Thinking neuro?  Always ask about pain, headache, numbness, tingling, weakness!


  • Extrapyramidal disorders
    • Tremor: resting vs. use-dependent
    • Rigidity:
    • Akinesia
    • Postural instability
  • Micrographia (printing gets smaller, change in signature)
  • Cognition (thinking, memory)

Shy-Drager: Parkinson’s with autonomic features (i.e. postural hypotension)
Acute hydrocephalus
Progressive supranuclear palsy: lose vertical eye movements first; poor vertical saccades; fall backwards; cognition difficulty; Parkinson’s


Past Medical History

  • Head injury
  • Psychiatric disorders
  • Manganese (found in mines)
  • Carbon monoxide

Family History


  • Antipsychotics
  • Valproic acid

Physical examination

  • General: vitals (look for postural hypotension); depressed affect, loss of spontaneous movements
  • MSE/MMSE: paucity of movement, decreased blink, rapid and low volume speech, monotonous speech
  • Inspection:
    • Face: mask-like facies, open mouth, sialorrhea, facial seborrhea, blepharospasm, Glabellar tap (Positive Myerson’s sign), decreased vertical eye moevements in PSP
    • Tremor: rest tremor (decreased with finger to nose, increase in L if clench R), 4-8 Hz, pill rolling, begins distally
    • Dampening: difficulty with repeating movements (toe tap)
    • Gait and posture: trunkal instability, and postural instability; getting out of chair, instability (pull back – 2 steps), bent knees and elbows when standing, lack of arm swing, propulsion/retropulsion, festination, shuffling, difficulty initiation, stopping, turning (en bloc turn)
  • CN exam (PSP – decreased vertical gaze)
  • Motor: pronator drift, bulk, power (strong/normal), increased spasticity (velocity dependent), increased rigidity – cog wheeling (wrist), finger/foot tapping (decreasing amplitude and speed), tremor, dyskinesias 2O to Rx, stooped posture
  • Sensory: normal
  • Reflex: normal
    • Primitive reflexes present:
      • Glabellar (tap between eyes = blink, then adapt – not seen in Parkinson’s)
      • Palmar grasp
      • Palmomental (tap palm = eyebrows raise, chin wrinkle)
  • Coordination: slower, Romberg
  • Gait: decreased swing in affected arm, festinating, length of stride decreases, speed, turning, initiating, stopping
  • Frail elderly: vibratory loss in feet, vertical eye movement decreased

Treatment: depends on quality of life

  • Selegiline
  • Amatidine
  • Dopamine agonists (merapex, requip (AE: sleep attacks), bromocriptine)
  • L-dopa, carbadopa (Cinemet, use in older patients; causes hTN, nausea, and confusion/hallucinations/etc in frail elderly)

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