About five years ago she noticed the tremor in her right hand. Now as she sits in the examination room, her slightly swollen hand vacillates steadily as she rests it on the arm of the chair. She feels the muscles cramping and shortening and uses her other hand to straighten the fingers. Gradually she has lost most of the strength, dexterity and the ability to write legibly. She states she has taken Azilect for two years and sees little improvement.

Ah, but that's good, the doctor states. It means progression of your illness is slow; the other side of the body may be affected with disease, within that time. The comment buoys the patient's sentiments, somewhat. The specialist in movement disorders asks about her prior medical history and learns the patient underwent heart surgery to amend a leaking heart valve, seven months prior. Surgeons removed her thyroid two years ago and she suffers from high blood pressure, and high cholesterol. She states she is healthy, otherwise; comments from an optimist.

As the specialist dives into a description of how and who implicated dopamine as the neurotransmitter depleted in Parkinson's disease, the steady murmur of his voice and the quality of the fluorescent overhead lights lulls the listeners into a stupor. The patient has brought a cup of coffee with her, remarking it's decaffeinated, and the doctor remarks smoking and drinking coffee are two habits that are negatively correlated with illness and PD; the more one smokes and drinks coffee, the smaller the likelihood one will acquire PD.

On physical examination of the patient, the specialist discovers brisk reflexes; probably a byproduct of high blood pressure he comments. He inquires whether she has had an MRI of the brain, as people with long-standing high blood pressure commonly have a multitude of small white spots scattered just under the cortex of the brain. The neurologist feels the fluidity of movement from the left elbow and wrist and senses some rigidity in the muscles of the biceps. When he asks her to walk in the hallway, her gait is regular, with wide steps though she tends to hold the right arm and hand at her side, while she swings the left.

Sitting again in the examination room the patient asks about exercise. The doctor encourages the patient to discover when her cardiologist feels it safe to increase her heart rate, and then describes a clinical experiment in which researchers trained monkeys  to jog on a tread mill six hours a day. Those mokeys that underwent an experimental unilateral injection of a toxin that destroys dopamine neurons to one side of the brain, recuperated much faster, while those that did no exercise remained disabled. He states exercise, especially aerobic activity, enhances repair in the brain and provides a neuroprotective benefit. The patient confides she had to end her membership to the gym, as the temptation to get on the aerobic machines was overwhelming. She states she has always been an active person, and not allowing her heart rate to climb has been difficult. Yoga and Tai Chi are also helpful for those with PD, the physician states.

The doctor creates a chart for the patient, detailing how to increase the dosage of Sinemet. She should aim for the smallest dose that eliminates the stiffness and rigidity in her hand. He also encourages her to seek physical therapy for her hand, to regain strength and extensibility in the muscles. The doctor states he would like to see her again in three months time to see whether the transition to Sinemet has gone smoothly.

Before leaving, the patient reveals she lived in Alaska for sixteen years raising four children. The darkness of the winters never bothered her, or made her feel blue; an unusual blessing for a person with PD, where depression affects 70% of the patient population.

Entering the examination room the male patient sits in a chair with a large board for writing. Perhaps he has had a stroke and can't speak. The patient writes his wife will return soon and the physician begins speaking with him, as he sits down. This clinic, Tuesday morning clinic is a Parkinson's disease clinic, he explains to the patient, who nods in reply. In front of the doctor is a list of symptoms the patient deals with. Tremor is high on the list. The specialist continues speaking, reading the list of medications the patient relies on, and the three pages of medical history patients are asked to fill out.

The wife enters wearing a purple summer dress. The doctor asks when the tremor in the hands first began, and the spouse replies he has had tremor for a long time, and being a mechanic and depending on his hands, he has not worked in some time. The patient writes well, when he chooses to report something, with no indication of tremor in the handwriting. The wife clarifies the story by noting the patient required hospitalization in February after going on a drinking spree of four days. He became psychotic and lost touch with reality. In the care of a community hospital, the patient received an IV drip of saline, and nothing more. The nursing staff did not give the patient thiamine with the IV? The physician asks,and the wife, once a surgical nurse, reported never having seen anything more than saline.

Much earlier in his life, the patient was in a car accident that trapped his hands between his Thunderbird T- back and the asphalt road. Surgery attempted to reconstruct his fingers, but several digits remain stuck in a claw- like position. Another accident; the hammock he slept in collapsed during the night, resulting in fractures to vertebra in his neck and damage to nerves in the left arm, leaving the hand numb, and the left arm useless.

More recently, the wife having taken a position requiring traveling from Monday through Friday, saw little of her spouse and he began drinking heavilyHence the hospitalization for psychosis, in February. Four days after having returned home, the patient again became delirious, hallucinated and lost the ability to walk. The doctor states the scenario sounds reminiscent of Wernicke Korsakoff Syndrome, where drinkers undergo debilitating alcohol withdrawal. The wife took her spouse back to the hospital, where she claims hospital staff related they could do nothing for him. The cause of the syndrome is due to severe deficiency of thiamine, and if not treated the drinker undergoes damage to the brainstem; memory, gait and voluntary gaze are all affected.

On physical examination, the patient is weaker on the left, probably resulting from the old injury to the neck and damage to the nerves that innervate the arm. Muscle tone is supple, and the specialist feels no rigidity, and sees no slowness in movements. Resting tremor is slight.

The doctor views the MRI conducted in the community hospital and notes the poor test quality. Though judged normal, the physician notes some shrinkage of the midline cerebellum on the MRI, typical of those who drink heavily. He comments it's worth having the test repeated at the institution, as their current technology may be capable of catching something unremarkable on the poor quality image of the brain. He admits he does not know the cause of the patient's inability to speak. He asserts the problem may be a psychiatric one, though all psychiatric illness has a physical disturbance that can be explained, biochemically. The wife interjects the psychiatrist told her yesterday it is not a psychiatric problem. The doctor counsels the patient to care for himself, by eating a healthy diet, taking a multivitamin and exercising daily, and the brain will repair itself, and not to seek too many doctors as they're likely to mess things up.

There is no Parkinson's here, the doctor concludes. Sent by another neurologist who noted the tremor of his hands, the patient came to rule out a movement disorder. The effects of medications cause many movement disorders, the doctor concedes, and at least one of the drugs the patient uses, lists tremor as a side effect. The psychiatric medications the patient depends on have stabilized his bipolar disorder, and the neurologist feels reluctant to change any of them, though he feels the patient would benefit from physical and speech therapy, and a new MRI.

The patient's record describes a man of five feet, seven inches but wearing my rose- colored heels I tower above him; I stand five feet, four inches on a tall morning. He has the hunched posture seen in many Parkinson's patients and he comes to the clinic with the major complaint of falling. The nurse who accompanies him says she sees him most days, and she has not noted slowness in his motions. Perhaps this is what comes of living in a home for the elderly, the staff become accustomed to a new normal, where most of the population is slow, frail and hesitant to speak.

The doctor asks the pale patient what line of work he was in and the man reports he worked for the government in security and computer services. The physician reflects how in 1970 he used cumbersome discarded equipment from the phone company, with wires connecting networks, rather than a true computer to construct a feed automation system for a small population of monkeys. Today, a system performing the same type of tasks fits inside a tote bag.

When did you first notice the hand tremor? The doctor asks. The man replies it was approximately five years ago. The nurse states she has never seen the patient's hands shake. Problems walking developed about two years ago. He has fallen several times since then; the last accident resulted in a fractured arm. The doctor notes the patient is taking Risperdal, which is contra- indicated in patients over the age of sixty, because people in that decade of life are commonly depleted in dopamine, and the medication blocks the actioins of the little neurotransmitter that is left, resulting in a Parkinson syndrome. Hallucinations caused the nursing home doctor to order the medication for the patient. The movement disorder doctor is flustered, his tone of voice rises, as he adamantly states the drug is not recommended for those with parkinsonism or even healthy older persons. There is another medication, Seroquel that is superior for seniors with a propensity for seeing things. Later he confides physicians become too comfortable prescribing the same medications for all their patients, eschewing the newer drugs that may be more effective and have fewer complications.

The doctor rises quickly and begins the physical exam, noting the patient is quite rigid in the muscles of the right wrist. He has cogwheel rigidity in both wrists, slowness of movements, and acute stiffness and rigidity in the neck. While flexing the patient's joints he declares the left side seems worse than the right. The slowness also carries over to swallowing and blinking the eyes. The patient's record notes he takes Aricept, a medication given to improve his diminishing memory and intellect. The patient confirms he has had trouble remembering things.

After giving the patient a mini- mental examination, the physician wonders whether there may be something else behind his symptoms. The mature man has difficulty placing the twelve digits on the face of a clock, and difficulty in executing a copy of a polygon; the problem lies in spacial relations. Perhaps he has had an undiagnosed stroke, or perhaps the high blood pressure prevents oxygenation to the parietal lobe of the brain. A score of 24 correct answers from a possible 30 indicates the patient has mild to moderate cognitive deficits. The movement disorder physician urges the patient to undergo an MRI, as he has not had one, and it may give some clear reasons for his symptoms.

The doctor comments he would like them to return in four months time, to see whether the change from Risperdal to Seroquel has improved the patient's ability to move, and whether Sinemet has been effective in increasing the ability to move, swallow and blink. The patient rises without assistance from the office chair and uses the walker nearby to exit the room. He says he feels better already and heads spontaneously towards the right corridor and I correct them, to the left. The nurse takes the patient's jersey shirt in her fingers and tugs gently, "Left, baby".

A sixty- one year old patient comes in worried about the tremor in his hands. Told by his previous neurologist there are eighteen drugs that treat tremor, he was about to start the first trial when he opted instead to go on a long driving journey across the country. Not wanting to have to contend with the possible side effect of undue sedation, he put off treatment. The patient has no history of working with chemical toxicants. Past EMG and nerve conduction studies show he has no neuropathies, which might in some cases result in tremor. Unlike Parkinson's disease, where tremor first presents on one side of the body, the patient's tremor involves the hands and arms symmetrically.

The movement disorder doctor comments his symptoms bring to mind the diagnosis of essential tremor. The physician inquires whether alcohol decreases the movements, the patient notes that when dining out he, and his wife sometimes order a bottle of wine. With his first glass, he will see apparent tremor in his hands, by the time the bottle is half-empty, the tremor will have eased substantially.

On physical examination, the patient's muscles surrounding his joints are loose and supple. The doctor notes he has a fine tremor of the head, and asks whether the patient has ever noticed it. It is very mild, the specialist assures him. Performing fine movements of the finger, in touching a pen and then his nose, the patient's movements are obviously shaky. In writing, his hand is noticeably unsteady. He comments his characters tend to be hairy- looking, and at other times they are normal. Sometimes he says he forgets how to spell simple words, he concentrates so hard on trying to make the letters round.

The specialist peruses the file folder with details of previous tests the patient has undergone. The physician mentions the patient has some compression of nerve roots in his neck, but that is more likely, in the case of severe nerve root compression, to produce pain, weakness and muscle twitiching or fasiculations. He states the patient's symptoms are classical examples of essential tremor, with the minor deviation that people usually notice the tremors much earlier in life. The patient is sixty- one and first noticed the tremor in his hands just over a year ago. Inderal (propranolol), a beta blocker is the medication most commonly given for essential tremor. It has an advantage over the current medication the patient uses to decrease blood pressure, as it will function for two issues- lowering blood pressure and decreasing tremor. The doctor creates a schedule for using Inderal, and mentions that essential tremor tends to increase and decrease, though with time it worsens and may come to involve the head and voice. He mentions people with debilitating tremor may choose to undergo deep brain stimulation surgery. The patient refers to his previous neurologist, who mentioned surgery for when tremor worsened to the extent he was starting to throw food around with his fork. The movement disorder physician laughs, conceding that's a creative way of putting things and he would like him to return in six months time, so they can re-assess the situation.

The patient has small cramped handwriting, poor sleep and difficulty turning in bed as well as rising from a chair. She has come for a second opinion on whether she has Parkinson's disease. The movement disorder specialist asks her rhetorically how does one distinguish a Parkinson Syndrome from the true disease. He answers his own question by noting to have a syndrome a patient must have three of the four cardinal signs of the disease; resting tremor, slowness of movement, cogwheel rigidity, and/ or loss of balance. The one way to determine whether one suffers from the true illness (idiopathic Parkinsons Disease) is to see whether there is a response to dopamine. If a patient has a deficiency of the neurotransmitter, movements will increase in fluidity and speed, tremor will disappear and rigidity will ease. Certain other illnesses and medications may mimic what patients experience in the illness. Vascular disease can lead to a syndrome of lower body parkinsonism. Diabetes can bring peripheral neuropathies that may result in the patient losing her balance and falling, or have a shuffling gait. Major tranquilizers can bring on characteristics of PD because the medication blocks dopamine receptors leading to an induced state of parkinsonism.

The doctor prefers to use levodopa and carbidopa over the medication called Stalevo. He thinks Stalevo is too expensive and does not permit the patient to adjust the medication to her own needs. Sinemet, he explains to the patient means sin emesis, or no vomit. The medication is the combination of levodopa and carbidopa. It comes as a generic, is less expensive and it is easier to adjust the dose.

The patient symptoms are worse in her right arm than the left, and she is right handed. She keeps the arm tightly at the side of her body. Shrugging the shoulders result in almost no movement. Cogwheel rigidity is present in the patient's wrist and elbow muscles. The patient confides she has fallen twice in the last year. The doctor is wary about this, he conveys patients with PD usually do not fall until the disease had progressed significantly, though it is possible she may be falling for other reasons.

At different times throughout the consultation, the patient became teary, and the doctor noted that the majority of patients with PD have significant depression. He advised her of the need for an antidepressant, stating that her disease appears quite mild. If she were on a suitable antidepressant, she might be better able to cope with the illness. The patient states she feels depressed because she does not like the limitations she has. He also indicated that the anti-depressant may eventually help her sleep better. She had confided that she has difficulty with sleep and last night only slept for two and a half hours, and got up repeatedly throughout the night.

Though the patient was not happy to receivetwo newprescriptions, the doctor asked her to return in four month's time to re-assess her symptoms and see how she is fairing.