PD I
PD II
PD+
PD Medications I
PD Medications II
100
Cardinal Features of Parkinsons (Name 2 of 4)
resting tremor, rigidity, akinesia, postural instability
100
When doing an autopsy of an individual with Parkinson's Disease, the pathologist finds these structures in the histology sections of the substantia nigra and locus coeruleus.
Lewy Bodies
Note:
Dense granular inner core with radiating filamentous outer zone
Outer zone = alpha synuclein
100
Name 3 "red flags" for atypical parkinsonism (We learned 9ish)
Rapid progression
Severe and symmetric parkinsonism; poorly responsive to levodopa
Early speech and swallowing difficulties (within 3 years of onset)
Severe and diffuse autonomic dysfunction
Early Cognitive changes
Early and repeated falls
Pyramidal signs (increased reflexes, + Babinski)
100
This cardinal symptom of PD is least responsive to levadopa.
Postural instability
Note: Akinesia/Bradykinesia is most responsive
100
Carbidopa increases the fraction of levadopa reaching the brain by inhibiting this enzyme. This allows for dose reductions that help prevent CNS and peripheral side effects.
peripheral decarboxylase
200
A patient presents with decreased movements in both amplitude and swing. When walking into the clinic, you note they have hunched-forward posture and take multiple shuffling steps. When doing the patient interview, you note that it seems they are "rolling a pill" in their hands. Degradation of these neurons are most likely behind this presentation.
Dopaminergic
200
These dopaminergic neurons are spared in Parkinson's disease while those of the substantia nigra are targeted.
Mesolimbic and mesocortical neurons/ventral tegmental area
200
The criteria for parkinsonism.
bradykinesia, resting tremor, rigidity
200
This oral drug is used with levadopa to manage its "off" periods, and is also used for restless leg syndrome. It does not require metabolism, is not affected by amino acids for GI/BBB transport, and does not need to be stored and released by nerve terminals.
pramipexole
200
A 64-yo male presents to clinic with early cardinal signs of Parkinson's Disease. They are prescribed a drug for monotherapy for these symptoms that also works to help depression. After a few weeks, they note having headaches and nausea, and their daughter tells you that they are often confused. The most likely prescribed drug is this.
selegiline
300
Loss of this neurotransmitter is responsible for gait and cognitive changes in Parkinson's Disease.
Acetylcholine.
Note:
Catecholamine loss = autonomic dysfunction
Acetylcholine loss = cognitive & gait changes
Other monoamine loss = depression & anxiety
300
The etiology of Parkinson's Disease is described as a multi-hit genetic process with influence by environmental and endogenous factors. Name 3 of the 5 targets/processes involved this theory.
Apoptosis, Mitochondrial dysfunction, Oxidative Stress, Excitotoxicity, Inflammation
300
A 57-yo male presents to clinic over concerns of erectile dysfunction and constipation. When walking in, you note that he is hunched the side, conjuring up an image of the leaning tower of Pisa. He also notes that he's been having some speaking and swallowing difficulties as well. The physical exam shows increased deep tendon reflexes and myoclonus. This patient's syndrome is due to the misfolding of a specific protein in this cell type.
Oligodendrocytes
Note: This is multiple system atrophy, which as due to misfolding of alpha-synuclein in oligodendrocytes causing neuronal cell death. The protein forms Glial Cytoplasmic Inclusions.
300
A drug is prescribed to a Parkinson's patient in a fixed-dose combination with levadopa and carbidopa to help reduce the number of "off" episodes the patient is having. A few weeks later the patient is noted to have increasing nausea and dyskinesia which warrants a dose reduction of the levadopa. The patient also says that their stool is now the color of flaming hot cheetos. This drug was likely the prescribed medication added to levadopa-carbidopa.
entacapone
300
This D2 agonist is an add-on to levadopa and is injected SC or taken sublingually to treat early morning off states or sudden unpredicted off episodes in advanced PD. Of the D2 agonists, it has the more rapid and reliable onset at 4-12 minutes.
apomorphine
400
Parkinson's disease has no cure, but there are multiple pharmacologic and non-pharmacologic options to help slow disease progression. This is the main non-pharmacologic option.
Exercise
400
A Parkinson's patient presents to clinic with new issues related to talking and swallowing. This has made it difficult to take his usual preparation of levadopa. Based on this information, this preparation would be suggested for the patient.
Parcopa (dissolving tablet)
Note:
Sinemet CR (extended release) - good for overnight wearing off
Rytary - goof for early wearing off
400
A 73-yo female presents to clinic with swallowing and balance issues. Her prior PCP had diagnosed her with Parkinson's due to her having bradykinesia and a rest tremor. They started her on levadopa, but she has not been responsive. Physical exam findings include retrocollis, procerus sign, positive applause sign and reduced blinking rate. Her partner says that she isn't like herself anymore, and that she is increasingly apathetic and impulsive in her behavior. What pathology would you suspect in this patient's brain?
neurofibrillary tangles of 4R tau
Note: This is progressive supranuclear plasy. It is a taupathy where aggregates of tau protein accumulate in neurons, astrocytes, and oligodendrocytes
400
A newly diagnosed PD patient is prescribed levadopa to help with the management of their symptoms. As the disease progresses, they start to have choreiform and ballism type movements. This is due to overstimulation of this receptor.
D2 receptor
400
A 75-yo female with Parkinson's disease comes in to clinic as a new patient. You are going through her medications list as see the following drugs used to help control her symptoms: levadopa-carbidopa, selegiline, and trihexyphenidyl. You decide to discontinue this drug due to possible issues of serious cognitive impairments given the patient's age.
trihexyphenidyl
500
A patient with advanced Parkinson's disease is having progressively worse motor fluctuations that are not responding well to medication. Due to this, her PCP is considering deep brain stimulation. In this procedure, this structure would be the primary target that would allow medication reductions.
subthalamic nucleus
Note: GPi targeted more in dystonia and dyskinesia
500
A patient with advanced Parkinson's disease is having progressively worse dyskinesias that are not responding well to their usual levadopa preparation. Due to this, her PCP is considering more advanced medical therapies, including this. (2 possible answers)
amantadine or DUOPA (intestinal gel)
Note: DBS also a possible management option
500
A 64-yo male presents to clinic with his wife who has concerns over his recent language and visuospatial impairments. Physical exam shows agraphesthesia, loss of two-point discrimination, and "Starfish sign". You also find that that patient can not perform simple hand gestures when asked, and does not seem to know how to use his left arm. You order an MRI which shows the following:
Based on these findings, what brain pathogogy would you expect to find with this patient.
corticobasal degeneration (4R taupathy)
Note: This is corticobasal syndrome