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CASE PRESENTATION
A patient was well until 3 years prior to review when she developed a right upper extremity resting tremor. The tremor became progressively more severe over the next year and she had difficulty with writing, knitting, and gardening. A year and a half later, she experienced difficulty using her right leg, and she developed an asymmetric impaired gait. She described a feeling of “restlessness” throughout the right side of her body that was not present on the left.
One year prior to review, she began using a cane for ambulation and then 8 months later transitioned to a walker. She would drag her leg and seemed unable to bear weight on it. She had some falls a year prior, but no recent falls, as her mobility was very limited. She denied symptoms of REM sleep behavior disorder or constipation. She had occasional bladder urgency without incontinence but no orthostatic hypotension. She denied involuntary movements, alien limb phenomena, or sensory changes involving the right side. She did not feel truly weak; rather, the right side of her body “doesn’t do what she wants it to do.”
When initially evaluated, the patient was diagnosed with Parkinson disease (PD). Initially no treatment was implemented, but subsequently, pramipexole was initiated. She discontinued this following a brief trial when she read about possible side effects. One year later, she received a second neurologic evaluation and was again diagnosed with PD and therapy with levodopa/carbidopa was initiated. Again, she discontinued this medication because of concerns regarding possible side effects. The trial was brief, and of uncertain benefit. Following a third neurologic evaluation, she was started on amantadine, which was discontinued because of drowsiness.
She had no cognitive impairment but had become depressed and was crying frequently.
Her past medical history was significant for hypertension, fibromyalgia, hypothyroidism, …
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