Reason to Get Dressed

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The patient suffers from very low blood pressure and parkinsonism (Shy-Drager Syndrome) and is wheelchair bound except for the days when her handsome physical therapist arrives. Then she walks with him and does all her exercises. She needs to have her hair done for therapy, and if another person is sent instead, she pretends she’s sleeping in bed. The doctor gives the daughter a new prescription for therapy, which she has been paying for, though insurance only covers it for an allocated number of days.
Six months ago the doctor suggested she should not eat proteins in the morning or at the afternoon meal, to maximize delivery of levodopa from blood to brain and to determine whether levodopa is helpful in relieving the patient’s Parkinson symptoms; not all patients with the disorder get relief from tremor, slowness and rigidity with levodopa. The daughter reports they attempted to stop providing milk after the last time they visited. The patient, however really enjoys a morning glass of milk. The specialist agrees that quality of life is important, and that if the patient is to continue having milk in the morning and at lunch, they need to consider increasing the morning dose of Sinemet, possibly by half a pill.
Patients with Shy-Drager syndrome lose the ability to regulate blood pressure. Sinemet, the medication containing levodopa, tends to lower blood pressure further. Within minutes of standing, the patient’s blood pressure plummets depriving her brain of blood flow, making fainting likely. For this reason, she is now in a wheelchair.
To increase blood pressure, the patient takes the medication, Florinef, which causes the kidneys to increase salt retention. Her body compensates by retaining more fluid, which increases the blood volume, thereby increasing blood pressure, so she is no longer light- headed and can sit and even stand with assistance. The doctor instructs the caregivers to not allow the patient to become truly flat, or prone because she could have excessively increased intracranial blood pressure. It’s preferable for patients with this disorder who are treated with Florinef to be at a slightly inclined angle when they lie in bed, as they’re less likely to have excessively increased intracranial blood pressure when the head is elevated. The daughter also reports the psychiatrist has switched the patient from Lexapro to Effexor, which he claimed would also augment blood pressure. The physician asked them to return in six months, though the daughter replied she would check in with the office staff in three months time.

Left Hand Evil

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The patient was forty-five years old when doctors told her they suspected she had Parkinson’s disease. Symptoms started in her left hand. She noticed her fingers failed to hit the keyboard correctly when she typed and it seemed clumsy when she washed the dog. Born in Italy and raised there until the age of eight, she was originally left handed. Her mother encouraged her to use her right hand, under the advice of others who told her using the left was evil. Her symptoms became aggravated when she shattered her right hip. She has undergone a total hip replacement and a subsequent surgery to further align the bones. A third surgery on the right side is scheduled to occur soon. The left hip was also been completely replaced, the damage due to the effects of arthritis.
The patient relates she takes her PD medication every 2, to 2 1/2 hours because anxiety kicks in just before the next dose. She is taking an anti-depressant as well as an anti-anxiety drug lorazepam. The movement disorder specialist notes he hopes she does not overuse the anti- anxiety agent Ativan (lorazipam), tolereance develops quickly to their benefits and tend to produce or worsen depression. He encourages her to continue on the anti-depressant but recommended she begin taking Seroquel at night. The medication allows patients to get a full six- hour night sleep, and anxiety levels tend to decrease as patients sleep better, allowing daytime hours to be more active, and less full of aggravation.
Instead of crushing her pills in her mouth, the specialist recommends she dissolve them in water, add a vitamin c capsule to prevent the medication from oxidizing, and keep the mixture in a cool dark place. This way she can sip her medication throughout the day; the more constant the levels of levodopa in the brain, the less apt she will be to suffer from motor fluctuations.
The specialist advises the patient to eat only the smallest levels of protein for breakfast and lunch, to get the most from the medication. At dinner if she is planning to go out dancing, or bowling, or engage in some activity she may chose to avoid protein at dinner as well. If she is to eat a protein heavy meal, she may also choose to up her medication slightly to compensate for the proteins in the diet that will compete with the medication for transport into the brain.
Amantadine caused small blisters to break out on the face of the patient, though she had taken the medication for its noted ability improve dyskinesias triggered by Sinemet. He inquires about past exposure to pesticides and the patient and her husband recall having their home sprayed repeatedly inside and out, and being doused with Malathion when planes were spraying to kill mosquitoes. The doctor notes a study he conducted with cotton farmers, noting the farmers and the surrounding population had high levels of the chemical Deldrin in their blood. He specifies it is not only the exposure that puts a population at risk, but the bodies’ own xenobiotic metabolism system, which determines the capacity to breakdown the chemicals once they enter. This capability is generally hereditary, akin to one’s immune system, and determines who becomes ill, and who remains unaffected.
The patient wonders whether she need consider deep brain stimulation. The specialist thinks it’s too early to be thinking of such an invasive measure, but to keep an eye on the new surgical method that targets the pedunculo- pontine nucleus, as it may prove to be helpful in correcting her problems with gait and balance in the future.


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The patient is a small woman with thick white hair who grew up on the island of Roatan, off the coast of Honduras. She has an Island accent, but her speech is so hushed it’s hard to hear. Twice a week she spends the day at an adult care center in Hillsborough County. Otherwise, she lives with her daughter, of which she had two. In her youth, she worked for the Delmonte fruit corporation. She sits with marked stooped posture in her chair. A member of her family has brought her to the clinic for a professional consult on what likely ails her. Past documentation from an MRI noted the patient harbors a calcified meningioma. The doctor says these are quite common. Women have them more often than men, and many do not produce symptoms. The image of the patient’s brain revealed moderate diffuse atrophy and medial temporal lobe atrophy, an Alzheimer- like neuroimage.
The family member and patient note the stooped appearance began approximately three years ago when the patient’s spouse passed away. The physician inquires whether stress from the death event amplified the patient’s symptoms; the patient agrees, nodding her head.
On physical examination, the specialist finds the patient has limited ability to move her eyes upward and downward, suggestive of an atypical parkinson syndrome known as progressive supranuclear palsy PSP). When manipulating the patient’s head he notes the older woman has moderate axial rigidity. Lack of downward gaze usually causes patients to become more erect in posture, so they are looking down the length of their nose; the patient lacks the standard posture of someone with PSP. When asking the patient to perform fine hand movements he notes she has difficulty. When she concentrates, her chin has a fine tremor. Due to the difficulty she has, the doctor performs a mini- mental test. Of a possible 30 points for a perfect score, the patient had trouble with several items including the date, year and day of the week. Her total score is 4/30, denoting the patient suffers from dementia.
This is a small revelation to the family member, who concedes, the patient has been having hallucinations, especially after watching a lot of television. The doctor notes he would like to have the patient begin physical therapy and a trial of Sinemet, to see whether she receives any benefit from the medication. In benefit, the patient should become looser in her body movements, and have enhanced capacity for performing small hand motions, like buttoning a shirt. He begins a chart of increasing dosage of Sinemet, noting that it is a staircase, they can go up a step and they can also retreat a step. He says he would like to give them a prescription for the medication Seroquel, with several reservations. Sinemet can bring on hallucinations, especially in someone who is demented. They will use Seroquel in combination with Sinemet to thwart visual hallucinations and to improve sleep. Seroquel given at night will help the patient sleep better, and reset the REM cycle, he urges the patient and family member to begin both doses small, gradually working towards higher doses.
The doctor would like the patient to return in four months time, though they may call if they have questions. The member of the family notes the patient woke with a urinary tract infection one morning, and it was only discovered because she was unable to rise from bed. She ran no fever because her body did not react to the infection. This is common the physician notes, when the brain no longer receives signals from the body.

Large Problems, Petite Patient

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The patient is a petite woman, fifty- four years old. Gazing at her, you notice her head shakes with a fine tremor, as does her left hand. She reports her legs have also shaken; now they appear still. Surgeons removed a malignant grade three follicular lymphoma from her abdomen and the patient underwent a course of chemotherapy. The shaking began approximately a year after she had the chemotherapy. Since then, the patient feels nauseated. She takes two prescriptions for the nausea; both are mixtures of drugs that have the potential to induce parkinson- like symptoms in the patient. The doctor notes this to the patient and she comments her doctors are trying to kill her. She explains she received the prescription through hospice. The specialist in movement disorders and the student in neuroscience consult the internet for anti- emetic drugs that do not block dopamine receptors in the brain, and find one among many that appears safer to recommend for the patient.
Skeptical why a physician would provide a prescription that could cause the patient to shake; I assume the oncologist knows what works best. The student enlightens me; commenting physicians are stuck using medications within a certain box, and rarely venture outside that zone. The patient asks about the side effects of the anti- nausea drug they recommend. The physician notes the medication may drop her blood pressure somewhat, which might be a positive side effect, as she takes a medication for high blood pressure, as well.
On physical examination, it is readily apparent the tremor is worse on the left side of her body. She notes in 2002 she suffered a, “mini- stroke”. The doctor is interested in this and questions what she means by, “mini stroke”. He gathers the patient suffered from a lacunar stroke, though it seems she fully recovered. He notes she is a complicated patient because she comes with several possible sources of tremor; the lymphoma she suffered from may bring on tremor, the medications she has taken may induce fine movements, the prior stroke may account for some of the physical symptoms evident on examination, and the final possibility is paraneoplastic syndrome. The last possibility occurs as a consequence of cancer in the body, but not due to the physical presence of cancer cells. Instead, symptoms such as ataxia- difficulty with walking and balance, dizziness, rapid uncontrolled eye movements, difficulty swallowing, loss of muscle tone, loss of fine motor coordination, slurred speech, memory loss, vision problems, sleep disturbances, dementia, seizures, and sensory loss in the limbs, are caused by an immune response, or a similar reaction to cancerous agents given off by tumor cells. To ascertain whether the last is occurring, the doctor asks the patient to undergo a blood test. The laboratory will check whether the patient harbors specific antibodies in her blood, anti- hu and anti-yo, which attack her own brain cells. The syndrome is quite rare. If the test is positive, the doctor feels it would be best for the patient to see a neuro- oncologist, who typically sees more cases of the disorder. Otherwise, he would like her to return in two months. He provides the patient with new prescriptions and the student notes the medications she needs to stop taking.

The Baker

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The new patient is a woman in her late forties. She arrives with a teenage daughter in tow. Is she just nervous, or does she have tremor? Her left hand shakes visibly as she sits in the chair. Her right foot flaps under the seat. Her daughter looks at her and tells her to ‘Chill’. They have been waiting in the patient area for the last thirty minutes and the mother’s face is tight with apprehension, anxiety and anger.
The physician appears to notice the tension in the patient and apologizes for the wait, apparently the office staff has double booked patients, which never works. This seems to relieve some stress. The specialist asks why she has come and the patient concedes she has been worried about her left hand for some time, because she’s right handed, she’s put off seeing a doctor, feeling she could function with the small tremor. Socially she feels embarrassed by the jiggling in the hand. The physician asks if the tremor is worse when she uses the hand and she hesitates, but responds slowly that it is probably worse when she is not using the hand. The specialist reviews the patient’s history and notes she is otherwise healthy, with low blood pressure. He inquires into whether she grew up using well- water and she replies, yes her parents owned a dairy farm. He asks whether she was exposed to insecticides, herbicides, or heavy metals and she shakes her head yes. It was her job to place the ear tags on the lactating cows; the tags repelled flies, ticks and lice. The patient explains each cow gets a tag in each ear, similar to ear rings she clarifies. How long did she perform this work? The patient looks towards the ceiling, and admits it was for a while, maybe five years.
The specialist notes epidemiological studies have found well- water consumption and exposure to the toxins in insecticides or the like, increase the chance of acquiring the illness. He asks whether she has other family members who have been diagnosed with Parkinson’s disease or tremors and she shakes her head to the affirmative. Her father currently suffers with the illness, and her oldest brother has some issue with movements in his hand and foot, though he refuses to see a doctor. The specialist nods and notes she may have a genetic predisposition to acquiring the disease. He asks when she first recognized the tremor of her hand. The patient pauses, and the daughter answers for her mother, saying it was about a year ago, last spring. The older woman agrees, nodding her head. The daughter quips that her mom complained about the twitching to her, and she had shown her how her hand moves, involuntarily.
The doctor asks the patient to sit on the examination table so he can assess her movements. He asks about work. She has worked for Panera bread for the last eight years. She wakes early in the morning and is finished before noon; and is one in the team of bread makers. As she speaks, the doctor takes her right hand and asks her to leave the wrist loose. He moves her hand back and forth, then moves the same elbow back and forth, and reports to the young medical student who is standing, that he feels no rigidity on the right side. He performs the same actions on the left and shakes his head, yes, denoting some rigidity exists in the muscles of the left side. He asks the student to come and check, and the student appears abashed but performs the same test. He gives a brief, ‘Hm’, saying little else. The specialist asks the patient to perform various other actions, finger tip to nose eventually he asks the patient to walk in the hallway so they can observe her gait. The two men agree the way she walks indicates symptoms of Parkinson’s disease; she fails to swing the left arm, holding it rather close to her torso, though she swings her right arm fully.
They regroup in their original seats. The movement disorders specialist agrees she has some of the symptoms of the illness, though she is quite young for the disease; the average diagnosis occurs in the sixth decade. He encourages the patient to exercise daily to maintain her health. He would like to prescribe a medication that may delay some of the symptoms of the disease. Azilect should be taken once a day, at bedtime. He reassures the patient that though Parkinson’s disease has no cure, there are treatments that address the symptoms. He would like her to return to the clinic in six months, though she may call the office staff if she has questions or problems.

Steady Hands for Golf

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A sixty- one year old patient comes in worried about the tremor in his hands. Told by his previous neurologist there are eighteen drugs that treat tremor, he was about to start the first trial when he opted instead to go on a long driving journey across the country. Not wanting to have to contend with the possible side effect of undue sedation, he put off treatment. The patient has no history of working with chemical toxicants. Past EMG and nerve conduction studies show he has no neuropathies, which might in some cases result in tremor. Unlike Parkinson’s disease, where tremor first presents on one side of the body, the patient’s tremor involves the hands and arms symmetrically.
The movement disorder doctor comments his symptoms bring to mind the diagnosis of essential tremor. The physician inquires whether alcohol decreases the movements, the patient notes that when dining out he, and his wife sometimes order a bottle of wine. With his first glass, he will see apparent tremor in his hands, by the time the bottle is half-empty, the tremor will have eased substantially.
On physical examination, the patient’s muscles surrounding his joints are loose and supple. The doctor notes he has a fine tremor of the head, and asks whether the patient has ever noticed it. It is very mild, the specialist assures him. Performing fine movements of the finger, in touching a pen and then his nose, the patient’s movements are obviously shaky. In writing, his hand is noticeably unsteady. He comments his characters tend to be hairy- looking, and at other times they are normal. Sometimes he says he forgets how to spell simple words, he concentrates so hard on trying to make the letters round.
The specialist peruses the file folder with details of previous tests the patient has undergone. The physician mentions the patient has some compression of nerve roots in his neck, but that is more likely, in the case of severe nerve root compression, to produce pain, weakness and muscle twitiching or fasiculations. He states the patient’s symptoms are classical examples of essential tremor, with the minor deviation that people usually notice the tremors much earlier in life. The patient is sixty- one and first noticed the tremor in his hands just over a year ago. Inderal (propranolol), a beta blocker is the medication most commonly given for essential tremor. It has an advantage over the current medication the patient uses to decrease blood pressure, as it will function for two issues- lowering blood pressure and decreasing tremor. The doctor creates a schedule for using Inderal, and mentions that essential tremor tends to increase and decrease, though with time it worsens and may come to involve the head and voice. He mentions people with debilitating tremor may choose to undergo deep brain stimulation surgery. The patient refers to his previous neurologist, who mentioned surgery for when tremor worsened to the extent he was starting to throw food around with his fork. The movement disorder physician laughs, conceding that’s a creative way of putting things and he would like him to return in six months time, so they can re-assess the situation.

Teary Eyes

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The patient has small cramped handwriting, poor sleep and difficulty turning in bed as well as rising from a chair. She has come for a second opinion on whether she has Parkinson’s disease. The movement disorder specialist asks her rhetorically how does one distinguish a Parkinson Syndrome from the true disease. He answers his own question by noting to have a syndrome a patient must have three of the four cardinal signs of the disease; resting tremor, slowness of movement, cogwheel rigidity, and/ or loss of balance. The one way to determine whether one suffers from the true illness (idiopathic Parkinsons Disease) is to see whether there is a response to dopamine. If a patient has a deficiency of the neurotransmitter, movements will increase in fluidity and speed, tremor will disappear and rigidity will ease. Certain other illnesses and medications may mimic what patients experience in the illness. Vascular disease can lead to a syndrome of lower body parkinsonism. Diabetes can bring peripheral neuropathies that may result in the patient losing her balance and falling, or have a shuffling gait. Major tranquilizers can bring on characteristics of PD because the medication blocks dopamine receptors leading to an induced state of parkinsonism.
The doctor prefers to use levodopa and carbidopa over the medication called Stalevo. He thinks Stalevo is too expensive and does not permit the patient to adjust the medication to her own needs. Sinemet, he explains to the patient means sin emesis, or no vomit. The medication is the combination of levodopa and carbidopa. It comes as a generic, is less expensive and it is easier to adjust the dose.
The patient symptoms are worse in her right arm than the left, and she is right handed. She keeps the arm tightly at the side of her body. Shrugging the shoulders result in almost no movement. Cogwheel rigidity is present in the patient’s wrist and elbow muscles. The patient confides she has fallen twice in the last year. The doctor is wary about this, he conveys patients with PD usually do not fall until the disease had progressed significantly, though it is possible she may be falling for other reasons.
At different times throughout the consultation, the patient became teary, and the doctor noted that the majority of patients with PD have significant depression. He advised her of the need for an antidepressant, stating that her disease appears quite mild. If she were on a suitable antidepressant, she might be better able to cope with the illness. The patient states she feels depressed because she does not like the limitations she has. He also indicated that the anti-depressant may eventually help her sleep better. She had confided that she has difficulty with sleep and last night only slept for two and a half hours, and got up repeatedly throughout the night.
Though the patient was not happy to receivetwo newprescriptions, the doctor asked her to return in four month’s time to re-assess her symptoms and see how she is fairing.

Teacher in Trouble

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The patient taught middle school for forty years, and she sits without leaning on the back of her chair. She comes for a consultation about whether she has Parkinson’s disease. Her husband has come with her, as a witness to the changes he has seen in her health. Her falls scared both of them. In the most recent, the patient carried groceries in each arm. She fell straight forward and broke her nose. When on the floor she was unable to rise without assistance.

The medical history of the patient has some red flags for the doctor; the patient doused her garden with spectricide and the toxin caused her thyroid to quit functioning. He mentions that there is a relationship, though not a causal one, between Parkinson’s disease and exposure to pesticides, heavy metals and other environmental toxins. She comments she has suffered from trigeminal neuralgia, inflammation of the fifth cranial nerve that produces intermittent bouts of shooting pain to the side of her face and jaw. Her husband notes he has seen tremor in her hands and a stiff walk, while the patient says she has experienced left- sided weakness, fatigue, forgetfulness, and problems with bladder control.

The patient has taken some medications that may have deleterious side effects. Pravastatin, being one of the cholesterol- lowering statins, recently made the news for its under- reported tendency to invoke muscle pain and weakness, especially in the legs. Her primary care doctor added Abilify, a novel tranquilizer to her medications when he thought Prozac was inadequate for her symptoms of depression. Abilify can block dopamine receptors and produce some signs and symptoms of parkinsonism and in addition can induce tardive dyskinesia in patients, uncontrollable movements of the face, tongue or other body parts and these may wane if discontinued, or become permanent with continued treatment.

On physical examination, the doctor finds no stiffness or rigidity in her muscles, and her gait is normal with a full arm swing. He comments that he can detect no signs of parkinsonism. When he places a tuning fork on the bones of her foot, and she is unable to feel the metal buzzing, though she can feel the vibration in the knuckles of her hands. She is able to discern whether her toes are up or down, but her perception of temperature is also impaired. The doctor tells her that she does not have the clinical features of Parkinsons disease now. She may have had some symptoms of parkinsonism while taking Abilify, but those have gone away after stopping the medication. Based on her examination he diagnoses a peripheral neuropathy to explain some of her symptoms. The cause of her neuropathy will require more extensive evaluation. A B-12 deficiency, low thyroid function, medications or toxic insult are possible causes of neuropathy. He conjectures a toxic bath, like the kind she experienced, might result in a neuropathy, though the lower extremity problem resembles what a diabetic patient might incur. He urges her to see another physician whose specialty is the peripheral nervous system. He hands the patient and her husband a referral form. The other specialist will thoroughly explore the function of other nerves (nerve conduction studies), and order the appropriate blood and other tests that will aid in ruling out other disorders.


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About five years ago she noticed the tremor in her right hand. Now as she sits in the examination room, her slightly swollen hand vacillates steadily as she rests it on the arm of the chair. She feels the muscles cramping and shortening and uses her other hand to straighten the fingers. Gradually she has lost most of the strength, dexterity and the ability to write legibly. She states she has taken Azilect for two years and sees little improvement.

Ah, but that’s good, the doctor states. It means progression of your illness is slow; the other side of the body may be affected with disease, within that time. The comment buoys the patient’s sentiments, somewhat. The specialist in movement disorders asks about her prior medical history and learns the patient underwent heart surgery to amend a leaking heart valve, seven months prior. Surgeons removed her thyroid two years ago and she suffers from high blood pressure, and high cholesterol. She states she is healthy, otherwise; comments from an optimist.

As the specialist dives into a description of how and who implicated dopamine as the neurotransmitter depleted in Parkinson’s disease, the steady murmur of his voice and the quality of the fluorescent overhead lights lulls the listeners into a stupor. The patient has brought a cup of coffee with her, remarking it’s decaffeinated, and the doctor remarks smoking and drinking coffee are two habits that are negatively correlated with illness and PD; the more one smokes and drinks coffee, the smaller the likelihood one will acquire PD.

On physical examination of the patient, the specialist discovers brisk reflexes; probably a byproduct of high blood pressure he comments. He inquires whether she has had an MRI of the brain, as people with long-standing high blood pressure commonly have a multitude of small white spots scattered just under the cortex of the brain. The neurologist feels the fluidity of movement from the left elbow and wrist and senses some rigidity in the muscles of the biceps. When he asks her to walk in the hallway, her gait is regular, with wide steps though she tends to hold the right arm and hand at her side, while she swings the left.

Sitting again in the examination room the patient asks about exercise. The doctor encourages the patient to discover when her cardiologist feels it safe to increase her heart rate, and then describes a clinical experiment in which researchers trained monkeys to jog on a tread mill six hours a day. Those mokeys that underwent an experimental unilateral injection of a toxin that destroys dopamine neurons to one side of the brain, recuperated much faster, while those that did no exercise remained disabled. He states exercise, especially aerobic activity, enhances repair in the brain and provides a neuroprotective benefit. The patient confides she had to end her membership to the gym, as the temptation to get on the aerobic machines was overwhelming. She states she has always been an active person, and not allowing her heart rate to climb has been difficult. Yoga and Tai Chi are also helpful for those with PD, the physician states.

The doctor creates a chart for the patient, detailing how to increase the dosage of Sinemet. She should aim for the smallest dose that eliminates the stiffness and rigidity in her hand. He also encourages her to seek physical therapy for her hand, to regain strength and extensibility in the muscles. The doctor states he would like to see her again in three months time to see whether the transition to Sinemet has gone smoothly.

Before leaving, the patient reveals she lived in Alaska for sixteen years raising four children. The darkness of the winters never bothered her, or made her feel blue; an unusual blessing for a person with PD, where depression affects 70% of the patient population.

Mute and Temulous

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Entering the examination room the male patient sits in a chair with a large board for writing. Perhaps he has had a stroke and can’t speak. The patient writes his wife will return soon and the physician begins speaking with him, as he sits down. This clinic, Tuesday morning clinic is a Parkinson’s disease clinic, he explains to the patient, who nods in reply. In front of the doctor is a list of symptoms the patient deals with. Tremor is high on the list. The specialist continues speaking, reading the list of medications the patient relies on, and the three pages of medical history patients are asked to fill out.

The wife enters wearing a purple summer dress. The doctor asks when the tremor in the hands first began, and the spouse replies he has had tremor for a long time, and being a mechanic and depending on his hands, he has not worked in some time. The patient writes well, when he chooses to report something, with no indication of tremor in the handwriting. The wife clarifies the story by noting the patient required hospitalization in February after going on a drinking spree of four days. He became psychotic and lost touch with reality. In the care of a community hospital, the patient received an IV drip of saline, and nothing more. The nursing staff did not give the patient thiamine with the IV? The physician asks,and the wife, once a surgical nurse, reported never having seen anything more than saline.

Much earlier in his life, the patient was in a car accident that trapped his hands between his Thunderbird T- back and the asphalt road. Surgery attempted to reconstruct his fingers, but several digits remain stuck in a claw- like position. Another accident; the hammock he slept in collapsed during the night, resulting in fractures to vertebra in his neck and damage to nerves in the left arm, leaving the hand numb, and the left arm useless.

More recently, the wife having taken a position requiring traveling from Monday through Friday, saw little of her spouse and he began drinking heavilyHence the hospitalization for psychosis, in February. Four days after having returned home, the patient again became delirious, hallucinated and lost the ability to walk. The doctor states the scenario sounds reminiscent of Wernicke Korsakoff Syndrome, where drinkers undergo debilitating alcohol withdrawal. The wife took her spouse back to the hospital, where she claims hospital staff related they could do nothing for him. The cause of the syndrome is due to severe deficiency of thiamine, and if not treated the drinker undergoes damage to the brainstem; memory, gait and voluntary gaze are all affected.

On physical examination, the patient is weaker on the left, probably resulting from the old injury to the neck and damage to the nerves that innervate the arm. Muscle tone is supple, and the specialist feels no rigidity, and sees no slowness in movements. Resting tremor is slight.
The doctor views the MRI conducted in the community hospital and notes the poor test quality. Though judged normal, the physician notes some shrinkage of the midline cerebellum on the MRI, typical of those who drink heavily. He comments it’s worth having the test repeated at the institution, as their current technology may be capable of catching something unremarkable on the poor quality image of the brain. He admits he does not know the cause of the patient’s inability to speak. He asserts the problem may be a psychiatric one, though all psychiatric illness has a physical disturbance that can be explained, biochemically. The wife interjects the psychiatrist told her yesterday it is not a psychiatric problem. The doctor counsels the patient to care for himself, by eating a healthy diet, taking a multivitamin and exercising daily, and the brain will repair itself, and not to seek too many doctors as they’re likely to mess things up.

There is no Parkinson’s here, the doctor concludes. Sent by another neurologist who noted the tremor of his hands, the patient came to rule out a movement disorder. The effects of medications cause many movement disorders, the doctor concedes, and at least one of the drugs the patient uses, lists tremor as a side effect. The psychiatric medications the patient depends on have stabilized his bipolar disorder, and the neurologist feels reluctant to change any of them, though he feels the patient would benefit from physical and speech therapy, and a new MRI.


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