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Difficulty: HardPhysical Examination Findings

A 71-year-old retired accountant is evaluated in the neurology clinic for recurrent, unprovoked backward falls and a progressive slowing of movements over the past year. His family reports that his voice has become increasingly monotonic, and he frequently spills food because he 'cannot look down' at his plate. On mental status examination, he exhibits mild executive dysfunction. The physician suspects progressive supranuclear palsy. Which of the following specific physical examination findings would best confirm this diagnosis and differentiate it from other parkinsonian syndromes? (Select TWO that apply)

  1. Loss of voluntary downward eye movements with preservation of the vestibulo-ocular reflexAnswer
  2. Axial rigidity that is disproportionately more severe than appendicular rigidityAnswer
  3. C
    A 4- to 6-Hz resting tremor that is temporarily suppressed during voluntary action
  4. D
    A paradoxical decrease in systolic blood pressure greater than 20 mm Hg upon standing without compensatory tachycardia
  5. E
    Marked asymmetric apraxia accompanied by stimulus-sensitive myoclonic jerks of a single limb

Answer

The correct findings are loss of voluntary downward eye movements with preserved vestibulo-ocular reflex, and disproportionately severe axial rigidity.
Progressive supranuclear palsy (PSP) is an atypical parkinsonian syndrome (tauopathy). The hallmark physical examination finding is a vertical supranuclear gaze palsy. 'Supranuclear' means the neurodegenerative deficit originates above the level of the cranial nerve nuclei; thus, while voluntary downward gaze is impaired, the primitive brainstem reflexes (like the vestibulo-ocular or oculocephalic reflex, tested via the doll's head maneuver) remain intact. Additionally, unlike idiopathic Parkinson disease where rigidity is predominantly appendicular (in the limbs), PSP is characterized by profound axial (neck and trunk) rigidity, which contributes heavily to the classic early backward falls.

Step-by-Step Solution

1
Analyze the clinical presentation in the stem.
The patient exhibits parkinsonian features (slowing of movements) combined with 'red flag' symptoms for an atypical syndrome: early backward falls, executive dysfunction, and an inability to look down.
Identifying the specific constellation of symptoms narrows the differential diagnosis from idiopathic Parkinson disease to a Parkinson-plus syndrome.
2
Identify the suspected pathology.
The constellation of symptoms strongly points to progressive supranuclear palsy (PSP), a tauopathy.
The inability to look down while eating is a classic historical clue for vertical gaze impairment.
3
Select the physical examination findings that specifically confirm PSP.
A supranuclear gaze palsy (loss of voluntary vertical gaze but intact brainstem reflexes) and severe axial rigidity correctly identify PSP and distinguish it from other conditions like multiple system atrophy or corticobasal degeneration.
Each atypical parkinsonian syndrome has distinct, pathognomonic physical examination findings required for clinical diagnosis.

Key Concept

Physical examination findings differentiating Progressive Supranuclear Palsy (PSP) from other parkinsonian syndromes.
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Physical Examination Findings

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