The Golfer’s Daughter

With some reservation, the patient allows the medical student and others to sit in during her first appointment with the movement disorder physician. She is young, petite and blond. Whether it is nerves or something else her right hand jiggles as does her right foot. The foot movement disappears when the physician asks what brings her into the clinic. Her right hand continues to shift in her lap. She glances down at her hand and tells the doctor the tremor in her hand used to appear only from time to time, but lately she has found the movement never diminishes, the way it had. She takes a breath and relates that it is hard for her to write on the blackboard, and that in desperation she has begun using her left hand, though her penmanship is worse.
Initially she attributed the tremor to nerves, and the start of the new school year, and her first year teaching third grade. She fears she has Parkinson’s disease, because her father was diagnosed with the illness when he turned sixty- two. His first symptom was a shaking right hand, and being a golfer the tremor compromised his swing.
The physician asks about other symptoms, and her face seems unsure. Her gaze takes in her torso and stops at her feet. With some hesitation, she confides sometimes her right foot taps, and she cannot control the movement. She used to tap her foot voluntarily while sitting at her desk in the classroom. Now she finds her foot will be tapping and she will suddenly become aware of its movement and will be unable to suppress the action.
As the physician asks her to move to the examination table, he asks her age. She is twenty- nine. He opens and closes her arm, holding her arm at the elbow. Then he asks her to pat her left hand on her thigh while he works the arm open and closed. Hmm. He looks at the people observing, and comments to the young woman he can feel some rigidity in the muscles on right side. He compares sides and narrates that her left side feels normal. The doctor leads her in several dexterity skills and comments the movements of her right hand seem a bit slower than the left. Then he opens the door and asks the patient to walk down the hallway so he can observe her gait. She holds her right elbow in towards her waist while her left arm swing is full.
Returning her to her chair, the physician asks how long ago did she first detect hints that something in her body might be awry, she gazes up at the ceiling and estimates it has been less than a year. He nods and remarks that people receive a diagnosis of PD when they have three of the classical textbook symptoms: tremor, slowness, and rigidity. Though many people have different presenting symptoms; a masked face, cramped small writing and low volume speech are several others. At present, she has some slowness in the movements of her right hand, as well as tremor and some rigidity. She looks into her hands in her lap as tears well in her eyes and run down her cheeks. Behind the desk, the physician comments that she may have what is called young- onset illness. He states that replacement of dopamine with levodopa should be reserved for later, but that relief of symptoms of tremor can be done with anti-cholinergic medications, like trihexyphenidyl. Also he suggests that a dopamine agonist (pramipexole) might also alleviate slowness and rigidity with a lessened likelihood of development of the motor fluctuations that are often seen within a few years when levodopa is started in young patients. She wipes her eyes, nods and states she would like to give it a try.

Close

Your Name (required)

Your Email (required)

Subject

Your Question