Is this PD?

The physician prefaces the clinical visit stating the patient has an atypical type of PD. Arriving with her daughter, the patient reveals her balance has gotten noticeably worse since December, her daughter nods her eyebrows high. The physician concedes Sinemet has little affect on gait and balance.
Two years ago, the older woman was hospitalized when she had an episode of being unable to move from her bed. The daughter explains the root cause was due to a urinary infection, and her mother decompensated. After several days, she recovered use of both limbs and was walking soon after. Looking for a potential stroke, physicians ordered an MRI of the brain, which revealed two old lacunar strokes, and diffuse changes due to insufficient blood flow caused by chronic microvascular disease. The doctor behind the desk explains when these sorts of changes occur in the front of the cortex, a syndrome of lower body parkinsonism results. Slowness and rigidity affects the legs much more than the hands and arms. People with this diagnosis typically have a full arm swing, yet small shuffling steps.
The patient agrees this seems to be her scenario; her feet and legs are much more impaired than her hands and arms. The low volume of the patient’s speech causes the physician to ask whether she has always had such a light voice. The daughter nods agreeing her voice has changed, and looks over at her mother who points out that sometimes she talks too fast and people fail to understand her. The doctor nods declaring the speech pattern is similar to how patients walk, with quick small steps, and he begins to explain that Parkinson’s disease impairs sensory integration. How do we know this is true? He answers his own question, stating when a patient with PD acquires additional sensory input, for example, a therapist instructs the patient to step directly on red stripes on the floor, by concentrating on the lines and placing the foot on each one, the patient is able to pass through a doorway she previously froze in midway.
Both the patient and her daughter are uncertain Sinemet is really helping her symptoms. In prior times, the doctor states, a patient would be admitted to the hospital for a drug holiday. All the medications would be completely stopped and then gradually reintroduced at much smaller doses. It is clear then, whether Sinemet actually relieves slowness and rigidity. Instead, because drug holidays are deemed extremely dangerous, the patient can now slowly cut back on the Sinemet, by eliminating a dose every other day. The goal is to discover whether the patient suffers from a deficiency of dopamine. He warns this may take several weeks, because some dopamine terminals may retain the ability to store an excess of the neurotransmitter. At any point in the process, the patient may decide she feels more agile with the medication, and then gradually resume building towards her customary dose. Discovering what exactly the patient’s body needs means she will not be taking medication needlessly.


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