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.


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