceftriaxone is therefore the currently recommended treatment, and amoxicillin, ciprofloxacin, and erythromycin are no longer recommended because of resistance to these drugs. Doxycycline can be used but should be continued for 7 days.
Note: In 2011, the CDC changed the recommendation to dose ceftriaxone at 250 mg, which is an increase from the previously recommended dose of 125 mg.
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