New patients at the clinic receive one-hour appointments. The expert in movement disorders sees patients referred from other physicians, due to unusual symptoms involving motion of the body. The most prevalent of movement disorders is essential tremor, affecting 4% of the population over the age of forty. Parkinson's disease is the second most common neurodegenerative illness after Alzheimer's disease. The patient was probably referred to the specialist to rule out Parkinson's disease, as some symptoms might make a case for the illness, deteriorating handwriting, shaking of the right hand, lack of sleep, and tiredness.

At fifty-one years old, the patient had a list of other complaints that spoke to some other diagnosis, entirely.  With several car accidents in the history, and a laminectomy of L4-L5 for nerve root compression, with another possible surgery looming due to compression of the spinal cord in the cervical area, it was hard to separate symptoms possibly caused by damage to nerve roots, from an active disease process. Might the sensory symptoms; numbness and tingling of the right side of the face be due to compression high in the vertebra of the neck, while the same symptoms in the legs be due to compression addressed by the past surgery? Complicated migraines may be accompanied by sensory symptoms like numbness and tingling, and migraines were something the patient had endured since quite young.

The physician explained that in neurology doctors tend to work with a cluster of symptoms that suggest an illness. In Parkinson's disease a patient needs to have two of the four cardinal signs of the illness; slowness of movement, rigidity, tremor of the hand or foot, and impaired postural reflexes.

In trying to ascertain a diagnosis, the patient had undergone an MRI, spinal tap and nerve conduction studies. On MRI, the brain was noted to harbor several areas of concern, specifically low-density areas that might have been present in someone who had suffered a stroke, or had high blood pressure and diabetes. The physician noted the signals in the brain might also be due to mini strokes brought on by migraines. Nerve conduction studies were found to be normal, as was the lumbar puncture; two tests that might have pointed to a demyelinating illness like multiple sclerosis. The patient also underwent testing to see whether the problem might be Lyme's disease, tests were negative.

While examining the patient, the foot and leg moved spontaneously. The term for such unintended random movements is myoclonic jerks. When forceful and prolonged the motions cause the patient's muscles to ache a day later. A former physician noted the patient's hands were five degrees cooler than the average skin temperature. The neurology exam was normal except the patient could not stand with eyes closed and feet together, or perform heel to toe gait.

The most bothersome problem of all however, was failing memory.  The cognitive changes were not something the doctor could gauge in the hour allocated; he referred the patient for neuropsychological testing to determine what areas of cognition were affected. Testing may give some clue about the process of the illness and point in a direction to explore further.