DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: We are seeing the patient in followup visit. He is a (XX)-year-old man with several problems.
1. Parkinsonism, most likely multiple system atrophy with camptocormia, Pisa syndrome. The patient responded well to high doses of L-dopa.
2. Enlargement of the ventricles of the brain, no benefit after large volume spinal tap in the past.
3. Fiber neuropathy.
4. Autonomic dysfunction.
We had not seen the patient for three years. He is coming in today with his wife and his daughter. In the interim, he had been seen by Dr. John Doe and also Dr. Jane Doe for question of myopathy. Dr. Jane Doe felt that the symptoms are not typical for myopathy. She recommended a possibility of repeat EMG and muscle biopsy, but the patient declined.
There have been several changes in the last three years. The patient’s gait deteriorated further. He is having more of a shuffling gait with multiple freezing episodes. He is using a walker or he holds onto the furniture. He reports no falls, but he is very cautious. He also lost significant amount of weight, approximately 40-50 pounds, within the last two years. He has a good appetite.
The patient denies any cognitive changes or visual hallucinations. He denies any swallowing difficulties. He denies any tremor.
PAST MEDICAL HISTORY: Notable for atypical parkinsonism, most likely multiple system atrophy; prostate cancer; hyperlipidemia; right-hand Dupuytren’s contracture; hypothyroidism; hypertension; neuropathy; enlargement of the ventricles, but no improvement after spinal tap.
MEDICATIONS: Sinemet 25/100 mg 3-1/2 tablets at 7:00 a.m., 2 tablets at 11:00 a.m., 2-1/2 tablets at 3:00 p.m., and 3-1/2 tablets at 8:00 p.m.; Sanctura; diazepam; Synthroid; aspirin 81 mg; Allegra; and calcium.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY AND FAMILY HISTORY: Reviewed and is unchanged from previous note.
REVIEW OF SYSTEMS: Notable for weight loss, urinary incontinence, constipation, problems with ambulation, insomnia. The patient denies any cardiovascular problems. Occasional cold hands. The rest of the review of systems is negative.
PHYSICAL EXAMINATION: On examination, the patient is a very pleasant man in no acute distress. He is sitting in the wheelchair. His blood pressure is 132/62, pulse 66, respirations 18. He has prominent choreiform dyskinesias in all four extremities. He also has orofacial dystonia with mild spasm in the platysma and jaw dystonia. He has hypophonic speech. He has decreased upgaze. His face is symmetrical. Tongue is midline. He has generalized bradykinesia rated as 1 on all tasks in the upper extremities, very symmetrical picture. He has bradykinesia in the lower extremities rated as 0.5. He does have pretty normal tone. He can stand up with problems; we had to help him. We were able to walk part of the corridor with significant problems. He was taking very short steps; he was not responding to verbal cueing. He also had Pisa syndrome with tilt of the trunk to the right side. He had mild antecollis.
IMPRESSION:
1. Multisystem atrophy: He deteriorated quite significantly but still seems to have response to high doses of Sinemet. Because he is taking the medication every four hours, we would like to change it and give him same dose of L-dopa during the day, but every three-hour intervals. He will take the medication at 7:00, 10:00, 1:00, 4:00 and 7:00. He will take 2-1/2 tablets in the morning and 2 tablets, 2-1/2, 2-1/2, and 2 tablets. We are also adding Sinemet CR 25/100 mg at bedtime. He will start with 1 tablet and we might increase to 2 tablets. We might also try Azilect in the future to see whether it might help his freezing gait.
2. Weight loss: Unclear etiology.
RECOMMENDATION AND PLAN: As above. The patient’s wife will call us in approximately three weeks to report whether he had any benefit. He will be seen in approximately four months.
