Clinical Reasoning: A 58-year-old man with hand tremor and episodes of neck pain

A 58-year-old man presented with a 1-year history of progressive right-hand tremor and slowness of movement. Three months before admission, he developed notable loss of motivation and fluctuations in attention and cognition culminating in episodes of transient blank staring while he was unresponsive. He was able to perform the activities of daily living with some difficulties. In the month before presentation, he complained about episodes of moderate pain in the neck and shoulder on standing (“coat-hanger pain”) and presented occasional and sudden episodes of transient loss of consciousness with falls. He also referred a 10-year previous history of hyposmia and dream-enacting behavior. Constipation, mostly nighttime urinary incontinence, and erectile dysfunction were reported to have started 3 years before. Medical history revealed myocardial infarction and depression with generalized anxiety disorder. His brother had been diagnosed with dementia at age 57 years and his father with Parkinson disease (PD) at age 60 years. Current medication included aspirin and bromazepam 3 mg/d.