He’s just twenty-six. He’s slumped over staring at his hands in his lap when he recounts the tremor of his left hand. It appeared when he began working in New York City. He noticed it first when taking the train from Brooklyn into the city. At first he thought he’d had too much coffee. Then he thought he was simply anxious about the new position he’d taken at the law firm. As the day progressed he forgot about the tremor. The next day, it was there again, in the morning on the train ride to work. He’d been grasping a pole to steady himself in the crowded cab, when he noted his left hand moving spontaneously, intermittently touching a woman’s thigh. She turned, as he did to see his resting left hand fluttering like a leaf. He apologized to the woman and she nodded to him when she saw he could not control the movement.
The doctor asks about other symptoms; constipation, depression, sleeping problems, anxiety or loss of smell. The patient glumly smiles and nods. He claims he has all of those. The loss of smell, he recalls dates back to the days when he lived in a fraternity on campus. A fire started in the kitchen on the main floor, only when the smoke detector went off in the bedroom next to his and his house mates pounded on his door, did he wake and exit through a second-story window. He never smelled the smoke.
Constipation has been a problem for him since he was a child. As a teenager he began eating All Bran cereal and drinking a quart of water after every meal. Those habits he thinks have solved the issue, though he still has occasional irregularity.
He shrugs when asked about depression, admitting he has never been a very sunny character. His girlfriend has told him he seems depressed, but he thinks he has always felt more blue, than happy.
The doctor asks him to come to the examination table, where he pulls out the step. The young man stands, fixes his brown hair behind an ear and sits at the end. As the doctor takes his arm he asks about the quality of his sleep.
After some moments, he confides he’s always slept fitfully. While he’d like to blame his poor sleep on anxiety over work, he recalls sleeping poorly while in school. As a child and teenager he walked in his sleep. His housemates in the fraternity frequently reported finding him wandering through house, with no apparent purpose. He has lashed out at his girlfriend while sleeping. She tells him he has conversations in his sleep.
The doctor moves his hand at his wrist, then his arm at his elbow, feeling for fluidity of movement then accesses the left side. He pauses there as he moves the joints, then looks to the medical student and asks her what she feels when she moves the arm. She takes the patient’s arm, closes her eyes and moves it back and forth. Opening her eyes she looks to the physician and reports some friction in the motion. The doctor nods and asks about other health issues, while he scans the form the patient has left on his desk.
The doctor gazes at him and reports, though he is young he has some rigidity, a sign of Parkinson’s disease. Diagnosis requires a patient have three of the cardinal symptoms; slowness, rigidity, tremor. His age forbids the use of standard dopaminergic therapy. The doctor would like him to begin exercising regularly, getting his heart rate up to eighty percent of his maximum, in a daily routine. He’d like the patient to begin taking coenzyme Q10 in a relatively high dose. He asks whether the symptoms interfere with his ability to work. The patient states he’d like to hide the tremor as much as possible from those at work. This was the reason for the appointment in Florida. The doctor nods in understanding and begins explaining the options for medication.