A patient reported today the Neupro patches they requested from a Spanish pharmacy were returned because the dry ice required for shipping required special consent and paperwork. The patient continues to try and balance his medications, attempting to find a happy equilibrium between over medication and dyskinesia, and under medication resulting in more slowness, rigidity and episodes of freezing. The specialist in movement disorders commented freezing episodes usually occur independent of medication dosages. However, the patient claims Sinemet relieves such episodes. To manage the balancing act, the physician recommended cutting back on the Requip; he prescribed 1 mg tablets, to replace the 2 mg dose.
The patient had been interested in deep brain stimulation for controlling dyskinesia, and had visited a specialist in another city for a consultation. The clinical physician commented, of the six patients he has that have undergone surgery, only two continue to do well with their implants. He emphasized the surgery doesn't cure anything, and the operation comes with considerable risks; settings require adjusting and not all clinical staff are capable of superior post- operative care. While training is required to adjust settings, a spectrum of talent is employed to maximize the beneficial effects of neurostimulation.
The patient scheduled for 2:00pm sat in the waiting room for an hour and a half before the staff realized the allotted patient appointment drifted past. Consequently, the patient was in an ugly frame of mind. Though the reason for the visit was called, "Tremors" the patient exhibited none of the characteristic motions. Instead, the patient described spontaneous, involuntary movements like sudden face slaps, jerks, or kicks. The physician inspecting the patient's medical record noted the patient took a wide variety of antidepressants, and pain pills. Several of the daily medications are capable of producing involuntary movements and slurred speech. While the patient waited two months for an examination by the movement disorder specialist, hoping that the doctor would be able to identify the ailment and how to fix it. The patient's hopes crushed, tears flowed. The specialist stated he was the wrong doctor to be handling the case
and in his opinion the medications were the cause of the involuntary movements.
The specialist recommended the patient phone the social worker and begin the process of applying for disability. Clearly, it would be hard to keep a telephone position with a slurred voice, and inability to write in a timely manner. The good news was the patient suffered from no neurological degenerative sickness; the bad news was the patient was too depressed to appreciate good physical health.
Monday, July 13, 2009
Saturday, June 13, 2009
Lewy Body Disease?
The son and daughter of the patient bring her to the movement disorder specialist with a provisional diagnosis of Lewy Body Disease. Frederic Lewy gave his name to the bits of protein he found in the cytoplasm of cells throughout the brain in the early 1900s. The illness is characterized by dementia, fluctuations in cognition- attention, alertness and thinking ability from day to day, and Parkinsonism.
Lewy Body Disease might have made a more simple patient case. The actual patient had a history of high blood pressure, neurosurgery to correct a potentially fatal aneurysm, which Wikipedia defines as a "blood-filled dilation (balloon-like bulge) of a blood vessel caused by disease or weakening of the vessel wall." Neuroradiology discovered a tumor on her cerebellum while performing an MRI to ascertain the state of the aneurysm. The children of the patient noted she had trouble finding the appropriate words for objects, following surgery, an observation that coincides with an aneurysm on the left side of the brain, the language center. After surgery, patients routinely receive Dilantin, prophylactically, to avoid seizures caused by minute scarring of cortical tissue. The patient never took the medication and suffered a seizure in the presence of her 85-year-old husband. The children also reported an incident in which the patient, "went crazy" after her medications were changed. Though the craziness subsided with new drugs, she still suffered from significant mental changes, for example she could not report her correct age.
With all her troubles, the children of the patient commented she was in good health and rarely needs medical attention. On physical examination, the specialist noted tremor in her left hand and arm with less involvement on the right side. He felt some rigidity, more on the left than right, when the patient was distracted by performing a concurrent activity- in this case; she tapped her palm on her thigh. Parkinsonism also appeared as decreasing amplitude in repeated finger to thumb tapping. Of note also were brisk reflexes and upward going toes- a Babinski sign indicative of brain disease, specifically damage to the corticospinal tracts. The patient felt incapable of independent walking, so the physician gauged her standing and balance skills. Without support, she could stand with feet touching, though the left side of her body twitched noticeably. With her eyes closed, she stood considerably less still and when jostled she lost balance quickly.
The patient complained most about the tremor on the left side of her body. This symptom is what the specialist addressed, by recommending a medication that successfully quells tremor that would not interact with her other medications. To complicate matters a bit more, the doctor learned the patient refuses to take any medications given to her by her husband, with whom she lives. The patient fears he is trying to kill her. For this reason, an independent person must visit the home bringing the necessary drugs.
When the dilemma unfolded, the physician commented Medicare pays for home health to dispense medications. He wrote a prescription for this service, as well as for physical therapy. The patient left the office on the arm of her son, and was clearly unstable with tremor rocking the left side of her torso.
Lewy Body Disease might have made a more simple patient case. The actual patient had a history of high blood pressure, neurosurgery to correct a potentially fatal aneurysm, which Wikipedia defines as a "blood-filled dilation (balloon-like bulge) of a blood vessel caused by disease or weakening of the vessel wall." Neuroradiology discovered a tumor on her cerebellum while performing an MRI to ascertain the state of the aneurysm. The children of the patient noted she had trouble finding the appropriate words for objects, following surgery, an observation that coincides with an aneurysm on the left side of the brain, the language center. After surgery, patients routinely receive Dilantin, prophylactically, to avoid seizures caused by minute scarring of cortical tissue. The patient never took the medication and suffered a seizure in the presence of her 85-year-old husband. The children also reported an incident in which the patient, "went crazy" after her medications were changed. Though the craziness subsided with new drugs, she still suffered from significant mental changes, for example she could not report her correct age.
With all her troubles, the children of the patient commented she was in good health and rarely needs medical attention. On physical examination, the specialist noted tremor in her left hand and arm with less involvement on the right side. He felt some rigidity, more on the left than right, when the patient was distracted by performing a concurrent activity- in this case; she tapped her palm on her thigh. Parkinsonism also appeared as decreasing amplitude in repeated finger to thumb tapping. Of note also were brisk reflexes and upward going toes- a Babinski sign indicative of brain disease, specifically damage to the corticospinal tracts. The patient felt incapable of independent walking, so the physician gauged her standing and balance skills. Without support, she could stand with feet touching, though the left side of her body twitched noticeably. With her eyes closed, she stood considerably less still and when jostled she lost balance quickly.
The patient complained most about the tremor on the left side of her body. This symptom is what the specialist addressed, by recommending a medication that successfully quells tremor that would not interact with her other medications. To complicate matters a bit more, the doctor learned the patient refuses to take any medications given to her by her husband, with whom she lives. The patient fears he is trying to kill her. For this reason, an independent person must visit the home bringing the necessary drugs.
When the dilemma unfolded, the physician commented Medicare pays for home health to dispense medications. He wrote a prescription for this service, as well as for physical therapy. The patient left the office on the arm of her son, and was clearly unstable with tremor rocking the left side of her torso.
Friday, June 5, 2009
Hints of PD
She just wanted to be told she didn't have Parkinson's disease. Unfortunately, the doctor couldn't dispel her worries. She did have tremor; what sort of tremor is questionable. Sometimes causes are unclear, time helps clarify issues, though few people can ever pinpoint the cause of Parkinson's disease. Those who can identify a true cause of the illness may subscribe it to having a genetic mutation, though familial patterns of Parkinson's disease are quite rare.
The patient suffered from temporal arteritis, inflammation of the temporal artery. The harrowing condition has symptoms like tenderness of the scalp and hair, pain in the jaw and when chewing, and loss or blurriness of vision. Doctors prescribe oral steroids to bring inflammation under control, because vision can be lost and never regained if flow through the ophthalmic artery gets disrupted and the patient has no secondary means of blood circulation to the eye. For some reason, women are three times more likely to suffer from this problem than men. Rheumatoid arthritis or systemic lupus erythematosus may coincide with the ailment; the patient lived with the former.
Upon examination, the doctor noticed brisker reflexes on the right side as well as slight rigidity when engaged in a simultaneous task. Though the patient reported a tremor that could shake wine from her glass, the tremor during examination was mild and fine. Might arteritis be the cause of her physical symptoms? Rigidity may result from inflammation in the brain, but the spouse reported tremor was worsening. With the course of steroids, inflammation should resolve, causing rigidity to improve.
Worsening tremor is unlikely to result from inflammatory processes in the brain. If the patient suffers from a Parkinsonian syndrome then tremor should gradually worsen and involve both sides of the body at rest, or other symptoms should appear. With the request to return to clinic in six months to a year, the physician prescribed Selegiline with the hope of forestalling and diminishing a possible loss of dopaminergic neurons.
The patient suffered from temporal arteritis, inflammation of the temporal artery. The harrowing condition has symptoms like tenderness of the scalp and hair, pain in the jaw and when chewing, and loss or blurriness of vision. Doctors prescribe oral steroids to bring inflammation under control, because vision can be lost and never regained if flow through the ophthalmic artery gets disrupted and the patient has no secondary means of blood circulation to the eye. For some reason, women are three times more likely to suffer from this problem than men. Rheumatoid arthritis or systemic lupus erythematosus may coincide with the ailment; the patient lived with the former.
Upon examination, the doctor noticed brisker reflexes on the right side as well as slight rigidity when engaged in a simultaneous task. Though the patient reported a tremor that could shake wine from her glass, the tremor during examination was mild and fine. Might arteritis be the cause of her physical symptoms? Rigidity may result from inflammation in the brain, but the spouse reported tremor was worsening. With the course of steroids, inflammation should resolve, causing rigidity to improve.
Worsening tremor is unlikely to result from inflammatory processes in the brain. If the patient suffers from a Parkinsonian syndrome then tremor should gradually worsen and involve both sides of the body at rest, or other symptoms should appear. With the request to return to clinic in six months to a year, the physician prescribed Selegiline with the hope of forestalling and diminishing a possible loss of dopaminergic neurons.
Saturday, May 30, 2009
Dad- a Clinic Day without PD Patients
My father used to be 5'10", now he's 5'6" or so. With my high heels on, I am as tall as he is. He's got that hunched over Parkinsonian posture. I tried to fix it by putting my shin near his spine and pulling his shoulders back. He shouted at me. I couldn't get him to extend his chest at all, his shoulders and pectorals have very little 'give'.
At home, he has a regular exercise routine, but the day I saw him he and his generation opted to eat dinner in the hotel restaurant, rather than walk the block and a half to the grill and microbrewery. When we did walk together, I took his arm, hoping that a little support would encourage a more spirited pace. Usually it failed, but at least he could hear me. He stops when he talks. I acquired the habit of either not talking, or monopolizing all the words, so we could continue moving.
Apathy comes. He is content to read the paper all day, drinking black coffee. I hear he does little housework and does not help with chores. When these things are pointed out, he shrugs his shoulders. My Dad has always favored well-cooked meat. At the hotel restaurant, he requested well- done bacon; it looked like jerky, he was delighted. He ate his bacon with dry toast- also well- done. I informed him the protein in the meat would affect how well his medications worked. He has never been science - oriented, he is an English and History teacher. I told him about neurotransmitters and how dopamine and proteins compete for the same sites, but I don't think he knew what I was saying, except that I thought the bacon was a bad choice.
Ages ago, I found a map of Wyoming or North Dakota with a town bearing our family surname. I showed it to him at the hotel breakfast.
"Yeah, I knew about that." He wasn't impressed.
On certain nights of the week when his wife works late, he cooks dinner. It can be a contentious event, apparently. Dad would not disclose what was for dinner on a recent night; he'd already had one argument about it. He likes meat and potatoes and tolerates a vegetable. How do the bowels of this man work? He lives primarily on bread and meat, and drinks no water, just black coffee during the day.
I am the delinquent one, the daughter who has never visited him, and he is nearing 78. At the end of our visit, I hug him and tell him I love him. He may have become apathetic, but he is teary to see his three daughters leave.
At home, he has a regular exercise routine, but the day I saw him he and his generation opted to eat dinner in the hotel restaurant, rather than walk the block and a half to the grill and microbrewery. When we did walk together, I took his arm, hoping that a little support would encourage a more spirited pace. Usually it failed, but at least he could hear me. He stops when he talks. I acquired the habit of either not talking, or monopolizing all the words, so we could continue moving.
Apathy comes. He is content to read the paper all day, drinking black coffee. I hear he does little housework and does not help with chores. When these things are pointed out, he shrugs his shoulders. My Dad has always favored well-cooked meat. At the hotel restaurant, he requested well- done bacon; it looked like jerky, he was delighted. He ate his bacon with dry toast- also well- done. I informed him the protein in the meat would affect how well his medications worked. He has never been science - oriented, he is an English and History teacher. I told him about neurotransmitters and how dopamine and proteins compete for the same sites, but I don't think he knew what I was saying, except that I thought the bacon was a bad choice.
Ages ago, I found a map of Wyoming or North Dakota with a town bearing our family surname. I showed it to him at the hotel breakfast.
"Yeah, I knew about that." He wasn't impressed.
On certain nights of the week when his wife works late, he cooks dinner. It can be a contentious event, apparently. Dad would not disclose what was for dinner on a recent night; he'd already had one argument about it. He likes meat and potatoes and tolerates a vegetable. How do the bowels of this man work? He lives primarily on bread and meat, and drinks no water, just black coffee during the day.
I am the delinquent one, the daughter who has never visited him, and he is nearing 78. At the end of our visit, I hug him and tell him I love him. He may have become apathetic, but he is teary to see his three daughters leave.
Friday, May 8, 2009
Hope is Hard to Kill
The patient hoped there was something in her a neurosurgeon could fix, to alleviate the tremor of her left hand. Unfortunately, she lived with several poorly aligned vertebrae in the cervical area and the doctor could see no reason on the MRI for a tremor. He wasn't the first physician to tell her this. Two neurosurgeons and a neurologist confided they saw no cause for tremor on the images of her brain and upper spinal column. Still hope is hard to kill. Clinically, the tremor she endured would be classified as mild, yet because it was her arm and hand, she conceived the movement as pronounced and problematic.
An older woman- she thought herself so, her birthday three years before the physician behind the desk, she suspected her tremor might be part of aging. The doctor assured her she was not old, and tremor is not a natural consequence of increasing age. He pointed with both hands to his head of dark hair shot through liberally with graying streaks, encouraging her to change her thinking on that matter.
With a Latin surname, a Florida speech pattern and the pale eyes and skin, I assumed she was a descendant of an original Florida family, but I was wrong. She still used the name of her former husband. Her manner so mild, I feared she would cry, outnumbered in the examination room by the clinical coordinator, the physician and myself.
The specialist recommended amantadine for the tremor, two pills a day- one at breakfast another at dinner or before bed. The drug has other properties as well as reducing tremor; it is anti- viral, so patients experience less flu and colds while taking it. While Azilect might stabilize symptoms, it is also an MAO inhibitor and possibly problematic, as one must avoid certain foods- aged meats, cheeses, and certain other drugs. He also strongly advised an antidepressant to lighten the cloud she carries over her head.
The MRI mages produced an unusual finding, a calcified meningioma: a very slow- growing tumor of tissue involving the tissue of the meninges. The doctor fished into the large envelope searching for a report to see what the radiologist concluded, and confirmed his own diagnosis. Women apparently have a greater quantity of such tumors.
Small, round, light splotches speckled the brain on the MRI. The doctor gave this a medical term, "leukoareosis". Apparently, leaky blood vessels in the brain show up on MRIs due to their excess fluid, a natural consequence of high blood pressure. They also, cannot be blamed for instigating the tremor of the left hand.
An older woman- she thought herself so, her birthday three years before the physician behind the desk, she suspected her tremor might be part of aging. The doctor assured her she was not old, and tremor is not a natural consequence of increasing age. He pointed with both hands to his head of dark hair shot through liberally with graying streaks, encouraging her to change her thinking on that matter.
With a Latin surname, a Florida speech pattern and the pale eyes and skin, I assumed she was a descendant of an original Florida family, but I was wrong. She still used the name of her former husband. Her manner so mild, I feared she would cry, outnumbered in the examination room by the clinical coordinator, the physician and myself.
The specialist recommended amantadine for the tremor, two pills a day- one at breakfast another at dinner or before bed. The drug has other properties as well as reducing tremor; it is anti- viral, so patients experience less flu and colds while taking it. While Azilect might stabilize symptoms, it is also an MAO inhibitor and possibly problematic, as one must avoid certain foods- aged meats, cheeses, and certain other drugs. He also strongly advised an antidepressant to lighten the cloud she carries over her head.
The MRI mages produced an unusual finding, a calcified meningioma: a very slow- growing tumor of tissue involving the tissue of the meninges. The doctor fished into the large envelope searching for a report to see what the radiologist concluded, and confirmed his own diagnosis. Women apparently have a greater quantity of such tumors.
Small, round, light splotches speckled the brain on the MRI. The doctor gave this a medical term, "leukoareosis". Apparently, leaky blood vessels in the brain show up on MRIs due to their excess fluid, a natural consequence of high blood pressure. They also, cannot be blamed for instigating the tremor of the left hand.
Tuesday, May 5, 2009
Rigid and Akinetic
He is a model of rigid akinetic Parkinson's disease, as opposed to the tremor dominant type. A compact man with a receding hairline of thick wavy and whitening hair, his nose is hooked. The skin of his face is pale and wraps his cheekbones tightly. He admits he's never suffered from tremor, a good thing when welding. He's an artist, primarily a sculptor. He calls himself an art teacher. The doctor asks to see his work, noting he appreciates art. All sorts of toxic substances- manganese, cobalt and solvents increased the risk he would acquire the illness. Today he is either
under- medicated or does not have PD. He sits like a rock in the yellow plastic chair. As he speaks he moves his mouth, but he doesn't fidget, scratch, blink or shift his weight. He shoots his left eyebrow up, once.
The patient and the doctor begin their words at the same time, more than once their voices overlap. When a pronounced delay in response sends the room to silence, the wife tries to help by reminding her spouse of the sequence of events. It has been six or seven years since the diagnosis, the initial symptoms are hard to recall. Still symptoms, diagnosis and treatment began within a period of a year. Not good, in the opinion of the physician...He can't recall feeling any improvement with medications. The specialist declares the patient is inadequately medicated or doesn't respond to levodopa.
He begins drawing a chart, describing how to increase the dose of Sinemet from one pill, four times daily to a possible maximum of ten pills daily. The idea is to increase the dosage, then observe the response the body makes on the following two days. Always increase the dose by half a pill, in a staircase fashion, halting progression if feeling nausea. If nausea continues at that dose, then step backward a half pill. The object is to discover what the correct dose is to alleviate most symptoms. Fluidity of movement, increased arm swing in walking, loosening of joints are as three aspects for possible improvement.
The doctor hands the patient the medication progression chart, requesting he return in three months. He is not free, yet. Both patient and spouse agree to provide their blood for a study searching for possible biomarkers in PD. This entity in blood would change along with the progression of illness, providing another source to document disease progression. Physicians determine the progression of illness by physical exam, but it gets tricky when patients rely on medication to be fully functional. Visual scanning techniques can also document loss of dopamine in the substantia nigra, but the procedure is costly, and dopamine-producing cells dwindle naturally with aging before producing parkinsonian symptoms.
b
under- medicated or does not have PD. He sits like a rock in the yellow plastic chair. As he speaks he moves his mouth, but he doesn't fidget, scratch, blink or shift his weight. He shoots his left eyebrow up, once.
The patient and the doctor begin their words at the same time, more than once their voices overlap. When a pronounced delay in response sends the room to silence, the wife tries to help by reminding her spouse of the sequence of events. It has been six or seven years since the diagnosis, the initial symptoms are hard to recall. Still symptoms, diagnosis and treatment began within a period of a year. Not good, in the opinion of the physician...He can't recall feeling any improvement with medications. The specialist declares the patient is inadequately medicated or doesn't respond to levodopa.
He begins drawing a chart, describing how to increase the dose of Sinemet from one pill, four times daily to a possible maximum of ten pills daily. The idea is to increase the dosage, then observe the response the body makes on the following two days. Always increase the dose by half a pill, in a staircase fashion, halting progression if feeling nausea. If nausea continues at that dose, then step backward a half pill. The object is to discover what the correct dose is to alleviate most symptoms. Fluidity of movement, increased arm swing in walking, loosening of joints are as three aspects for possible improvement.
The doctor hands the patient the medication progression chart, requesting he return in three months. He is not free, yet. Both patient and spouse agree to provide their blood for a study searching for possible biomarkers in PD. This entity in blood would change along with the progression of illness, providing another source to document disease progression. Physicians determine the progression of illness by physical exam, but it gets tricky when patients rely on medication to be fully functional. Visual scanning techniques can also document loss of dopamine in the substantia nigra, but the procedure is costly, and dopamine-producing cells dwindle naturally with aging before producing parkinsonian symptoms.
b
Bikes and Ladders
Bikes and Ladders
There are no symptoms when he's working. He climbs ladders and walks on roofs. When he comes home he freezes between doorways, as he does at the movies. He and his wife wait to be among the last to exit, to avoid the rush of people. He comments he doesn't sleep much, but it doesn't bother him. His energy level is high. It's been ten years since his diagnosis and his gait appears unaffected by the illness now; he has a natural arm swing and his steps are fluid. I ask the doctor whether he questions the diagnosis, and he says no. The patient responds to levodopa. The only troublesome time is around four in the morning after a bowl of cereal when the medication never seems effective; he shuffles. The doctor asks if he pours milk in the bowl. He does.
Milk protein is an especially competitive amino acid, and competes with levodopa for space on receptors. Other proteins will have a similar action, making levodopa much less effective. It's hard to fathom the patient doesn't know this. Both indicate this is the first time they have heard dietary proteins can interfere with uptake of the medication. The clinical coordinator nods and mentions this is something a support group can be helpful with. She is in the process of setting up a support group for patients in their area, and she gathers their contact information.
The next patient has had the illness since his mid thirties. He sits with his right shoulder drawn up towards his ear as his left hand flails and the right hand is stuck in a dystonic spasm. He recounts a story of hospitalization after falling backwards in his yard. They gave me morphine, he notes. The doctor raises his eyebrows and asks whether he liked the sensation. No, he thought they were trying to put him to sleep. They did x-rays of his chest after listening to his lungs. He had six x-rays, they only needed to take two, he relays indignantly. They put him on a course of several antibiotics, with names this long- he gestures a distance of about a foot. This is his worst nightmare; he will die in a hospital of pneumonia. He was strapped to a gurney, journeying into the belly of the hospital deep underground with patients lining the hallways all waiting for testing. Before they let him go, they made him sign a paper promising to take another two bags of IV antibiotics. He is in the midst of writing an angry letter to the hospital- a lawyer still.
The caregiver accompanying him is blond and well dressed, and has pink lipstick. Her face is pleasant and her demeanor quiet but assertive. She makes notes while the clinician speaks. Asking him to clarify what symptoms of an "off" episode look like. The answer is complicated because the patient experiences wearing off symptoms in one arm with dyskinesia on the opposing side. Learning about Parkinson's will be rough with this patient as the model.
He wants to ride his new bike, it has two wheels, not three, as the doctor would have preferred. It was lightning when it arrived, but he had to try it out before the rain began. The pretty caregiver found him a block away frozen in the pouring rain.
There are no symptoms when he's working. He climbs ladders and walks on roofs. When he comes home he freezes between doorways, as he does at the movies. He and his wife wait to be among the last to exit, to avoid the rush of people. He comments he doesn't sleep much, but it doesn't bother him. His energy level is high. It's been ten years since his diagnosis and his gait appears unaffected by the illness now; he has a natural arm swing and his steps are fluid. I ask the doctor whether he questions the diagnosis, and he says no. The patient responds to levodopa. The only troublesome time is around four in the morning after a bowl of cereal when the medication never seems effective; he shuffles. The doctor asks if he pours milk in the bowl. He does.
Milk protein is an especially competitive amino acid, and competes with levodopa for space on receptors. Other proteins will have a similar action, making levodopa much less effective. It's hard to fathom the patient doesn't know this. Both indicate this is the first time they have heard dietary proteins can interfere with uptake of the medication. The clinical coordinator nods and mentions this is something a support group can be helpful with. She is in the process of setting up a support group for patients in their area, and she gathers their contact information.
The next patient has had the illness since his mid thirties. He sits with his right shoulder drawn up towards his ear as his left hand flails and the right hand is stuck in a dystonic spasm. He recounts a story of hospitalization after falling backwards in his yard. They gave me morphine, he notes. The doctor raises his eyebrows and asks whether he liked the sensation. No, he thought they were trying to put him to sleep. They did x-rays of his chest after listening to his lungs. He had six x-rays, they only needed to take two, he relays indignantly. They put him on a course of several antibiotics, with names this long- he gestures a distance of about a foot. This is his worst nightmare; he will die in a hospital of pneumonia. He was strapped to a gurney, journeying into the belly of the hospital deep underground with patients lining the hallways all waiting for testing. Before they let him go, they made him sign a paper promising to take another two bags of IV antibiotics. He is in the midst of writing an angry letter to the hospital- a lawyer still.
The caregiver accompanying him is blond and well dressed, and has pink lipstick. Her face is pleasant and her demeanor quiet but assertive. She makes notes while the clinician speaks. Asking him to clarify what symptoms of an "off" episode look like. The answer is complicated because the patient experiences wearing off symptoms in one arm with dyskinesia on the opposing side. Learning about Parkinson's will be rough with this patient as the model.
He wants to ride his new bike, it has two wheels, not three, as the doctor would have preferred. It was lightning when it arrived, but he had to try it out before the rain began. The pretty caregiver found him a block away frozen in the pouring rain.
Contrasting Patients
Dyskinesia of the diaphragm is what he suffers from. The area below his rib cage seizes, moving the t-shirt that covers him, I think of a belly dancer's abdomen and wonder whether the doctor will lift the t- shirt. The pulling can get so intense he buckles over, while sitting. He was diagnosed only two years ago, and the disease affects both sides of the body. Dyskinesia affects both hands, and they move spontaneously while he sits in the examination room. Amantadine helps the dyskinesia and he's been without it since Sunday.
As the doctor examines the patient he notes the dark freckles that cover the area from the ankles up towards the knee. It's a side effect of Amantadine. In lighter skinned people the color appears reddish- purple. Since he's been without the medication the swelling in the feet has diminished.
The doctor recommends rotigotine and the clinical coordinator goes to search for samples. He explains to the daughter and patient what he would like to try- diminish the Sinemet while adding rotigotine, to see whether the new combination will help eliminate the excess movements. As the physician explains he writes the steps down on a sheet of paper he discovered in the printer.
This patient is almost floating. She enters and sits and speaks with the coordinator mentioning the book she recommends to all with a relative or spouse with PD, but can't remember the title. She wears green patterned long shorts and a yellow shirt. Her glasses sit on her nose and her skin is pale and clear and a hint of pink covers her cheeks. In her animated speech she kicks her legs out from below the chair.
The doctor searches the computer for the note he dictated last, while she speaks. There was a time when she fell into a fit of depression. She had reached fifty, got divorced and her children were away. 'You have to dig yourself out, anyway you can.' She is doing much better these days and would feel even better if she didn't have to spend $485. every month on the Neupro patch she acquires from Canada. This month she called twelve pharmacies before finding the medication at the thirteenth. They gave her free shipping.
The doctor encourages her, telling her she looks very well. She's had the illness for fifteen years and now sees symptoms of the illness on her left side. She confides she has been living with her boyfriend for the past eleven years. He is a calming influence and doesn't mind waiting until her medications are working, to leave the house.
When the patient has left, the doctor comments he has seen her for a long time. He remembers the husband who was Italian and reminded him of a mobster, wearing a baseball hat and a large belly. When I leave I note her new partner; a tanned fit man also wearing a ball cap.
As the doctor examines the patient he notes the dark freckles that cover the area from the ankles up towards the knee. It's a side effect of Amantadine. In lighter skinned people the color appears reddish- purple. Since he's been without the medication the swelling in the feet has diminished.
The doctor recommends rotigotine and the clinical coordinator goes to search for samples. He explains to the daughter and patient what he would like to try- diminish the Sinemet while adding rotigotine, to see whether the new combination will help eliminate the excess movements. As the physician explains he writes the steps down on a sheet of paper he discovered in the printer.
This patient is almost floating. She enters and sits and speaks with the coordinator mentioning the book she recommends to all with a relative or spouse with PD, but can't remember the title. She wears green patterned long shorts and a yellow shirt. Her glasses sit on her nose and her skin is pale and clear and a hint of pink covers her cheeks. In her animated speech she kicks her legs out from below the chair.
The doctor searches the computer for the note he dictated last, while she speaks. There was a time when she fell into a fit of depression. She had reached fifty, got divorced and her children were away. 'You have to dig yourself out, anyway you can.' She is doing much better these days and would feel even better if she didn't have to spend $485. every month on the Neupro patch she acquires from Canada. This month she called twelve pharmacies before finding the medication at the thirteenth. They gave her free shipping.
The doctor encourages her, telling her she looks very well. She's had the illness for fifteen years and now sees symptoms of the illness on her left side. She confides she has been living with her boyfriend for the past eleven years. He is a calming influence and doesn't mind waiting until her medications are working, to leave the house.
When the patient has left, the doctor comments he has seen her for a long time. He remembers the husband who was Italian and reminded him of a mobster, wearing a baseball hat and a large belly. When I leave I note her new partner; a tanned fit man also wearing a ball cap.
Cotton and Linen
A white blouse, natural undyed linen skirt and huarache sandals; the patient's appearance hints at affluent comfort. Her height, shoulder length white hair and the pleasant proportions of her face require the attention of those around her. Making eye contact with those passing in the hall, her facial expression does not change. Dyskinesia gently rocks her head from side to side. The husband is shorter and rounder. Her legs are long, perhaps a model's legs in younger years.
The doctor inquires into her health, commenting on the movements of the head. He has never seen her so mobile. They are in Sun City now, their winter place. But New York beckons. Their return North means physical therapy with a previous therapist who worked on her neck and shoulder. Years ago a surgeon placed metal plates to stabilize the cervical vertebrae of the neck, but the excess motion of dyskinesia creates pain that moves through her shoulder and down the left arm. The doctor comments deep brain stimulation can readily improve the unwanted movements. She comments she takes a blood thinner, Coumadin and avoids green leafy vegetables for their wealth of vitamin K- a blood coagulator. No, surgery is not an option for her.
As the doctor types information into the computer system the pace of his words slow. She reaches into her bag for the diary, where she has recorded her physical condition for the past month. There are days when she froze repeatedly, other days when she was "on" and forgot to take the medication. The doctor re-emphasizes the times when symptoms are known to worsen; with stress, any colds or flu, dental work...From the occurrence of movements and the time since the last pills the physician deduces she suffers from peak dose dyskinesia. If she cut back her dose a bit, relied more on agents that prolong dopamine's affect, or spaced the doses out more through the day she might experience less dyskinesia. The husband shakes his head, commenting a large party is approaching and his wife worries
The doctor inquires into her health, commenting on the movements of the head. He has never seen her so mobile. They are in Sun City now, their winter place. But New York beckons. Their return North means physical therapy with a previous therapist who worked on her neck and shoulder. Years ago a surgeon placed metal plates to stabilize the cervical vertebrae of the neck, but the excess motion of dyskinesia creates pain that moves through her shoulder and down the left arm. The doctor comments deep brain stimulation can readily improve the unwanted movements. She comments she takes a blood thinner, Coumadin and avoids green leafy vegetables for their wealth of vitamin K- a blood coagulator. No, surgery is not an option for her.
As the doctor types information into the computer system the pace of his words slow. She reaches into her bag for the diary, where she has recorded her physical condition for the past month. There are days when she froze repeatedly, other days when she was "on" and forgot to take the medication. The doctor re-emphasizes the times when symptoms are known to worsen; with stress, any colds or flu, dental work...From the occurrence of movements and the time since the last pills the physician deduces she suffers from peak dose dyskinesia. If she cut back her dose a bit, relied more on agents that prolong dopamine's affect, or spaced the doses out more through the day she might experience less dyskinesia. The husband shakes his head, commenting a large party is approaching and his wife worries
Shakes and Pains
Six month follow- ups help the doctor and patient stay on top of shifting symptoms, though more frequent appointments are possible. The doctor has said he likes movement disorders because there are no emergencies. Though the first incident of freezing may feel catastrophic to the patient, it passes. They are bumps in the road. Sometimes the journey is lightened by sharing it.
The Parkinson's disease coordinator speaks with the patient about attending possible support group meetings in his area. He responds, stating not all patients want to talk about their problems. Not deterred, she explains the sessions will be run according to group preference. Some people may want lectures, others may just want the social time.
The shooting pain in the left knee is new and it worries him. It never occurs when he's doing Tai chi and it moves up, not down, as the doctor would prefer. Pain moving downward may emanate from the spine, a bony prominence can easily impinge on the fibers of a nerve, sending scintillating pain down through the leg. That's not it. This is pain moving up towards the thigh and it's fast, not throbbing and deep as the pain patients with PD describe. Both his mother and father are diabetic...The patient climbs onto the examination table and the physician tries to replicate the sensation. Both legs have bruises at the lower mid- shin. The tightness of the muscles in the patient's legs is extreme; the doctor comments he would like him to continue with physical therapy.
Parkinson's disease in this patient is evident in the constant tremor of his hands. Six months ago, it was not as prominent as it is today. He describes shaving, his right hand wavering towards his cheek. The doctor recommends wearing wrist weights to dampen the movements, the patient nods. Tremor is one of the hardest symptoms to suppress, and he takes a distinct drug to soften the constant shaking. Yet he walks well, with head and shoulders erect, an arms swing, and ample step size.
The Parkinson's disease coordinator speaks with the patient about attending possible support group meetings in his area. He responds, stating not all patients want to talk about their problems. Not deterred, she explains the sessions will be run according to group preference. Some people may want lectures, others may just want the social time.
The shooting pain in the left knee is new and it worries him. It never occurs when he's doing Tai chi and it moves up, not down, as the doctor would prefer. Pain moving downward may emanate from the spine, a bony prominence can easily impinge on the fibers of a nerve, sending scintillating pain down through the leg. That's not it. This is pain moving up towards the thigh and it's fast, not throbbing and deep as the pain patients with PD describe. Both his mother and father are diabetic...The patient climbs onto the examination table and the physician tries to replicate the sensation. Both legs have bruises at the lower mid- shin. The tightness of the muscles in the patient's legs is extreme; the doctor comments he would like him to continue with physical therapy.
Parkinson's disease in this patient is evident in the constant tremor of his hands. Six months ago, it was not as prominent as it is today. He describes shaving, his right hand wavering towards his cheek. The doctor recommends wearing wrist weights to dampen the movements, the patient nods. Tremor is one of the hardest symptoms to suppress, and he takes a distinct drug to soften the constant shaking. Yet he walks well, with head and shoulders erect, an arms swing, and ample step size.
Test Pilot
A German patient and his Austrian wife have recently moved from Iowa, and need a new neurologist. His voice resonates in the small room with only a hint of German lilt left. He has the voice for radio, but he is a test pilot. The doctor is in education mode conferring to the patient all things related to Parkinson's and discusses the personality type others have given to the stereotypical sufferer. Well controlled, averse to adventure, given to detail and methodical work, the patient admits that describes himself.
The wife describes the onset of symptoms a few years ago; trembling in a hand that in time involved the foot as well. Today there is little evidence of any symptom. The doctor feels some cog- wheel rigidity in the muscles at the elbow joint on the left side otherwise the patient's symptoms are very well disguised by medications- Mirapex and Sinemet. The movement disorder physician commends the patient's management, he is doing the right things- exercising daily... He would add something thought to slow illness- perhaps coenzyme Q10 or deprenyl.
The doctor conducts a physical exam. Performing the finger to nose task, first with the right hand and then left, I note the patient's hands. His skin is taught and smooth, unlined and young- looking. He is in his sixties and he has the hands of a young man. The wife has skin appropriate to someone of her age, and a flare for fashion evident in pale pink clogs with an open toe and well- cut red hair. She is un-intimidated by the doctor and presses him on why he speaks so much of animal research.
The patient's gait is flawless and his arm swing full and loose. 'Maybe I don't have PD...' the patient comments as the physician emphasizes how well his symptoms are covered. The doctor doesn't give the comment any reply. All witnessed the wife mimicking the tremor of the hand, and how the movement eventually affected the left foot. If he doesn't have Parkinson's he has something close enough
The wife describes the onset of symptoms a few years ago; trembling in a hand that in time involved the foot as well. Today there is little evidence of any symptom. The doctor feels some cog- wheel rigidity in the muscles at the elbow joint on the left side otherwise the patient's symptoms are very well disguised by medications- Mirapex and Sinemet. The movement disorder physician commends the patient's management, he is doing the right things- exercising daily... He would add something thought to slow illness- perhaps coenzyme Q10 or deprenyl.
The doctor conducts a physical exam. Performing the finger to nose task, first with the right hand and then left, I note the patient's hands. His skin is taught and smooth, unlined and young- looking. He is in his sixties and he has the hands of a young man. The wife has skin appropriate to someone of her age, and a flare for fashion evident in pale pink clogs with an open toe and well- cut red hair. She is un-intimidated by the doctor and presses him on why he speaks so much of animal research.
The patient's gait is flawless and his arm swing full and loose. 'Maybe I don't have PD...' the patient comments as the physician emphasizes how well his symptoms are covered. The doctor doesn't give the comment any reply. All witnessed the wife mimicking the tremor of the hand, and how the movement eventually affected the left foot. If he doesn't have Parkinson's he has something close enough
Undaunted
Undaunted
The patient begins explaining as soon as the doctor sits and the list is long. He thinks he's always had a tremor of the hands but now he thinks it may be worse; sometimes he has troubling controlling the mouse on the computer so the cursor sprints across the screen. He has a low body temperature, usually about 96 degrees. Another autonomic sign is erectile dysfunction..
On examination the doctor finds some rigidity in the muscles of the right arm, a hint of rigidity in the left arm but none in the wrists. His gait is fluid, with an arm swing. Facial expressions are complete. His eye movements are full, but then he has only one eye; he lost the left one when he was seven, when he accidentally stuck a knife in it. He was also hit by a car and spent a year in the hospital trying to acquire appropriate healing of the left tibia- leg bone. As a child he watched his brother die when he had a seizure and never recovered. His father died before age thirty-five and two of the patient's daughters also died. Yet he is not depressed, he's an optimist. We laugh. So much death and he is undaunted.
He is a working engineer, and he's past retirement age, at 72. Traveling he uses his Irish passport; in Libya they have negative associations about Americans and he travels a lot; India, Northern Africa... He speaks French, some Arabic, Spanish, some Italian and he used to speak Gaelic.
He worries about his enlarging waistline, and the doctor asks him whether he has had his thyroid tested. He admits the skin of his arms gets very dry, unless he uses lotion his skin flakes like the scales of a fish.
The doctor explains a study he is in which seeks a biomarker for the progression of Parkinson's disease. The patient is a wonderful candidate because he is early in the disease process, if he has Parkinson's. The only way to be sure about the diagnosis and whether he has a deficit of dopamine, is to gauge the response to levodopa.. Yet the doctor hesitates to give him medications when he functions so well, choosing instead to give him a drug thought to delay onset of symptoms, Selegiline. A prescription for physical therapy will help him form an exercise routine to keep him active.
The patient begins explaining as soon as the doctor sits and the list is long. He thinks he's always had a tremor of the hands but now he thinks it may be worse; sometimes he has troubling controlling the mouse on the computer so the cursor sprints across the screen. He has a low body temperature, usually about 96 degrees. Another autonomic sign is erectile dysfunction..
On examination the doctor finds some rigidity in the muscles of the right arm, a hint of rigidity in the left arm but none in the wrists. His gait is fluid, with an arm swing. Facial expressions are complete. His eye movements are full, but then he has only one eye; he lost the left one when he was seven, when he accidentally stuck a knife in it. He was also hit by a car and spent a year in the hospital trying to acquire appropriate healing of the left tibia- leg bone. As a child he watched his brother die when he had a seizure and never recovered. His father died before age thirty-five and two of the patient's daughters also died. Yet he is not depressed, he's an optimist. We laugh. So much death and he is undaunted.
He is a working engineer, and he's past retirement age, at 72. Traveling he uses his Irish passport; in Libya they have negative associations about Americans and he travels a lot; India, Northern Africa... He speaks French, some Arabic, Spanish, some Italian and he used to speak Gaelic.
He worries about his enlarging waistline, and the doctor asks him whether he has had his thyroid tested. He admits the skin of his arms gets very dry, unless he uses lotion his skin flakes like the scales of a fish.
The doctor explains a study he is in which seeks a biomarker for the progression of Parkinson's disease. The patient is a wonderful candidate because he is early in the disease process, if he has Parkinson's. The only way to be sure about the diagnosis and whether he has a deficit of dopamine, is to gauge the response to levodopa.. Yet the doctor hesitates to give him medications when he functions so well, choosing instead to give him a drug thought to delay onset of symptoms, Selegiline. A prescription for physical therapy will help him form an exercise routine to keep him active.
Friday, January 9, 2009
Two Men and a Mute
Shy Drager's Syndrome takes away the body's ability to regulate blood pressure so there is a lot of lightheadedness and falling. That's why the spouse wears tight hose and uses the wheel chair in the middle of the night. It's all happened before. The doctor likes to give these patients erythropoietin, a substance that promotes formation of red blood cells. The patient also takes Florinef, a drug that causes the kidney's to hold onto salt, thereby increasing blood volume.
The patient asks the medical student whether she's a dancer. Her blond hair hangs straight down past her shoulders and she responds easily, replying when she was younger. The spouse teaches dance, and has owned a dance studio for forty years.
The last episode lasted about 15 minutes. She was ready to call 911. It began with shaking in the arms. The trembling got more violent, his eyes rolled back in his head, and his torso straightened in the wheelchair. His breathing changed and he lost bladder control. The wife has described the episodes before, apparently with less emotion. The doctor worries about seizures and recommends an EEG and MRI. He comments it is rare to have PD and seizures appear together, they tend to be inversely related - though hypoxia can induce them.
The man with the thick hair and heavy rectangular glasses asks about scotch and water. He never remembers the seizures, even right after they've occurred. When would you like a drink? The physician asks. Before and after dinner the patient answers, but the wife returns and vetoes all scotch with a wave of her hand. He won't be able to walk, she claims. No scotch.
He recalls a meeting he recently attended. Hugo Chavez was there and he didn't look well. He and his wife had just returned and their bags were still in the hall near the front door. It was a dream, his wife reminds him. He looks at her. As the doctor hands her a new prescription, she turns to her husband, explaining there will be three more pills to add to the regular five. He never believes he needs to take them- she comments, he thinks I am poisoning him.
The next patient comes to clinic with his son. They are speaking Greek when the team enters. He is small and bald and when the doctor asks him to walk down the hallway, he jogs. He exercises everyday. The doctor asks about the hallucinations, and the patient replies he sees them all the time, all kinds of people. Sometimes they walk next to him. Mostly they are happy. Women appear and beckon to him. Some are naked and lie in bed with him and his wife. He has woken in bed, wet with semen. When the dreams occur, he says he feels like dancing and waltzes side to side, his arms carrying an invisible partner.
The patient in the wheelchair hasn't used her feet in a long, long time. They are crooked underneath her white socks, with permanent contractures. Her head almost sits on her chest cavity, the bowing of her upper back is so pronounced. The mother who has been reading a magazine, doesn't comment on the others in the room as the doctor asks permission to let the medical student and writer attend. Clearly, she is bothered. The doctor laughs softly as the stuffed bear the girl holds in her lap speaks. He looks at the girl with short-cropped dark hair, and asks her a question. He wants her to hold out her hands and demonstrates. The girl creeps her right hand towards her mother's left arm and squeezes. Does she speak? He asks. No.
With cerebral palsy from birth, the daughter never speaks. Since the last appointment, the medicines have calmed her dystonic movements. Then the mother leans forward and asks for a recommendation for a Spanish- speaking psychiatrist. She says her daughter screams when people touch her, when she tries to change her diaper or brush her teeth, or change her clothes, or bathe her. When the daughter is tired of family company, she screams. She constantly grinds her teeth and refuses to drink. Mother puts her in her room, closing the door to scream alone. She fears neighbors will call the police, fears they think she is abusing her daughter. Mother confides she gave her daughter three times the dose of a drug to make the child manageable for the appointment.
What kind of quality of life is that? The doctor asks. Screaming is clearly no way to live.
The patient asks the medical student whether she's a dancer. Her blond hair hangs straight down past her shoulders and she responds easily, replying when she was younger. The spouse teaches dance, and has owned a dance studio for forty years.
The last episode lasted about 15 minutes. She was ready to call 911. It began with shaking in the arms. The trembling got more violent, his eyes rolled back in his head, and his torso straightened in the wheelchair. His breathing changed and he lost bladder control. The wife has described the episodes before, apparently with less emotion. The doctor worries about seizures and recommends an EEG and MRI. He comments it is rare to have PD and seizures appear together, they tend to be inversely related - though hypoxia can induce them.
The man with the thick hair and heavy rectangular glasses asks about scotch and water. He never remembers the seizures, even right after they've occurred. When would you like a drink? The physician asks. Before and after dinner the patient answers, but the wife returns and vetoes all scotch with a wave of her hand. He won't be able to walk, she claims. No scotch.
He recalls a meeting he recently attended. Hugo Chavez was there and he didn't look well. He and his wife had just returned and their bags were still in the hall near the front door. It was a dream, his wife reminds him. He looks at her. As the doctor hands her a new prescription, she turns to her husband, explaining there will be three more pills to add to the regular five. He never believes he needs to take them- she comments, he thinks I am poisoning him.
The next patient comes to clinic with his son. They are speaking Greek when the team enters. He is small and bald and when the doctor asks him to walk down the hallway, he jogs. He exercises everyday. The doctor asks about the hallucinations, and the patient replies he sees them all the time, all kinds of people. Sometimes they walk next to him. Mostly they are happy. Women appear and beckon to him. Some are naked and lie in bed with him and his wife. He has woken in bed, wet with semen. When the dreams occur, he says he feels like dancing and waltzes side to side, his arms carrying an invisible partner.
The patient in the wheelchair hasn't used her feet in a long, long time. They are crooked underneath her white socks, with permanent contractures. Her head almost sits on her chest cavity, the bowing of her upper back is so pronounced. The mother who has been reading a magazine, doesn't comment on the others in the room as the doctor asks permission to let the medical student and writer attend. Clearly, she is bothered. The doctor laughs softly as the stuffed bear the girl holds in her lap speaks. He looks at the girl with short-cropped dark hair, and asks her a question. He wants her to hold out her hands and demonstrates. The girl creeps her right hand towards her mother's left arm and squeezes. Does she speak? He asks. No.
With cerebral palsy from birth, the daughter never speaks. Since the last appointment, the medicines have calmed her dystonic movements. Then the mother leans forward and asks for a recommendation for a Spanish- speaking psychiatrist. She says her daughter screams when people touch her, when she tries to change her diaper or brush her teeth, or change her clothes, or bathe her. When the daughter is tired of family company, she screams. She constantly grinds her teeth and refuses to drink. Mother puts her in her room, closing the door to scream alone. She fears neighbors will call the police, fears they think she is abusing her daughter. Mother confides she gave her daughter three times the dose of a drug to make the child manageable for the appointment.
What kind of quality of life is that? The doctor asks. Screaming is clearly no way to live.
Hushed
The patient's voice is so soft it's hard to believe he's not pulling some sort of joke. The voice or the lack of one doesn't change the doctor's regular speech pattern. He wants to know what medications the patient takes. The patient responds slowly and softly, indicating he doesn't know the dose of the pill he takes. The doctor gazes down at the chart at the list of medications and asks the patient how the drugs got in the chart.
"I remembered them." The doctor shakes his head in agreement but he's not convinced the patient is lacking more than a voice. He asks the medical student to get a mini- mental form, then asks the patient whether he knows where he is and what the date is. Satisfied somewhat the doctor questions the man about why he takes two pills per day. The pale man responds he had the sensation he was wearing long gloves on his forearms so he stopped increasing the dosage.
With two pills per day, the doctor can't say whether a patient would experience any relief from symptoms. He's irritated. It's been six months since the patient's last visit and he still can't determine whether the man is benefiting from the drugs. The doctor writes out a drug schedule, increasing half a pill every three days until the man takes up to two tablets three times per day. It's an outline, or a staircase the patient can go up and down on. The physician clarifies he wants the patient on a larger dose to determine whether levodopa is helping the symptoms or not. Signs of illness appear a little worse.
The man's noticed a slight drool from the side of his mouth, his facial expression seldom changes and his blood pressure is quite low. So low, the clinician worries an increased dose of levodopa will send it plummeting; he writes a prescription for florinef, which will keep blood volume high so the slight man won't faint when he stands up. Another worrisome symptom is anemia; patients with Shy- Drager Syndrome frequently are anemic. A stool softener, I notice in the chart, another sign of autonomic nervous system involvement.
We watch the slender man walk down the hallway. Is it the cell phone hooked to the belt that makes his left arm jut out? He breaks the turn in fractions rather than gliding through it. The forward head and rounded back catch in the doctor's teeth. He will recommend physical and speech therapy and will see him again in six months.
"I remembered them." The doctor shakes his head in agreement but he's not convinced the patient is lacking more than a voice. He asks the medical student to get a mini- mental form, then asks the patient whether he knows where he is and what the date is. Satisfied somewhat the doctor questions the man about why he takes two pills per day. The pale man responds he had the sensation he was wearing long gloves on his forearms so he stopped increasing the dosage.
With two pills per day, the doctor can't say whether a patient would experience any relief from symptoms. He's irritated. It's been six months since the patient's last visit and he still can't determine whether the man is benefiting from the drugs. The doctor writes out a drug schedule, increasing half a pill every three days until the man takes up to two tablets three times per day. It's an outline, or a staircase the patient can go up and down on. The physician clarifies he wants the patient on a larger dose to determine whether levodopa is helping the symptoms or not. Signs of illness appear a little worse.
The man's noticed a slight drool from the side of his mouth, his facial expression seldom changes and his blood pressure is quite low. So low, the clinician worries an increased dose of levodopa will send it plummeting; he writes a prescription for florinef, which will keep blood volume high so the slight man won't faint when he stands up. Another worrisome symptom is anemia; patients with Shy- Drager Syndrome frequently are anemic. A stool softener, I notice in the chart, another sign of autonomic nervous system involvement.
We watch the slender man walk down the hallway. Is it the cell phone hooked to the belt that makes his left arm jut out? He breaks the turn in fractions rather than gliding through it. The forward head and rounded back catch in the doctor's teeth. He will recommend physical and speech therapy and will see him again in six months.
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