Six-month followup of a patient with Lewy Body Disease

Six months have passed and the patient returns for a follow-up visit, to assess symptoms and make any changes in his treatment plan. Hallucinations are no longer a problem. Adding Seroquel seems to have alleviated that issue. The specialist in movement disorders notices the physician at the nursing home has added an anti-cholinergic drug to the list of medications the older man takes. The prescription will give the patient a drier mouth, so he will not drool, but it will also increase the likelihood of more hallucinations despite seroquel. In addition, it will worsen memory problems and likely result in difficulties with empyting the bladder. He writes a note in the patient’s chart, advising the medication be discontinued.
On the last visit, the physician recommended the patient have an MRI to determine whether he might have a lesion in the right parietal lobe of his brain because of spatial orientation difficulties. Today, the MRI showed moderate generalized atrophy (shrinkage) of his brain. As he lives in an assisted living facility, the patient brings a nurse along with him when he travels. On his right wrist he wears a plastic ID band.
The doctor asks whether he is sleeping better, and if the tremor he experienced continues to bother him. The patient nods his head, reporting sleeping has improved, and the movements he used to have are a bit better. The doctor replies the medication (levodopa/carbidopa) is probably competing for entry into brain with the proteins in his diet. This information sparks a response and the patient reports a blood test reported his serum albumin was low and he now takes a protein supplement, twice a day. Nodding, the physician states we will probably have to increase the dose of Sinemet, for him to see an effect on his tremor.
The doctor adjusts the patient’s chair, turning it sideways so he can access the patient as he does a physical exam. Feeling the movement of the arm muscles as he opens and closes the arm at the elbow the physician reports the patient lacks the ratchet- like movement in the joint, so typical of people with PD. Performing fine movements of the hand, the patient has more trouble with his left side, with movements being less dexterous. He is unable to copy a movement the doctor performs, but is able to replicate the actions of screwing in a light bulb, and hammering a nail into the wall; the doctor reports the patient suffers from a motor apraxia- but not an ideo-motor apraxia.
He slips the disc into the computer and waits for the image of the MRI to register on the computer. The patient comments the MRI apparatus was quite loud and the doctor replies the time he had an MRI he felt uncomfortable within the machine’s noisy core. The images of the brain show overall moderate atrophy extending into the cerebellum. The patient asks whether the MRI confirms his diagnosis of parkinsonism, and the doctor replies he thinks the patient suffers from a variant of Parkinson’s disease, Lewy Body disease which frequently presents first with the patient having hallucinations.


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