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Old 01-11-2012
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Question Daily Questions #3 (Man with general slowing of movements)

A 55-year-old man is brought to your office by his wife for complaints of general slowing of movements, frequent falls, and difficulty in turning over in bed or getting up from a sitting position. His wife also reports that he has difficulty sleeping, appears more depressed, fearful, and anxious, and refuses to join social gatherings. He has episodic symptoms of delirium. He works as an accountant and has been unable to work lately. He is more forgetful and is misplacing things. These symptoms have been present for a year. The patient has visual hallucinations. Physical examination shows a normal blood pressure and no signs of cardiac or vascular disease. Neurological examination reveals a slight impairment in cognition. He is unable to perform serial sevens. His speech is soft and slow, and there is normal upward and downward gaze, with micrographia, tremors, and hypometria. The plantar responses are extensor, and there is a festinating gait. His memory is impaired. What is the most likely diagnosis?

(A) Parkinson's disease
(B) Diffuse Lewy body disease
(C) Progressive supranuclear palsy
(D) Shy-Drager syndrome
(E) Corticobasal ganglionic degeneration
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Old 01-11-2012
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diffuse lewy body disease...
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Old 01-12-2012
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Originally Posted by qurat21 View Post
diffuse lewy body disease...
Hey buddy..it would be really nice to explain a little bit ur explanation....will be helpful for others too..the whole point of these questions is to discuss...
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Old 01-12-2012
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Originally Posted by podebrad View Post
Hey buddy..it would be really nice to explain a little bit ur explanation....will be helpful for others too..the whole point of these questions is to discuss...
He has episodic dementia +visual hallucinations +parkinson's like symptoms....these wouldn't be found in any other of the options.
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(B) Diffuse Lewy body disease

Explanation:

This patient has all the symptoms and signs of Parkinson's disease (PD). In addition, he has the early onset of dementia, visual hallucinations, and cognitive fluctuations, which are pathognomonic of diffuse Lewy body disease. These patients have clinical parkinsonism combined with dementia, as well as symptoms similar to delirium occurring in an episodic fashion. Dementia rarely occurs on initial presentation of PD and is usually a very late finding. PD patients do not have hallucinations but may develop them as a side effect of dopaminergic treatment.

Patients with progressive supranuclear palsy have impairment in downward gaze initially and later in upward and lateral conjugate gaze. These patients complain of difficulty seeing. Mild to moderate dementia is a late sign, and tremors almost never occur. Multisystem atrophy or Shy-Drager syndrome leads to orthostatic hypotension, lightheadedness, incontinence, sexual impotence, and other autonomic symptoms besides parkinsonism. Corticobasal ganglionic degeneration is another form of multisystem degeneration. These patients have apraxia, jerky tremor, alien limb phenomenon, and nonfluent aphasia.
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