Posts Tagged ‘shuffling gait’

Six clinical triumphs and a tornado

March 17, 2017

I had me a wonderful day

I was keeping the blindness at bay

And I helped stop the shakes

Oh, the difference it makes!

To start steroids without a delay.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I can’t write about particular patients but I can write about clinical trends.

Sometimes I suspect Parkinson’s in the first 60 seconds after I meet a patient. I note a shuffling gait with arms that don’t swing, a face with limited movement, and a quiet voice lacking in music.  After the patient finishes their concerns,  I ask about shrinking handwriting size and loss of sense of smell.  Then, if the patient lacks the characteristic resting tremor, I’ll hold the patient’s hand.  If I feel the muscles between the thumb and forefinger quivering, I strongly suspect the disease.

No single sign or symptom serves as a gold standard. Without a lab test for Parkinson’s, the diagnosis frequently relies on response to the medication Sinemet, (levodopa and carbidopa).

Parkinson’s always progresses, but the rate varies. No matter what stage I find the patient in, I tell them that we have no medication that will slow disease progression, but we have a whole sequence of drugs for the symptoms.  Most elect to try the meds, a few don’t.

I love seeing a person in the hour or two after their first Sinemet dose, especially if I find the family close at hand. It really deserves the term, awakening, the title of the Oliver Sachs book and Robin Williams movie about the development of the drug.

I have picked up more than one case per week here.

I’m also finding an inordinate number of people with polymyalgia rheumatica (PMR), also called giant cell arteritis or temporal arteritis. For unknown reasons, worse with advancing age, occasionally a person’s body will attack the arterial lining with very large immune cells.  As a result, people feel terrible, lose strength in their shoulders and hips, and get severe morning stiffness lasting more than an hour.  The symptoms can sneak up over the course of months, or ambush over the course of days.  I ask if their jaw gets tired while chewing.  I feel the arteries over the temples; once in a while I feel hot, ropey spots on the scalp, where the blood vessel pulses .  We use two non-specific blood tests, the C-reactive protein (CRP) and the erythrocyte sedimentation rate (sed rate or ESR), which help make the diagnosis.  The conclusive test is the temporal artery biopsy, but only if it’s positive, which it never is.

Blindness ranks as the most feared complication of the untreated PMR; the artery that supplies the retina can clot off. Thus if I have strong suspicion I start steroid therapy promptly.  A quick response helps make the diagnosis.

Last Tuesday I had the wonderful experience of seeing more than one Parkinson’s patient and more than one PMR patient in their initial positive response to therapy.   Bethany picked me up at the hospital, and in the time it took for me to walk out the front door and get into the car the sky darkened so fast that the street lights came on.  As we drove to the gym I started to recount my day full of successes, but halfway there our phones interrupted with the announcement of a tornado warning.  We continued on, but the noise of the hail drowned out my words.  Three blocks later we arrived at the gym just as the tornado sirens started.

We sat on a bench inside and watched the vacant pool while I finished recounting my 6 clinical triumphs in one day.

Another EMR, and a Parkinson’s patient improved.

December 19, 2015

A tremor after the Great Flu
Is Parkinson’s, we already knew.
There’s more! Please just wait,
There’s a shuffling gait,
And the facial movements are few.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Towards the end of his life, my father developed Parkinson’s disease, which eventually killed him. Ever since I’ve been alert to the diagnostic clues.

When I started in training, 80% of the Parkinson’s that we saw came in the wake of the Great Influenza of 1918. By the 90’s I could tell you from across the street who had escaped that flu (the spry) and who hadn’t (the slow movers). That generation has passed.

When most people think of Parkinson’s, they think of the characteristic “pill-rolling” tremor that goes away when the person moves with intent. But I don’t often see that tremor. I look for facial expression that doesn’t change much, a stiff, shuffling gait, and very small handwriting (micrographia). I listen for monotonous, quiet speech. I inquire about loss of sense of smell (anosmia). I feel the muscles between the thumb and forefinger while I talk tot he patient, which will show the beginnings of a resting tremor long before it becomes visible.

Today a patient made my day with Parkinson’s visibly improved. I had made the diagnosis relatively early. The voice had more music, and the small, involuntary facial and hand movements had returned. Much work remains to fine-tune the medication.

I now have access to the current EMR, NextGen, the 7th EMR I’ve learned since January. I have left off dictating my records like I did in the first two weeks. The computer gets in the way of patient care, but complaining about it does no more good than honking one’s horn in a traffic jam. Nonetheless I worked three unscheduled patients in, and for each one I spent a good deal more time entering data into the computer than I did with the patient. I’ve had lots worse EMRs here in this country (New Zealand’s, MedTech32, stands as a shining ray of hope that we could have a good system), but I have had better, too. It doesn’t stick very much. When I run into a click-and-wait, it doesn’t last more than 20 seconds. Sign on takes less than 3 minutes. But it has design flaws. The button to sign off sits in the top left corner right next to the button used to clear one patient’s chart and move to another. Every drug for every patient comes with a warning, mostly frivolous, but a lot like the boy who cried wolf.

The clinic won’t have it much longer, Cerner will replace it in February.