Reason to Get Dressed

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.


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