Patient from Boston

The patient is from Boston and she pronounces the word head with two syllables. She wears her grey hair short around her face and the frames of her glasses are stylish and complement her eyes. Her spouse is small and Italian. He wears a hearing aid in his left ear, a turquoise polo shirt and he speaks loudly with the accent of a hitman. She scans the three women observing and tells them not to get old. She is seventy- five, but has the energy and demeanor of someone younger.
She says she has trouble eating, and adds perhaps that’s not a bad thing; referring to her rounded shape. The doctor asks exactly what seems to be the problem, because the typical parkinsonian tremble occurs at rest, not when engaged in activity. That sort of tremor is an action tremor, or an essential tremor, what Katherine Hepburn suffered from. He asks her to perform several dexterity measures, and her tremor appears slight, hardly incapacitating. The physician points at her and tells her she is not being honest with him and she concedes, that she feels the tremor is larger than it perhaps appears.
Though she currently takes two and a half pills of Sinemet three times a day, she feels little effect from the medication. The doctor asks what she eats for breakfast, and she tells him she had a bowl of cereal with milk. His eye brows shoot up and he exclaims the amino acid building blocks of proteins in the milk compete with the levodopa for access from blood to brain. That may be why she has noted no benefit from the medication. If she is uncertain whether her medications are working, she should attempt a purely vegetarian diet for a week or two, with as little protein as possible to see if the levodopa is working to alleviate her symptoms. A second solution is to increase the dosage of Sinemet (levodopa/carbidopa). He tests her arms and feels some cogwheel rigidity in the muscles. She writes a sentence for him to demonstrate the state of her penmanship, and her handwriting is miniscule. Yes, the physician nods, her writing is typical of someone with Parkinson’s.
The doctor asks the spouse whether he sees any improvement in his wife’s symptoms and he shrugs. He comments later she has told him she feels unable to move from her chair, and the physician nods and states initiation of movement is hard for those with PD, though when they get moving it becomes hard to stop. She mentions she exercises every morning and the other day performed thirty-one repetitions of sitting to standing. The physician praises her for exercising and encourages her to continue, telling her that is the best thing she can to for herself. He writes a new dosage schedule to increase her medication and arranges for a followup visit.

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