The patient arrives early, a guy in uniform pushing his wheelchair. His head looks like it is attached directly to his torso; it’s called a kypho- scoliosis. He is only sixty- six, but his body says much older. In 1995, a physician diagnosed him with Parkinson’s disease. He recalls a tremor in his right hand that improved with the Sinemet he received a prescription for. The specialist in movement disorders is skeptical he truly suffers from Parkinson’s disease. He asks the patient to recall the sequence of events that brought him to a diagnosis with the neurological condition.
He’s a bit hazing. His speech is whispery, and the three in the room bend inwards to understand what he says. Some things he is sure of. He broke his neck when he was about fifty years of age, which coincides with the time of diagnosis with PD. The physician wonders whether the weakness and subsequent atrophy of the right arm was due to the cervical myelopathy, a stroke or cardiovascular disease. However the insult occurred, his right arm is fixed in a rigid position, bent at the side of his body, with the right hand tightly caught in a fist. When the doctor asks him to straighten his arms out in front of his body, his left arm cooperates. The right arm maintains its flexed position inward, and he is unable to tap his index finger and thumb together. He reports he used to be right handed.
Some things he is clearer about. The last time the hospital admitted him, he suffered from a urinary tract infection, fecal impaction, hypertension, chronic hepatitis C, an ulcer on his buttocks, and pneumonia. It was then that the staff recognized the prior diagnosis of Parkinson’s disease. This seems to be the reason for his visit this morning, to confirm whether the diagnosis has merit and resolve whether he should be taking Sinemet, and if so, what dose.
The doctor peruses the patient’s records that appear on the computer monitor. He informs the medical student and myself the patient has undergone multiple surgeries on his spinal column, to fuse and in some places to cut the bony growths that pressed upon his spinal cord. Areas fused on the spinal cord were bound with metal anteriorly, so he will never be able to undergo an MRI.
The physician begins the physical exam noting first the patient has no cogging of his muscles. The type of stiffness he feels is spastic, unlike that seen in PD. The patient has no reflexes in either the lower or upper extremities. Wondering aloud, the doctor asks the patient whether he feels the vibration of the tuning fork, and the patient reports his left leg scarcely feels the sensation. This fact seems to confirm the patient also suffers from a neuropathy. Hopeful, the patient states he is able to walk still, with a walker. The cause of the neuropathy may have been his low- functioning thyroid, or uremia. It bothers the physician that the patient has been using Sinemet for the last fifteen years and he suffers from no dyskinesia. It indicates he does not suffer from depletion of dopamine, meaning he does not have Parkinsonism. The doctor prescribes physical therapy and the patient wonders whether he will ever be allowed out of the assisted living facility. The doctor gazes at him directly and declares he is severely compromised, has but one useful hand and is at risk of falling.


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