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Louise Bermel is a 60 year old female who presents to the office with difficulty using her right
arm. Ms. Bermel states that the difficulty in using her right arm has occurred over the past 2
months. She is right-handed. The clumsiness and intermittent tremor have become
progressively worse. No other symptoms are present. To direct questioning she says the right
shoulder aches, "it may be bursitis," and that she has noted saliva on her pillow in the mornings.
Her children feel she is slower and looks depressed. She denies any visual disturbances, vertigo,
palpitations, sensory symptoms or unconsciousness. She denies headaches and there is no
history of trauma.
The problems with her shoulder and arm are making it more difficult for her to carry out her
work. There is no history of neurological diseases in the family except for her mother who had a
slight shake of her head in old age. There is no history of early cerebrovascular or coronary
artery disease in the family. There is no family history of hypertension. Her father died of
pneumonia and her mother died of cancer of the breast.
Neurologic Exam:
Normal cranial nerves II-XII and finger to finger and heel to shin on gait
testing (cebellar). Her right arm swings less and on turns her neck looks stiff. Deep tendon
reflexes, sensation, and fine coordination are almost normal. There is no significant weakness.
Initiation of gait is slow (what is this called?) and a little unsteady, but when pulled from behind
she does not lose her balance. There is a slight tremor of her right hand intermittently at rest that
disappears when she reaches for something. It is also noted when she is walking.

she has?
a. huntingtons chorea
b. parkinsonism
c. normal pressure hydrocephalus
d. G B syndrome
e. myopathy


brady kinesia, mask facies, resting tremors all indicate parkinsonism!


correct grin

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