Sister, Daughter and Caretaker

Mother the patient sits securely in the wheelchair. Her son accompanies them. Twenty years ago, a drunk driver hit him, head- on. The car crash accident left him blind, brain damaged and physically impaired. He uses a walker to ambulate. The threesome takes awhile to sit in the examination room; they find space for all the wheels, the patient’s four- pronged cane and the walker.
The movement disorders specialist begins speaking, clarifying they have come to a clinic for people with presumed Parkinson’s disease. The daughter nods, looking up from the paperwork she’s engaged in. Addressing the patient in the wheelchair, the physician sees her facial expression change only slightly when asked a question. Perhaps she suffers from slight dementia. The daughter doesn’t come to her aid, she lets the silence expand, before looking up at her and asking the same question as the doctor. Together the women agree they first heard the diagnosis of Parkinsonism four to five years ago. The doctor asks what the first indication of illness was and the silence takes over again, before the doctor explains how Parkinson’s disease usually presents with slowness, rigidity or a trembling limb. This jogs the patient’s memory and she remembers her left hand shaking. Dizziness is another symptom. The doctor explains parkinsonism doesn’t typically involve dizziness, though it may become a problem if blood pressure is too low.
Asking about her memory, the patient concedes she frequently forgets things. The daughter looks up from her work and mentions her mother “is orthostatic” and she has a medication, mididrine that increases her blood pressure, though she fails to use it regularly because her blood pressure fluctuates so much, she fears she will give her mother a stroke. Nodding his head in agreement, the doctor understands and sympathizes, stating he would do the same. Today the patient’s blood pressure was 157/90, somewhat high, though the daughter explains it has been a rough morning; her brother was eating candy throughout the house.
The patient’s notes from her last stay in the hospital are available online, and the physician states at that time, the hospital staff found patient suffered from an ulcer. This is fresh news to the daughter who was unaware tests had found blood in her mother’s stool due to internal bleeding. At the time, they had prescribed Reglan, a medication that may worsen the symptoms of PD, the doctor adds. The daughter has no recollection of ever giving her mother Reglan.
On physical examination, the physician finds cogwheel rigidity in both arm muscles, and decreased dexterity in her hands. With a history of chronic hypertension, hyperlipidemia and two surgeries in which a surgeon inserted stents in the vessels to the patient’s heart, the physician is unclear about the cause of the patient’s hyper- reflexia. The wildly swinging blood pressure may herald Shy Drager’s Syndrome or Parkinson’s Plus; two names for the same diagnosis where the autonomic nervous system goes awry, typically seen in patient’s whose blood pressure varies according to body position. It is also possible that the patient suffers from consequences of heart disease and Parkinsonism.
The physician explains an MRI will help distinguish whether the patient has suffered a series of small strokes, which would account for the increased reflexes in her lower body, and her subsequent falls. He outlines the diet he would like the patient to adhere to- a low- protein plan for the day, with the daily protein allotment eaten in the dinner meal. The change in meals will help determine whether the patient has any benefit from the medication. If they see no improvement in the rigidity and dexterity of movement during the daylight hours, then they can conclude the mother does not suffer from dopamine deficiency, and does not require Sinemet, which drops the blood pressure further. The specialist concludes he would like them to return in six- month’s time, but may see them sooner if they have problems.

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