The husband pushes his wife in the wheelchair. They greet the physician preferring to speak in Spanish. They have no objection to the medical student, foreign doctor and myself witnessing their appointment. The wife remains in the wheelchair while her spouse takes a seat, and pulls a sheet from his breast pocket. Her hair is colored a light auburn and set. Like her hair, her nails and hands are cared for in detail. In the chair she moves spontaneously and continually. The doctor asks how much of the day does she experiences dyskinesia. She says she has about an hour where she is free of the uncontrollable movements. He shakes his head and reviews the list of medications the spouse has given him.
The two men confer in Spanish about how best to try and curtail the dyskinesia. The physician recommends they begin cutting back on the Sinemet while increasing the dopamine agonist, Ropinerole. The Neupro patch would be ideal for her. The husband states she has never tried the patch. At night she takes Seroquel to sleep, along with Mirtazapine which helps increase the appetite, as well as providing an antidepressant effect. The spouse mentions she only takes it sporadically and the physician states she should take it nightly to have an effect on her weight. Many women refuse to take the drug, for fear they will gain weight, and the patient scoffs at this. She continues to lose weight. The doctor says most PD patients begin losing weight. Swallowing problems make eating more difficult. The muscles involved in chewing fatigue, and the random movements of dyskinesia burn calories.
The husband mentions he gives his wife her pills, and would like to know whether they can switch to the generic form of Seroquel, quetiapine. The cost of generic will alleviate some of the stress in affording the various medications she takes daily. The physician wonders whether to switch to a 50 milligram pill, and have the spouse part the pill in two, rather than write a new prescription for two 25 milligram tablets. The spouse prefers the smaller dose. Breaking the larger pill in two gets complicated. Sometimes, most times, it doesn’t split evenly and he worries whether his wife is getting sufficient medication.
Before they rise to leave the physician asks whether they have undergone a swallowing evaluation. The husband nods, and the physician reiterates to the patient she needs to eat slowly, chew completely and cut her food into small pieces to avoid inhaling her calories. They will return in six months.
The patient and her spouse have been coming to see the doctor since before 2003, when all records went electronic. The doctor reads the earliest note he has from the patient. In 2003 he noted she suffered with dyskinesia. At that time he used high doses of the drug Pergolide to subdue unwanted dyskinesia. The drug was subsequently discovered to cause fibrosis of the heart valves in a minority of patients. On reflection, the doctor comments many patients were helped by the medication. Now he doesn’t prescribe the medication at all.