The Baker

The new patient is a woman in her late forties. She arrives with a teenage daughter in tow. Is she just nervous, or does she have tremor? Her left hand shakes visibly as she sits in the chair. Her right foot flaps under the seat. Her daughter looks at her and tells her to ‘Chill’. They have been waiting in the patient area for the last thirty minutes and the mother’s face is tight with apprehension, anxiety and anger.
The physician appears to notice the tension in the patient and apologizes for the wait, apparently the office staff has double booked patients, which never works. This seems to relieve some stress. The specialist asks why she has come and the patient concedes she has been worried about her left hand for some time, because she’s right handed, she’s put off seeing a doctor, feeling she could function with the small tremor. Socially she feels embarrassed by the jiggling in the hand. The physician asks if the tremor is worse when she uses the hand and she hesitates, but responds slowly that it is probably worse when she is not using the hand. The specialist reviews the patient’s history and notes she is otherwise healthy, with low blood pressure. He inquires into whether she grew up using well- water and she replies, yes her parents owned a dairy farm. He asks whether she was exposed to insecticides, herbicides, or heavy metals and she shakes her head yes. It was her job to place the ear tags on the lactating cows; the tags repelled flies, ticks and lice. The patient explains each cow gets a tag in each ear, similar to ear rings she clarifies. How long did she perform this work? The patient looks towards the ceiling, and admits it was for a while, maybe five years.
The specialist notes epidemiological studies have found well- water consumption and exposure to the toxins in insecticides or the like, increase the chance of acquiring the illness. He asks whether she has other family members who have been diagnosed with Parkinson’s disease or tremors and she shakes her head to the affirmative. Her father currently suffers with the illness, and her oldest brother has some issue with movements in his hand and foot, though he refuses to see a doctor. The specialist nods and notes she may have a genetic predisposition to acquiring the disease. He asks when she first recognized the tremor of her hand. The patient pauses, and the daughter answers for her mother, saying it was about a year ago, last spring. The older woman agrees, nodding her head. The daughter quips that her mom complained about the twitching to her, and she had shown her how her hand moves, involuntarily.
The doctor asks the patient to sit on the examination table so he can assess her movements. He asks about work. She has worked for Panera bread for the last eight years. She wakes early in the morning and is finished before noon; and is one in the team of bread makers. As she speaks, the doctor takes her right hand and asks her to leave the wrist loose. He moves her hand back and forth, then moves the same elbow back and forth, and reports to the young medical student who is standing, that he feels no rigidity on the right side. He performs the same actions on the left and shakes his head, yes, denoting some rigidity exists in the muscles of the left side. He asks the student to come and check, and the student appears abashed but performs the same test. He gives a brief, ‘Hm’, saying little else. The specialist asks the patient to perform various other actions, finger tip to nose eventually he asks the patient to walk in the hallway so they can observe her gait. The two men agree the way she walks indicates symptoms of Parkinson’s disease; she fails to swing the left arm, holding it rather close to her torso, though she swings her right arm fully.
They regroup in their original seats. The movement disorders specialist agrees she has some of the symptoms of the illness, though she is quite young for the disease; the average diagnosis occurs in the sixth decade. He encourages the patient to exercise daily to maintain her health. He would like to prescribe a medication that may delay some of the symptoms of the disease. Azilect should be taken once a day, at bedtime. He reassures the patient that though Parkinson’s disease has no cure, there are treatments that address the symptoms. He would like her to return to the clinic in six months, though she may call the office staff if she has questions or problems.

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