Six month follow- ups help the doctor and patient stay on top of shifting symptoms, though more frequent appointments are possible. The doctor has said he likes movement disorders because there are no emergencies. Though the first incident of freezing may feel catastrophic to the patient, it passes. They are bumps in the road. Sometimes the journey is lightened by sharing it.
The Parkinson's disease coordinator speaks with the patient about attending possible support group meetings in his area. He responds, stating not all patients want to talk about their problems. Not deterred, she explains the sessions will be run according to group preference. Some people may want lectures, others may just want the social time.
The shooting pain in the left knee is new and it worries him. It never occurs when he's doing Tai chi and it moves up, not down, as the doctor would prefer. Pain moving downward may emanate from the spine, a bony prominence can easily impinge on the fibers of a nerve, sending scintillating pain down through the leg. That's not it. This is pain moving up towards the thigh and it's fast, not throbbing and deep as the pain patients with PD describe. Both his mother and father are diabetic...The patient climbs onto the examination table and the physician tries to replicate the sensation. Both legs have bruises at the lower mid- shin. The tightness of the muscles in the patient's legs is extreme; the doctor comments he would like him to continue with physical therapy.
Parkinson's disease in this patient is evident in the constant tremor of his hands. Six months ago, it was not as prominent as it is today. He describes shaving, his right hand wavering towards his cheek. The doctor recommends wearing wrist weights to dampen the movements, the patient nods. Tremor is one of the hardest symptoms to suppress, and he takes a distinct drug to soften the constant shaking. Yet he walks well, with head and shoulders erect, an arms swing, and ample step size.
Friday, March 27, 2009
Thursday, March 19, 2009
Test Pilot
A German patient and his Austrian wife have recently moved from Iowa, and need a new neurologist. His voice resonates in the small room with only a hint of German lilt left. He has the voice for radio, but he is a test pilot. The doctor is in education mode conferring to the patient all things related to Parkinson's and discusses the personality type others have given to the stereotypical sufferer. Well controlled, averse to adventure, given to detail and methodical work, the patient admits that describes himself.
The wife describes the onset of symptoms a few years ago; trembling in a hand that in time involved the foot as well. Today there is little evidence of any symptom. The doctor feels some cog- wheel rigidity in the muscles at the elbow joint on the left side otherwise the patient's symptoms are very well disguised by medications- Mirapex and Sinemet. The movement disorder physician commends the patient's management, he is doing the right things- exercising daily... He would add something thought to slow illness- perhaps coenzyme Q10 or deprenyl.
The doctor conducts a physical exam. Performing the finger to nose task, first with the right hand and then left, I note the patient's hands. His skin is taught and smooth, unlined and young- looking. He is in his sixties and he has the hands of a young man. The wife has skin appropriate to someone of her age, and a flare for fashion evident in pale pink clogs with an open toe and well- cut red hair. She is un-intimidated by the doctor and presses him on why he speaks so much of animal research.
The patient's gait is flawless and his arm swing full and loose. 'Maybe I don't have PD...' the patient comments as the physician emphasizes how well his symptoms are covered. The doctor doesn't give the comment any reply. All witnessed the wife mimicking the tremor of the hand, and how the movement eventually affected the left foot. If he doesn't have Parkinson's he has something close enough.
The wife describes the onset of symptoms a few years ago; trembling in a hand that in time involved the foot as well. Today there is little evidence of any symptom. The doctor feels some cog- wheel rigidity in the muscles at the elbow joint on the left side otherwise the patient's symptoms are very well disguised by medications- Mirapex and Sinemet. The movement disorder physician commends the patient's management, he is doing the right things- exercising daily... He would add something thought to slow illness- perhaps coenzyme Q10 or deprenyl.
The doctor conducts a physical exam. Performing the finger to nose task, first with the right hand and then left, I note the patient's hands. His skin is taught and smooth, unlined and young- looking. He is in his sixties and he has the hands of a young man. The wife has skin appropriate to someone of her age, and a flare for fashion evident in pale pink clogs with an open toe and well- cut red hair. She is un-intimidated by the doctor and presses him on why he speaks so much of animal research.
The patient's gait is flawless and his arm swing full and loose. 'Maybe I don't have PD...' the patient comments as the physician emphasizes how well his symptoms are covered. The doctor doesn't give the comment any reply. All witnessed the wife mimicking the tremor of the hand, and how the movement eventually affected the left foot. If he doesn't have Parkinson's he has something close enough.
Thursday, March 12, 2009
Tied In
The patient, a former internal medicine physician sits in a standard wheelchair, his wife on a yellow plastic seat at his right. The movement disorder doctor arrives as the medical student asks the principle reason for the visit. There are no other seats in the small hot room. I sit on the red hazardous waste garbage, an administrator hoping to learn the issues of Parkinson's is already standing. The Dr. stands, wearing a woolen- looking jacket leaning against the examination table until the soft voice of the patient forces him to relocate the wife's bag. He sits much closer in another yellow chair. The patient's words are so hard to wait for, he twists in his seat while the syllables are freed from his stuck mouth.
Hallucinations are what brings them in. He sees two or sometimes three women caring for him; the wife gives no other specifics. She doesn't define what she means by caring. Sometimes he hallucinates seeing his wife. How he knows the visions are hallucinations is murky; he doesn't reach out and try and touch them, he just knows they aren't real...
The doctor conveys REM sleep interrupts into daylight hours when the patient's sleep cycle is fragmented. He's not sleeping enough. The remedy is Seroquel, or the generic quetiapine in the tiniest dose, half of a 25mg pill. Because the prescription is supposed to allow for 6 hours of sleep, the patient will need to wear diapers at night. It may take several nights to find the correct dose needed to provide a six hour sleep window; the patient will need to wear soft restraints tied to hospital bed, to keep him from walking around in a groggy state and falling.
The doctor describes a personal scenario of his own. His mother needed restraints to keep her from walking around at night. A mother's care, and a spouse's care are two different fruits. The doctor proposes the wife tie her husband into his bed, so he will not be able to get up until she unties him in the morning. Restraints and a hospital bed- two items Medicare will pay for, and home health for instructions on how to use the nighttime devices. The wife leans into her husband, speaking softly and clearly.
"A hospital bed, a hospital bed, OK? " She doesn't mention the ties.
Hallucinations are what brings them in. He sees two or sometimes three women caring for him; the wife gives no other specifics. She doesn't define what she means by caring. Sometimes he hallucinates seeing his wife. How he knows the visions are hallucinations is murky; he doesn't reach out and try and touch them, he just knows they aren't real...
The doctor conveys REM sleep interrupts into daylight hours when the patient's sleep cycle is fragmented. He's not sleeping enough. The remedy is Seroquel, or the generic quetiapine in the tiniest dose, half of a 25mg pill. Because the prescription is supposed to allow for 6 hours of sleep, the patient will need to wear diapers at night. It may take several nights to find the correct dose needed to provide a six hour sleep window; the patient will need to wear soft restraints tied to hospital bed, to keep him from walking around in a groggy state and falling.
The doctor describes a personal scenario of his own. His mother needed restraints to keep her from walking around at night. A mother's care, and a spouse's care are two different fruits. The doctor proposes the wife tie her husband into his bed, so he will not be able to get up until she unties him in the morning. Restraints and a hospital bed- two items Medicare will pay for, and home health for instructions on how to use the nighttime devices. The wife leans into her husband, speaking softly and clearly.
"A hospital bed, a hospital bed, OK? " She doesn't mention the ties.
Subscribe to:
Posts (Atom)
