REASON FOR CONSULTATION: Muscle spasms.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who presented to the emergency room yesterday with the above episode. The patient has been seen in the hospital several times this year for various medical problems. His problems include 18 years of advanced Parkinson’s disease and an idiopathic peripheral neuropathy. He also has cardiac history. Investigations regarding his peripheral neuropathy showed no treatable cause of neuropathy found. Overall, the patient has no true dysesthesias but has some numbness in his feet and at times weakness in all four limbs.
The patient’s Parkinson’s disease is advanced, and he is on Sinemet and Mirapex. In addition to this, he has spasms of muscle in his neck causing him to hold intermittent dystonic postures of his neck. This does not affect his chewing, swallowing or breathing, according to the patient. He has had this on and off for many years. He has never tried any Botox injections to the neck. He is seen for further neurologic evaluation.
MEDICATIONS: Mirapex 1 mg five times a day and Sinemet 25/100 mg one and half tablets five times per day. He is on Neurontin 200 mg t.i.d. for his peripheral neuropathy.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient does not smoke or drink. No illicit drug use.
FAMILY HISTORY: Negative for neurologic disease.
CARDIAC HISTORY: The patient has a history of high blood pressure and open heart surgery.
REVIEW OF SYSTEMS: Reveals no chewing, swallowing or breathing difficulties. Vision and hearing are normal. He is not short of breath. He has had no fevers, confusion, seizures, falls or head injuries.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 182/90. This is somewhat labile as he had a blood pressure of 152/80 last night. Pulse 90 and respirations 20. Weight is 182 pounds and stable.
GENERAL APPEARANCE: The patient is in no apparent distress. The patient is a well-developed and well-nourished male with frequent dystonic side-to-side movements of the head with spasming of the platysma muscles bilaterally. He has some facial grimacing as well as facial dystonia as well.
The patient’s signs of parkinsonism include slowness of speech, but he has no hoarseness or whispering voice. He has masked facial expression, mild cogwheeling in the upper extremities, but no increase in tone. He has no resting tremor, and he has a difficult time initiating movement overall.
The patient actually has good strength in all three limbs, including right arm and bilateral lower extremities; although, he did have shoulder surgery on the left, which limits his range of motion and strength there. He has no fasciculations or atrophy in the intrinsic hand muscles, forearms or lower extremities. Sensory examination is intact in all primary modalities, expect over the feet where he has diminished sensation to light touch and vibration consistent with a leg-dependent symmetric peripheral neuropathy. Reflexes are intact in the upper extremities, absent in lower extremities with downgoing toes. There is no sensory level. There are no signs of myelopathy overall. He does have chronic alopecia over the extensor surface of the legs consistent with peripheral neuropathy. Cerebellar exam is normal. Gait is not tested.
Laboratories have been reviewed today showing normal CPK 91 and a slightly high ESR of 14.
IMPRESSION: The patient is a (XX)-year-old with severe Parkinson’s disease and probably overlying cervical dystonia and facial dystonia causing spasms of muscle. He also has an idiopathic polyneuropathy with negative workup this year.
RECOMMENDATIONS: We agree with the rehab inpatient consult, and he will likely need a course of rehab. He should keep his Sinemet and Mirapex as well as Neurontin the same. He states he is not really in pain at this point. We do not suspect a new process, but we think most of his spasms in muscles is either due to overlying cervical dystonia, which is a movement disorder, which can be seen with other movement disorder such as Parkinson’s disease.
We would refer to Dr. Jane Doe. She should be asked to consult for his Parkinson’s disease and management. Potentially, she can also refer the patient for Botox injections, which we think would at least help some of the spasms in muscle, in his neck, and would be safe to do if the patient agrees. The patient states he is interested in this at this point; however, we do not do this. The patient states he is not happy with his visits to the neurologist downtown and would like to change. We think Dr. Jane Doe would be an excellent reference for him as well as potentially do Botox injections to help his muscle spasms in his neck.
For now, we will not change any of his treatment, but would look for treatable cause of neuropathy in about three or four months as this should be done on a yearly basis. This includes a hemoglobin A1c, thyroid studies, B12, folate, homocystine, ESR, ANA panel, Sjogren antibodies, and a serum protein electrophoresis. He may go to rehab when medically stable and should see Dr. Jane Doe over there.
