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Chapter 28: Movement Disorders

A 60-year-old man is brought in by his family for a dementia evaluation. The patient is no longer able to feed himself without assistance. On examination, he demonstrates bradykinesia, left-sided rigidity, postural instability, and apraxia. The patient frequently raises his left arm into the air but appears unaware of this action. A brain MRI shows cortical atrophy that is greater on the right than the left. Which of the following is the most likely diagnosis?

A. Frontotemporal dementia

B. Dementia with Lewy bodies (DLB)

C. Progressive supranuclear palsy

D. Parkinson disease with dementia

E. Corticobasal syndrome

E. Parkinsonism plus apraxia or other asymmetric cortical signs is classic for corticobasal syndrome (CBS). The patient does not have the classic features of any of the other disorders. This vignette describes the classic alien limb phenomenon. Disproportionate lateralized atrophy on brain imaging can also be seen in CBS.

A 55-year-old woman presents with 4 months of tremor that affects both upper extremities and is present “most of the time.” She has a 15-year history of type 2 diabetes and hypertension. Medications are insulin, lisinopril, hydrochlorothiazide, and metoclopramide. On exam, her speech and mental status are normal. She has a paucity of facial expression, slow movements, and mild bilateral upper and lower extremity rigidity. Motor strength is normal, but sensory exam reveals distal pinprick loss. There is a 4-Hz resting tremor in both upper extremities that disappears with voluntary movement. Which of the following is the most likely diagnosis?

A. DLB

B. Drug-induced parkinsonism

C. Multiple system atrophy

D. Parkinson disease (PD)

E. Vascular parkinsonism

B. This is drug-induced parkinsonism from metoclopramide, which potently antagonizes central dopamine. Even without knowledge of the offending medication, parkinsonism that was symmetric at onset should be a clue because idiopathic Parkinson disease is nearly always unilateral at onset. There are no atypical features to suggest a Parkinson-plus disorder.

A 65-year-old man initially developed a left upper extremity resting tremor with mild left upper extremity rigidity and was diagnosed with PD. He returns for follow-up, and his wife reports that although his tremor is improved, he has been spending hours each day on the computer playing online poker. He has spent thousands of dollars, and this is creating significant stress for the family. Which of the following medications is the most likely culprit for causing this problem?

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