Restless

Brown and weathered from exposure to the sun, the patient explains the sensation in his legs and arms feels like his nerves are stretching. At night, he can’t sleep. The movement disorder specialist recognizes restless legs syndrome, and the wife agrees, she has heard the diagnosis before, adding her spouse also suffers from a neuropathy in both legs. Her dark hair contrasts sharply with her pale skin without wrinkles, and her blue eyes are surprising. With diabetes, high blood pressure, prostate cancer, eight surgeries in three years and mild cognitive impairment, the wife keeps a file folder and small notebook to track changes in medications and other things.
On physical exam, the doctor finds no rigidity in the upper body. The fine movements of his hand are wide and ample, and do not decrease in size, as they would when someone suffers from Parkinson’s disease. The patient has no reflexes in the legs, and has lost some ability to detect vibration and heat. The doctor notes he has the classic, “stocking and glove” presentation of neuropathy; meaning the patient has sensory changes in those areas. The spouse of the patient provides more information, explaining the problem extends to others in the family; both of their girls suffer from aspects of the same problem, as did the patient’s father and his grandfather.
The physician explains the problem seems to be a hereditary type of neuropathy, and there are many. He asks whether the patient has ever undergone nerve conduction studies, and the patient shakes his head, negative. What would help, he proposes, is for the patient to see a physician whose expertise is in nerve conduction. By taking a biopsy of a piece of nerve, the laboratory would be able to distinguish what type of neuropathy he suffers from, and that presents in the family in an autosomal dominant fashion. Whether it can be treated, is another problem.
Addressing the patient’s lack of sleep, the physician recommends exchanging an antidepressant, one of the older forms that has a heavy sedation affect, for the Lunesta which is habit forming and apparently of little use. He will take the new medication in the evening, along with extended- release Requip, which might alleviate some of the symptoms of restlessness in his limbs, and he provides the spouse with a few sample bottles, to try. He prints out the referral for nerve conduction studies, with another member of the faculty and states he would like them to return in six months.

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