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1. peripheral decarboxilase inhibitors

1.1. e.g. carbidopa

2. Step1

2.1. difficult words

2.1.1. with suffle

2.1.2. clumsy:moving and doing things in careless way

2.1.3. clenching

2.2. cues

2.2.1. 1- retied soldier

2.2.2. 2- he skipped a dental examiation

2.2.3. 3- 69yo

2.2.4. 4- posterior teeth discomfort in the last 6months .

2.2.5. 5- is appearant ige is considered more than the actual age.

2.2.6. 7- slowing down

2.2.7. 8- seems clumsy

2.2.8. 9- wooden face

2.2.9. 10-clenching his teeth is a habit for long time

2.2.10. 11recent deterioration in his oral hygen

2.2.11. 12-complain his face is stiff

2.2.12. symptos 6-walking with a shuffle

3. Step2: problem formulation

3.1. 69yo retired soldier, whose appearant age seems older than his actual age, was refferd from a dentist to seek medical care for many changes including posterior teeth discomfort. shuffling gate was noticed and he is clumsy. wooden face with a habit of clenching his teeth.

4. Step3: Hypothesis generation

4.1. by Yousef

4.1.1. movement disorder related to age

4.1.2. muscle regidity more release of ACH

4.2. by R. alsulamy

4.2.1. problem related to damage for substantia nigra Red nucleus pyramidal and extrapyramidal tract

4.3. by Homoud

4.3.1. might be a prolem affecting basal ganglion activated(direct) or inactivated(indirect) by Dopamin cerebellum

4.4. by Hassan

4.4.1. basal ganglia and substantia nigra are affecting the coordination

4.5. by Essam

4.5.1. movement disorder mainly parkinson's

4.5.2. by Faris infections or environmantal factors may lead to this pesentation mercury disolvment

4.6. By kashi

4.6.1. neurological problem

4.6.2. generalized musculer problem

4.6.3. central problem

4.7. by Adeeb

4.7.1. more investigation to find the diagnosis

5. Step4: Hypothesis organization

5.1. parkinsonism

5.2. Huntington

5.3. metallosis

6. Step5: Learning Objectives

6.1. To know about parkinsonism and huntington disease

6.1.1. define

6.1.2. sign&symptoms

6.1.3. pathophysiology

6.1.4. causes

6.1.5. investigations

7. Step6: Review

7.1. Parkinsonism

7.1.1. cardinal manifestation TREMOR RIGIDITY shuffling gait mask face BRADYKINESIA POSTURAL INSTABILITY

7.1.2. MANIFESTATION motor symptoms shuffling gait resting tremor craniofacial visual MSK gait non motor symptoms depression anxiety anosmia

7.1.3. pathophysiology neurodegeneration accumolation of body fluid nigrostriatal pathway. is affected indirect pathway predominate on the direct pathway lewy bodies accumolate in the olfactory tract first genetics park1 park2 park5 park8 ubiquitin not degradation for misfolded dopamine depletion

7.1.4. epidemiology 12000/100000 over 60 1%

7.1.5. causes idiopathic secondary causes mptp heroin anti psychotic drugs trauma

7.1.6. diagnosis

7.2. Huntington's disease

7.2.1. define autosomal dominant neurodegenerative disease affect the indirect way progressive disease of adult hood

7.2.2. pathology head of caudate nucleus affected

7.2.3. complications psychological effect

7.2.4. sign and symptoms chorea disappear late in the disease dementia late appearing dystonia myoclonus

7.2.5. life expectency is around 15yo

7.2.6. investigations having family history genetic testing 4q22 imaging MRI

8. Step7: Inquiry plan


8.1.1. 69yo

8.1.2. suburban



9. Step8: Diagnostic decision

10. Step9:review

11. Step10: management

11.1. symptomatic treatment

11.1.1. the gold standard carbidopa/levodopa 25/100 used givien in an empty stomach freezing phenomonon can't be used for long time

11.1.2. start with non-dopamenergic drugs anticholinergic drugs.

11.1.3. dopamin agonist ergot derivatives valvulopathies non-ergot derivatives

11.1.4. MAO inhibitors high possibility of hallucination when used with levodopa

11.1.5. COMT inhibitors entacapone act peripherally tolacapone

11.1.6. non-motor symptoms to prevent hallucination dementia anticholinestrase inhibitors seboric dermatitis steroid cream urinary urgency oxybutinin constipation fluid intake exercise GI problem domperidone sailorrhea oral anticholinergic sexual dysfunction either stopping the medications sildenafil orthostatic hypotenstion stopping antihypertensive drugs domaperidone pain gapapentin sleep disturbances PSYCHOSIS antipsychotic drugs

11.2. non-pharmacological treatment

11.2.1. cognitive behavioral therapy reduce anxiety

11.2.2. surgical therapy transplanted SN pallidetomy thalmotomy subthalatomy D B S

11.2.3. exercise

11.2.4. patient education

11.2.5. social support

11.2.6. canes and walkers

11.2.7. occupational therapy

12. Resources

12.1. Harrison's

12.2. medscape

12.3. kumar

12.4. up-to-date

12.5. mayoclinic