The wife of the patient spoke with the nurse during the week, requesting an early appointment. She is worried about his lack of sleep, his restlessness and feels he may be taking too much medication. She discovered he is gambling on the internet into the wee hours of the morning, when he finally puts his head on the pillow and gets several hours of sleep.
The couple is well dressed, amiable and unaccustomed to the small exam rooms which make up the movement disorder clinic. The husband is a recently retired executive, and wears dark grey pants a polo shirt and loafers. He and two others spent the morning on the golf course. He is tanned, his grey hair curly and slightly long. His symptoms are well masked, though he mentions his left hand was moving earlier in the day. He and his playing partners caddy for themselves and walk the course. They spend most of the morning there, allowing others to move past them.
The doctor comments retirement seems to agree with him, but the patient shakes his head commenting he misses work. Having something substantial to occupy his mind is what he misses most and he looks at his wife as he mentions this is why he likes on-line poker. It’s a mental challenge, and he enjoys it. The wife looks at the physician for his opinion, but he gives no judgment, though he points out the behavior worries your spouse. He shrugs his shoulders and states they have already had this conversation, earlier in the day. He does not intend to lose their savings or cash in any of their investments.
The doctor asks about his current medication regimen. The patient is taking 50/200mg of Sinemet four times per day, in addition to Mirapex .5mg. He also has a prescription for Parcopa 25/100mg which he used to take while traveling, to ensure he would be able to get through early morning meetings. He takes it now sometimes when he has to be on the golf course early. It’s been six years since his diagnosis, and the doctor asks whether his symptoms have moved to the right side. The patient nods his head, thinking. He’s noticed sometimes his right foot seems clumsier, especially on uneven ground, like the rolling hills at his favorite park. He keeps the Parcopa in his pocket when he plays golf, in case he needs a bit more. How often does he play? In the past week, he’s been three times, though he’s usually there only twice. The course gets expensive.
Asking about dyskinesia, the wife smiles faintly. The patient seems unaware of the small jerk to his head. The spouse asks if he cuts back on the medications, will the involuntary movements disappear? The physician explains Sinemet brings on such fall out and half of all patients develop such motions in two to five years following the beginning of treatment. The patient comments the movements are minor and don’t bother him too much. Sleeping, rather trying to sleep, bothers him a lot. He concedes he’s never slept much. Growing up he heard his brothers snoring long before he even felt tired. As a child he would sit up with his grandmother, watching the late show. His grandmother was an insomniac.
The physician mentions Seroquel, asserting that like a diet rich in fruit and vegetables provides the nutrition for health, so does a night’s rest. The patient looks doubtful. His grandmother lived to be ninety-seven.