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Parkinson's Disease for USMLE Step 3 / COMLEX-USA Level 3

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Clinical Presentation
  • Motor Symptoms:
    • Bradykinesia: Slowness in initiating and executing movements.
    • Rigidity: Uniform stiffness throughout the limbs and trunk.
    • Resting Tremor: Typically a "pill-rolling" tremor at rest.
    • Postural Instability: Increased risk of falls, typically observed in later stages.
  • Non-Motor Symptoms:
    • Neuropsychiatric: Depression, anxiety, and cognitive decline.
    • Autonomic Dysfunction: Constipation, urinary urgency, orthostatic hypotension.
    • Sleep Disturbances: Particularly REM sleep behavior disorder.
Diagnostic Approach
  • Clinical Evaluation: Diagnosis is primarily clinical, based on motor symptoms and response to dopaminergic therapy.
  • Imaging:
    • DaTscan: Helps confirm the diagnosis by showing reduced dopamine transporter in the striatum, not used routinely.
  • Neurological Assessment: Comprehensive assessment to rule out other causes of parkinsonism.
Management
  • Pharmacological Treatment:
    • Levodopa/Carbidopa: Most effective treatment, adjusted based on symptom control and side effects.
    • Dopamine Agonists: Such as pramipexole and ropinirole, useful especially in younger patients.
    • MAO-B Inhibitors: For mild symptoms or as adjunct therapy.
    • COMT Inhibitors: Used to extend the effect of Levodopa.
  • Non-Pharmacological:
    • Physical and Occupational Therapy: Focus on improving mobility and daily function.
    • Speech Therapy: Addressing speech and swallowing difficulties.
Complications
    • Motor Fluctuations: Such as "wearing off" effects or "on-off" phenomena.
    • Dyskinesias: Involuntary movements arising from long-term Levodopa use.
    • Cognitive Decline and Psychiatric Issues: Management of dementia and hallucinations, often requiring psychiatric consultation.
Prognostic Considerations
    • Progressive Nature of Disease: Monitoring for progression and complications.
    • Adjustments in Treatment: Based on disease stage, patient age, and comorbidities.
High-Yield Items for Step 3
1. Management of Advanced PD: Emphasis on the integration of pharmacological and non-pharmacological treatments to address both motor and non-motor symptoms. 2. Decision-Making in Drug Selection: Choosing appropriate therapy based on patient-specific factors such as age, symptom severity, and side effect profiles. 3. Handling Complications: Strategies for managing common and complex complications such as dyskinesias, psychiatric symptoms, and cognitive decline. 4. Interdisciplinary Care: Coordination with various healthcare professionals to provide comprehensive care, including palliative care considerations.

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