SUBJECTIVE: The patient returns with her son for followup of Parkinson’s disease. In the interim, we increased her Sinemet to 25/100 mg 1-1/2 tablets 3 times a day. She feels like she is doing very well. She is independent in her activities of daily living and ambulates independently. She has had significant improvement in all of her symptoms of parkinsonism over the last few months.
She has had no further episodes of presyncope or syncope. She is trying to take fluid and salt liberally. Her tremor is present mildly and only intermittently. It is primarily in the right hand. She continues to do tai chi twice a week and works out on the treadmill twice a week.
She denies depression, hallucinations, delusions, cognitive changes, dysphagia, dysarthria, hypophonia, freezing of gait, falls, sensory changes. She has mild bladder urgency. She also has mild constipation, which improves with the Rancho recipe.
MEDICATIONS:
1. Sinemet 25/100 mg 1-1/2 tablets t.i.d.
2. Naltrexone 5 mg nightly.
3. Coenzyme Q10 1200 mg a day.
4. Vitamin C.
5. Vitamin D.
6. Melatonin.
7. DHEA.
8. Memory Essentials supplement.
9. Magnesium and calcium supplement.
10. Acetyl-L-carnitine.
OBJECTIVE: The patient is a pleasant, well-groomed woman in no acute distress. Blood pressure is 98/60, pulse 78, respiratory rate 18. Affect is appropriate. She has only slight facial masking and much better facial expression today than at last visit. Extraocular movements are intact. Voice is of normal volume. Myerson’s is absent. Tone in the neck is trace increased. There is slightly reduced shoulder shrug on the right. There is a moderate amplitude intermittent rest tremor in the right upper extremity, which is infrequently present and less than the last exam. There is just a slight action tremor in the right upper extremity as well.
She has mild rigidity in the right upper extremity scored as a 1 on the UPDRS scale. On the left, she has just slightly increased tone in the left upper extremity scored as a 0.5. She has very mild bradykinesia bilaterally scored as a 1 on the right and a 0.5 on the left. Toe tapping is intact bilaterally. She rises from a chair easily without using her arms. Posture is erect. There is slight re-emergent tremor in the right upper extremity when she walks. Arm swing is intact. Pull test is negative.
Autonomic reflex testing revealed orthostatic changes with tilt of the bed. Supine blood pressure during the test was 126/62. When head was tilted up, blood pressure initially reduced to 118/66 with a heart rate of 96. Seven minutes tilt up, her blood pressure was 112/68 with a heart rate of 96. She complained of nausea at that time. It was found that she had an abnormal autonomic reflex study with evidence of cardiovagal dysfunction. There was also mild abnormality in sweat noted. There was no evidence of postganglionic sudomotor sympathetic function or adrenergic cardiovascular function.
ASSESSMENT AND PLAN: This is a (XX)-year-old woman with Parkinson’s disease and orthostasis.
1. Parkinson’s disease: She has really been doing quite well with a slight increase in her dose of Sinemet, and we would like her to continue on Sinemet 25/100 mg 1-1/2 tablets t.i.d.
2. Orthostasis: Though she has been asymptomatic since I saw her last, she continues to have low blood pressures, and tilt table test does show evidence of orthostatic changes. Given the fact that the Parkinson’s disease and the Sinemet combined can conspire to lower blood pressure further and in the future she will likely need increase in her dose of Sinemet, we would like her to start midodrine. She will start at 2.5 mg in the morning and increase after 1 week to 2.5 mg in the morning and 2.5 mg at noon. She will follow up with me in four months.
