A Painter’s Hands

The onset of tremor began only three to four weeks ago. It’s worse in the right arm, yet the patient can quiet the shaking by changing position. She states she has trouble following the events occurring in novels and feels at a disadvantage during meetings of her book club. The movement of her arms worsens under anxiety, and her children are converging at her home over the holidays. Worrying they will witness some decrease in her abilities, she feels embarrassed and self- conscious about the recent changes in her health.
A physician as well, her spouse allows her ample time to speak for herself. Presumably married for many years, she has come to lean on his judgment to relate the changes in her condition, yet she recounts an evening when she experienced a hallucinatory episode in which she found herself in a garden with flowers so vivid she might reach out and touch them. The only incidence of hallucinations she reports, the movement disorder specialist feels confident in discounting a diagnosis of dementia with Lewy bodies, in which cognitive changes and hallucinations occur simultaneously or precede other symptoms typical of Parkinson’s disease. The specialist posits tremor may come as a result of other health conditions, or as a side effect of a medication. He is especially interested in Amiodarone, and scans the web for documentation of the side effects, finding 40% of people taking the medication experience neurological sequelae, including neuropathies. At such a high percentage, he urges the pair to wean from the drug.
Physical examination reveals a hint of cogwheel rigidity in the muscles of her arms, though her head is supple and unaffected by stiffness. The dexterity of her hand movements, the specialist thinks is slightly slow. Eliciting reflexes, the doctor finds brisk responses, not typical of Parkinsonism, but suggesting damage to the brain resulting from microvascular disease brought on by long- term high blood pressure or diabetes. Disease from such a source may produce a series of small microvascular strokes, which might be evident on an MRI. To determine whether she suffers from a slight neuropathy, the doctor tests the patient’s ability to sense sharp and dull sensations, as well as vibration. Some loss of vibratory awareness coincides with decreased position sense, and holds merit, as the patient has suffered from falls. The worst of these resulted in a subdural hematoma, a bleed into the intracranial space.
In the end, the diagnosis of Parkinson’s disease can be determined by the patient’s response to levodopa. If the patient feels some amelioration of symptoms, while taking a therapeutic dose of medication without competing proteins in the diet, which would vie for the terminals into the brain, than one may surmise the patient suffers from a deficit of dopamine. The specialist in movement disorders outlines a method of increasing medication for when the patient feels ready to consider a trial of Sinemet, until then she will undergo a blood test for thyroid function, and diabetes and consult with a neuropsychologist who will scrutinize her cognitive function.

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