He’s Just Twenty-six

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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.

His High School Weight

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He’s down to 117 pounds and he used to weigh 150. His hands form the large belly he had. The doctor across from him cautions him not to lose anymore. He had been a borderline diabetic, and now he no longer has that diagnosis. Dyskinesias rock him in the seat but his is undeterred, and he asks the doctor whether decreasing the dose of Sinemet will help conserve his existing dopamine-producing neurons.

Behind the desk the physician responds, saying that Sinemet had at one time been thought to be detrimental to the neurons that produce dopamine. Scientists had thought levodopa might have a toxic affect on the dwindling population, but that idea has been discarded based on research that has shown that advancing illness affects other neurotransmitters, in addition to dopamine. The doctor even states some think that the levodopa gets converted to dopamine in the brain may actually have some protective value on the declining population of dopamine-rich neurons.

The doctor reviews the note he wrote after the previous visit. The only new presently available progress for patients with Parkinson’s disease is the Neupro patch. The company has said the patch would be available soon. For more than a year patients have been told that news. Now it seems it will be released in July. The patch provides a dopamine agonist that is taken up through the skin, at a steady rate for twenty-four hours. The method of absorption bypasses the digestive system. A dopamine agonist will not compete with dietary proteins for entry to the brain. The alternate source of dopamine will allow the patient to reduce the Sinemet he takes, thereby reducing the dyskinesias.

The doctor checks the rigidity in his arms and finds none. The patient is completely on. His joints are supple. He’s brought in a page of questions for the doctor. His handwriting is large and loose, atypical for a PD patient. He wonders whether he is taking too much vitamin D; 4000 mg per day. The doctor isn’t clear on the current information on the vitamin, it seems to be always changing.

An article by Salynn Boyles at Web MD health news from March of 2011, notes a study of patients with PD
found a high prevalence of vitamin D insufficiency, though levels did not continue to decline as the disease progressed.

The research is one suggesting a link between low vitamin D levels and Parkinson’s disease. A study from Finland published in 2010, showed people with the lowest levels of vitamin D were significantly more likely to develop Parkinson’s over almost three decades of follow-up, compared to people with the highest blood levels of the vitamin.

It’s not clear if vitamin D insufficiency raises Parkinson’s risk or if having high levels of the vitamin is protective, says study researcher Marian L. Evatt, MD, of Emory University School of Medicine and the Atlanta Veterans Affairs Medical Center.

“More research is needed to figure this out,” she tells WebMD. “There is certainly an association, but we can’t say if it is causal.”

In the newly published study, researchers examined the prevalence of vitamin D insufficiency in untreated patients with early Parkinson’s disease. They found 69.4% of patients had vitamin D insufficiency and 26% had vitamin D deficiency.

http://www.webmd.com/parkinsons-disease/news/20110314/low-vitamin-d-levels-seen-in-parkinsons-patients

Freelancer

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She says she’s a freelance writer. Woman’s Day recently published an article she wrote about care giving. She smiles and says it’s ironic, she never thought her own spouse would be the caregiver. The man is classically handsome, tall with dark hair and an easy smile. He pats her hand, when she divulges this information. Her dark hair is pulled back into a loose ponytail that hangs forward over her shoulder. The toes of her black shoes are so pointy, they cannot possibly house a foot. Talkative and anxious, she engages the medical student and me while the doctor takes an emergency call from another patient. The man by her side is silent, though he sits with a pleasant aspect on his face and demeanor.

Outside the doctor converses on the phone, we hear his words, ‘The only real emergencies in Parkinson’s disease are falls leading to fractures which should be handled in the emergency room . . . No. Take the dissolvable medication and lie down. Turn on soothing music. Listen to yourself breathing, inhale to the count of four, hold for three seconds and exhale to the count of four. NO. I’m in clinic, I have to go. Call me in an hour.’

The doctor enters, apologizing for his lateness. The patient begins talking about the tremor in her right hand, and the doctor sits, scanning the forms she’s filled in, and interrupts her with an upright finger. He asks for a moment to look over her paperwork. Though he begins questioning her immediately, ‘So you really are quite healthy . . .You exercise, you eat well, your blood pressure and blood work are normal. You’re fifty-five?’

The doctor smiles, ‘That would make this early onset Parkinson’s, if that is indeed what you have.’ He asks what symptoms she has and when they began. It’s been three months since she noticed the jiggling in her right hand. She was using the keyboard, typing when she felt her right hand acted more like her left, less useful. A subtle change, she admits, but she saw the tremor in the morning when folding laundry.

The doctor asks her to sit on the examination table. He takes her right arm in his hand and flexes the joint at the elbow. Moving it back and forth, he takes the other side and makes the same motion. He isn’t sure. He returns to her right side and states there may be some slight rigidity there, but it surely isn’t definite. Performing the other tasks, he asks her to return to her seat.

At his desk he says her symptoms, specifically the feeling her right hand was performing like her non-dominant side, sounds like very early Parkinson’s disease, but she lacks any of the cardinal symptoms- slowness, rigidity and resting tremor. He encourages her to maintain her exercise regimen, as that may be helping to put off the full onset of the illness. She may be very sensitive to alterations in her body and be able to detect early changes, though she may not manifest the illness at all. He would like to continue watching her, and asks her to return in six months. She’s content with his appraisal and shakes his hand before leaving.

Tremors

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He’s lived with the tremor for thirty years, since he was twenty-six. In those thirty years he has consulted several physicians. Whether he ever received any medication is an unanswered question. His attitude seems to be stoic, with the assumption that medicine has little to offer him. The tremor rocks his head back and forth. When he brings his chin to his chest the movement stops, and he can raise his head slowly before it resumes.

He’s convinced the agent that he used to clean jet engines, a supreme degreaser, is the cause. A toxic overdose from submerging his upper body in the solvent, on a regular basis, he believes is the culprit. Whether he is right or not is immaterial. The tremor haunts him, unrelenting. Sometimes while he lies in bed he feels his body shaking inside.

The doctor is certain he doesn’t suffer from Parkinson’s disease. His facial muscles are expressive, mobile. Actions are fluid. There is no slowness to him, if anything he does things quicker than normal. His voice is full volume, without hesitation. The tremor encompasses both hands.

On physical examination the muscles surrounding his joints are supple, his eye movements are normal, dexterity not compromised, though he complains his handwriting has degenerated. The doctor asks him to copy a spiral winding out from a point inside. The pen in his hand makes regular jolts as the tremor moves his hand. It’s the work of someone who has essential tremor. The same regular movement that made Katherine Hepburn’s head shake and voice waver.

An electrical engineer, he has the tenacity to draw his work at the computer. To accomplish this, he needs to subdue the tremor. He overcomes the tremor by pushing firmly downward. After three hours or so, his entire arm is aching.

Clearly, he’s ready for a change. The doctor prescribes Inderal, a beta blocker. He asks the patient to begin with one pill for three days then escalate to two pills for three days, than add the third pill for three days. After several weeks he’s to switch to a single pill of 60mg, that is a long-acting. The doctor asks him to call him in a month and report on his status, rather than give him another appointment. In the meantime, he requests a blood test, to look for heavy metal toxicity and an MRI of the brain, with contrast to rule out other more noxious diagnoses.

Her White Hair

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Her white hair, curled at the ends, her green cotton sweater and yellow capri’s attest to her casual sense of style. She stretches her long legs out in front of the chair she slumps in and tells the doctor her concerns. The book in her arm, has the title something like, Fifty Medications the Doctor’s Don’t Tell You About. She’s got the pages which mention Parkinson’s disease, tagged. The doctor checks the back and looks up the pages that speak to his specialty. Published in 1993, the text has nothing the physician is unaware of. A patient would hope her neurologist, who also has a PhD in Pharmacology, knows his craft.

The patient has none of the resting tremor, the stony facial expression, or slowness that regularly accompanies the illness. Her major concern is her ability to walk. She is hesitant in expressing it as a concern, she ventures really she fears her balance is declining. She’s never fallen. Several years ago she underwent some ‘walking therapy’ and felt it really helped. The doctor agrees she would benefit from physical therapy and writes her an order for PT. He also urges her to begin a daily regimen for her cardiovascular health. With a pacemaker and coronary artery disease, he asks her to check with her cardiologist before beginning. He’d like her to begin using a stationary bicycle. In the beginning, this would be a five minute commitment, though he would like her to increase her time by five minutes every week until she is spending twenty minutes on the bike. Additionally, he’d like her to raise her heart rate to eighty percent of her maximum for her age. With a pencil, he figures out what this figure would be.

He encourages her to participate in the yoga class being offered at her community center. The activity is very good for stretching out the joints and muscles, especially helpful for those with PD, who tend to get stiff and slumped. Balance is also addressed. Swimming is another activity that would complement her health.

Her spouse depends on her. She is the caregiver. She knows it will be her downfall, she’s aware of the demands that tax her. She thought he was talking in his sleep, but in fact he was wheezing. It was five in the morning. He seldom wakes her, generally.

On physical examination her limbs are loose, without rigidity. In medical terms she would be regarded as, “on”. Freezing also bothers her. She asks about it, but the doctor confesses, there are no medications that simply address freezing. She has written down the prescription for exercise, and mentions her handwriting has deteriorated, though that simply must be her age. The doctor faces the computer screen, typing in her renewals for medication and does not comment.

In her eighties, this patient has beauty in her face. Her blue eyes and features have a life behind them that is hidden from those of us who are not her friends, though we may see hints of her joy.

Wearing Magenta

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It’s been several months since his initial diagnosis. The medication- a 25/100 dose, three times per day has little, if any impact on his symptoms. Is it the protein in his diet, blocking the absorption of the drug? His last dose was about noon. Three hours later his left hand has noticeable tremor. The doctor concludes he is under-medicated.

They speak about augmenting the dose of levodopa. Higher doses of the medication increase the possibility of hallucinations. The doctor comments patients usually see small people, though animals are also common. The patient confides he already sees things that aren’t real. In a hanging print in his home, he sees the bicycle wheels spinning. The doctor nods and tells the couple that sort of visual trick is an illusion, where a hallucinations can be tested by reaching out towards the object. If the object is real it won’t dissapear. The doctor explains he likes to give Seroquel along with an increased dose of levodopa. Seroquel diminishes the likelihood a patient will experience hallucinations, and helps to provide more restful sleep. Nodding, the patient decribes a scenario where he has the same dream, over and over throughout the night.

Patients may choose to change their diet, rather than increase the dose of levodopa. In that case, the doctor recommends pooling the day’s protein into the last meal of the day, knowing that after dinner he’s apt to be more slow and rigid. Should he have an evening event scheduled, it would benefit him to avoid proteins in that meal as well.

A separate solution to under-medication is to add an dopamine agonist to the daily regimine. The agonist delays the absorbtion of levodopa, so it is remains available for a longer time. The Neupro patch (which delivers the dopamine agonist Rotigotine), bypasses the digestive system, transfering the medication directly through the skin. With both the patch samples and the larger dose of levodopa, the patient may find he needs less levodopa. The doctor cautions him, should he feel light-headed when he stands, it’s a sign his blood pressure is low. In that case he might cut the levodopa back slightly.

About the neuropsychological testing he underwent after the previous appointment, the doctor scans the note in the computer. No diagnostic determination was made. The physician felt the patient’s depression may have led to the low scores. In sum, the scores gave some indication the patient suffers from compromised executive function, which is in line with those who suffer from Parkinson’s disease. The results give credence to the patient’s complaint that he feels not as sharp as he once was.

Before allowing the couple to exit, the doctor asks about exercise. He reinforces the notion that cardiovascular exercise is a valuable tool to slow progression of the illness and improve the quality of life.

Influenza and PD

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The patient’s phone calls precede his appointment. He has read researchers have found a link between influenza and Parkinson’s disease. Diagnosed with PD not long ago, he found a journal from a year ago in which he describes a transient flu-like illness. The nurse coordinator brings the patient’s phone call notes, as the patient may want to discuss the matter directly with him. She recalls the Spanish influenza outbreak that occurred in 1918, with patients subsequently suffering with encephalitis lethargica and later developing Parkinson-like symptoms. The doctor begins to expound on the relationship between influenza and PD as the patient appears with the nurse.

A small, balding man the patient engages immediately with the doctor. He’s read an article exploring the relationship between inflammation brought on by a virus, and the loss of dopamine-rich cells in the brain. His interest was piqued because he’d discovered he’d had a virus before he was diagnosed with PD. The medical student asks, “How long was the gap in time?” She notes a recent study in Movement Disorders sites the span as being within weeks of diagnosis. The patient nods. His face and gestures enthusiastic, he states this describes his personal scenario. Behind the desk the doctor nods, lifts his eyebrows and shares that the relationship between influenza and later PD might be trickier than they think. For example, some researchers report inverse relationships between childhood infections and later PD. Childhood red measles may offer some protection against later viral infections that may threaten dopaminergic populations by activating the immune system at an early age.

The medical student notes a secondary issue bridging influenza and PD was the medical attention severe illness warrants, bringing an increased scrutiny of the patient, and therefore any symptoms would likely be caught by the healthcare team. The doctor concedes studies of antibodies would reveal what exposures a patient’s had. The student interrupts him, “They found no relationship between examination of influenza antibodies and PD patients, when compared to controls.”

The doctor adds an influenza virus may have been the final insult, precipitating Parkinsonism. Unfortunately, whatever the reason, the patient has symptoms that are worthy of management. Whatever the cause, the pathology; the dwindling population of dopamine neurons requires attention, if one hopes to lead a high quality of life. The doctor slides from his seat and take the patient’s elbow in his hands. He opens and closes the arm feeling the response of the muscles to movement. He notes a fraction of rigidity. The student follows him, mimicking his motions as the doctor asks whether the patient has other concerns. The patient asks about his research and how far into the future will it be before there is something new for the illness. The doctor agrees too many years have passed since the sixties when levodopa first became available. A lot has changed since those days, we think of Parkinson’s disease as a group of related illnesses now. Theories exist on how the illness develops. Drug companies are looking for ways to address other dwindling neurotransmitters. With an aging population such questions will demand more attention.

Greek Translation

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Two patients in addition to those scheduled have arrived in the last half hour. The department of Neurology allocates thirty minutes for people returning for a follow-up appointment. New patients are granted an entire hour. The scheduling error has the doctor in a mildly irritated state. The nurse coordinator pokes her head in the room indicating two patients are competing for his attention for the next appointment. The double booking was done by the university secretarial staff, who was unaware of the length of time given to the doctor’s patients.

The new patient, who has waited twenty-five minutes arrives with his grand-daughter. The patient is Greek. His language, and his parkinsonism make his speech difficult to understand. The black-haired girl comes along to translate his words. She begins speaking as soon as they enter the small space. Her grandfather has been cared for by his regular doctor. When his problems became more severe the family sought an appointment with the movement disorder faculty. The doctor explains his new patients normally receive an hour, but today’s situation is unusual as two others are waiting to see him as well. The doctor shakes off his aggravation with the wave of a hand and asks, “What brings you to the movement disorder clinic this afternoon?”

The young woman gazes at him, stating, ‘Yes, but this isn’t our problem. We have insurance and pay for our time.’ The doctor nods and sits as the grandfather speaks Greek in a whispery voice. The girl bends in towards him, translating his words.

The main problem is he gets stuck every night. Nodding, the doctor scans the paperwork. Medications are listed, as well as the dose. What does he mean by stuck? The doctor explains patients with Parkinson’s disease suffer from freezing episodes. The daughter translates, he has episodes of freezing but that’s not his current concern. His right leg gets stuck inward and it occurs in the middle of the night while lying in bed. The doctor nods and comes around the desk. He tells the granddaughter he must check the rigidity of the man’s muscles, to see how well the medication is working. As he moves the limbs of the bent man in the chair, he speaks about three common ailments people with PD tend to suffer from.

Tremor is the initial symptom in many patients, and he illustrates moving his hand in a fine jiggle. The girl nods, she’s seen the tremor. The left foot of her grandfather also jiggles. Dyskinesia. He repeats the word when the girl looks at him questioning. The word describes the somewhat writhing-like movements patient’s endure. Occurring after several years of treatment with levodopa, the unusual actions are caused by medication, a side effect. The grandfather shakes his head. What the physician pantomimes is not his problem. He stands carefully, pushing off the arm rests of the chair, then turns his right leg inward so the toes of his foot meet the instep of his left side. Standing, he speaks Greek and makes a face indicating with his hands the pain he experiences. Nodding at the old man, the doctor comments, “A lot of pain.”

“Much pain, too much” and he retakes his seat.

“Dystonia.” Explaining that it’s a muscle cramp that forces the limb into unusual sustained postures. The doctor concedes they can be quite painful, and afterward leave the tissue sore. He thinks if her grandfather switches his evening dose of medication to a sustained release variety, he may find some relief from the episodes. The girl translates this and the man gives a thumb up.

Forty-one

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The tremor in her right arm has been so intense she has taught herself to write with her left hand. A list of the medications she has tried include three- Sinemet, Stalevo and Comtan, which doctors routinely prescribed to patients with Parkinson’s disease, though the doses have not been sufficient to produce a therapeutic effect.
She’s only forty- one but her medical work- up has been so thorough she could be two decades older. Her recall of events began with a debilitating headache that sent her to bed early, four years ago. She woke in the morning fuzzy, feeling hung- over and with pain in both arms. Tremor came as the pain subsided. After some time, the movement on the left side disappeared and only the right arm was left with tremor. Around this time she experienced sharp shooting pains on the left side of her face and a physician diagnosed her with trigeminal neuralgia. From a plastic Dollar Tree bag, she pulls the medical reports of her past tests, noting the physician who tested her for Lyme’s disease found she tested positive for antibodies, meaning she had been exposed to the illness. The movement disorder specialist leafs through these reports and finds the statement that reads the test was negative. The doctor asks how many times she was tested, and the patient replies the lab analyzed her blood several times.
A well- known physician specializing in movement disorders in New York City told her she the cause of her symptoms was stress. The doctor facing her explains what he thinks when he hears a physician tell a patient those words; symptoms have a psychogenic basis, or stem from the patient’s unconscious. In the older days they called it hysteria; one might suffer from hysterical paralysis, muteness or any other odd manifestation of psychological illness. The patient takes this news stoically, she doesn’t appear insulted. The same New York physician tried to dissuade the patient from undergoing a fluorodopa-signal PET scan, at the Feinstein Institute for Medical Research that performs the highly specialized test, telling her the results would only make her more confused. The results showed the patient had the findings of people with Parkinson’s disease. The specialist has great respect for the testing facility, and feels if the results harmonize with the physical findings of his exam, than they can conclude with some certainty, she has the illness.
Indeed, the doctor finds rigidity in the muscles of the right arm and wrist, while the left side appears unaffected. As he plies open and closed the joint at her elbow, the patient reveals she recently traveled to Germany where she underwent an infusion of her own bone marrow stem cells to alleviate the tremor of her arm. The clinic promised a fifty- percent chance of alleviating her tremor, and cautioned it might take up to six months to see a positive effect. It has been four months and she feels no change in her symptoms. The news peaks the ire of the physician and he feels compelled to tell her of an Argentinean clinic that had purported to find a cure through bone marrow stem cell infusion for patients with Parkinson’s disease. He pulls up the news story on the internet and reads the details to the patient before he inquires about how much money she spent at the German clinic. Adamant about the highly unethical nature of the treatment, which is at best only shoddy research; he comments the clinic should not have charged for a service without definitive and published proof the treatment was effective, and should have been checking on her to determine what sort of outcome she experienced.
Eventually, he sits and begins constructing a diagram that will increase the dose of Sinemet by a half tablet every three days, until the patient is taking approximately 1000 mg. of levodopa per day. While he writes, he speaks about the possibility that she may need to avoid proteins in the diet if she does not respond to the medication. The amino acids that make up protein compete with levodopa for transport across the blood brain barrier with the medication. And avoiding the proteins will assure that she gets the most levodopa into brain. Typically avoidance of protein is not necessary when patients are first started on Sinemet. However, when individuals state they did not improve on Sinemet, the doctor wants to see if the highest dose tolerated while on a protein free diet has any effect at all. If there is no benefit, then he can conclude that the patient does not have a dopamine deficiency (idiopathic Parkinson’s Disease). He passes the sheet to the patient and begins explaining he has made a staircase that she will ascend, with the goal of finding the dosage of medication that she can tolerate well, has a minimum of side effects and sees a reduction in her symptoms. This might occur at any of the higher stairs. Should she find the side effects too cumbersome she may back off a stair, to a lower dose of medication, but she should not throw away the medication and abandon treatment entirely. He suggests returning in three months time, so he can reassess the situation.

David

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He gets anxious behind the wheel of the car, cursing at people who pull out unexpectedly from their hidden driveways; he grips the steering wheel tighter. When his daughter drives, he clasps the handrail by his temple and doesn’t let go until they have arrived at the grocery store. She needs to take him by the arm, because he walks slowly and will stop if she engages him in conversation. If she lets go of him she’s afraid they’ll never leave, he’ll get caught up in looking at the variety of breads, instead of just choosing the multigrain and moving on. With the three girls, he is less serious. Their energy draws away some of the anxiety he carries with him, all the time. The youngest asks him whether he likes a spread of sun-dried tomatoes. He has to adjust his hearing aid before he asks what she just said. She doesn’t mind repeating herself to her grandfather. Her face is intent and her thick eyebrows high when she’s asked him three times. He makes a face at her; sundried tomatoes are not his thing.
The daughter mentions her father’s driving to the physician, conveying her apprehension over the anxiety it causes him. The doctor asks whether he’s been involved in any accidents. She shakes her head. The father adjusts his hearing aid, and it squeals and he flinches. How often does he drive? The patient answers now that he can hear the questions, he drives several times a week, just around town to get groceries, sometimes to the hardware store, and to the senior center where he meets other chess players. The car gives him freedom. Without the car, he would be dependent on someone to take him places. The daughter sees that time coming; the patient cannot conceive of that life.
Quality of life is important, the doctor notes, as he begins the physical exam, and asks when the patient last had his medication. He takes his pills with 2% milk and coffee, Latin style, though he uses instant instead.
The daughter has urged him to try Cremora instead of milk, but he hasn’t tried it yet. She reminds him the milk protein in the coffee competes with his medication. He might have more energy to walk if he used Cremora, he nods, though she has told him before. The physician comments that he needs to try to exercise every day, if not a walk, then at least some stretching. The doctor takes an emergency call and steps outside the examination room, leaving the medical student briefly with the patient and daughter. It is silent in the room, until the student engages the two demonstrating something he has noticed in the patient. A stooped posture, he demonstrates by rounding his head and shoulders, impairs his breathing. He tells the patient he can hook a broom, or cane between his elbows, to open the chest and practice standing against a wall so that the heels, buttocks, shoulders and head all touch, then move away and stand erect. The doctor re- enters the room, corrects his posture and asks whether the senior center offers yoga. The patient smiles and admits he thinks only women attend the class.

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