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.

The patient taught middle school for forty years, and she sits without leaning on the back of her chair. She comes for a consultation about whether she has Parkinson's disease. Her husband has come with her, as a witness to the changes he has seen in her health. Her falls scared both of them. In the most recent, the patient carried groceries in each arm. She fell straight forward and broke her nose. When on the floor she was unable to rise without assistance.

The medical history of the patient has some red flags for the doctor; the patient doused her garden with spectricide and the toxin caused her thyroid to quit functioning. He mentions that there is a relationship, though not a causal one, between Parkinson's disease and exposure to pesticides, heavy metals and other environmental toxins. She comments she has suffered from trigeminal neuralgia, inflammation of the fifth cranial nerve that produces intermittent bouts of shooting pain to the side of her face and jaw. Her husband notes he has seen tremor in her hands and a stiff walk, while the patient says she has experienced left- sided weakness, fatigue, forgetfulness, and problems with bladder control.

The patient has taken some medications that may have deleterious side effects. Pravastatin, being one of the cholesterol- lowering statins, recently made the news for its under- reported tendency to invoke muscle pain and weakness, especially in the legs. Her primary care doctor added Abilify, a novel tranquilizer to her medications when he thought Prozac was inadequate for her symptoms of depression. Abilify can block dopamine receptors and produce some signs and symptoms of parkinsonism and in addition can induce tardive dyskinesia in patients, uncontrollable movements of the face, tongue or other body parts and these may wane if discontinued, or become permanent with continued treatment.

On physical examination, the doctor finds no stiffness or rigidity in her muscles, and her gait is normal with a full arm swing. He comments that he can detect no signs of parkinsonism. When he places a tuning fork on the bones of her foot, and she is unable to feel the metal buzzing, though she can feel the vibration in the knuckles of her hands. She is able to discern whether her toes are up or down, but her perception of temperature is also impaired. The doctor tells her that she does not have the clinical features of Parkinsons disease now. She may have had some symptoms of parkinsonism while taking Abilify, but those have gone away after stopping the medication. Based on her examination he diagnoses a peripheral neuropathy to explain some of her symptoms. The cause of her neuropathy will require more extensive evaluation. A B-12 deficiency, low thyroid function, medications or toxic insult are possible causes of neuropathy. He conjectures a toxic bath, like the kind she experienced, might result in a neuropathy, though the lower extremity problem resembles what a diabetic patient might incur. He urges her to see another physician whose specialty is the peripheral nervous system. He hands the patient and her husband a referral form. The other specialist will thoroughly explore the function of other nerves (nerve conduction studies), and order the appropriate blood and other tests that will aid in ruling out other disorders.