HISTORY OF PRESENT ILLNESS: We are asked to see this (XX)-year-old gentleman with question of mild Parkinson disease.
The patient was admitted after acute hospitalization for abdominal pain. He previously had been hospitalized for sepsis and pneumonia secondary to aspiration in May. A PEG had been placed because of the aspiration, etiology of dysphagia was worked up again and felt to be unclear, either neurogenic or related to significant deconditioning.
He gradually improved during his hospitalization and then he was transferred here for further care.
He had been diagnosed by Dr. John Doe with a mild Parkinson disease and started on Sinemet sometime over the last few months, precise date unknown.
He had reported dropping trays and having difficulty with his balance while attending to his wife every day at the nursing home where she lives. He is still able to drive and denied any difficulty with his memory; although, he said swallowing has been a problem for an unknown duration. He denies drooling.
PAST MEDICAL HISTORY: Significant for his PEG placement, significant cardiomyopathy, and decreased ejection fraction, around 25%, due to ischemia, questionable apical thrombus, and tricuspid and mitral regurgitation in the past. He also had prior atrial fibrillation.
SOCIAL HISTORY: The patient lives in an extended care facility where his wife is. She has been institutionalized with dementia. He apparently drives.
CT was done of the chest, but no MRI and no imaging was done.
MEDICATIONS: Sinemet regular one tablet t.i.d., Diflucan, Lasix 80 mg b.i.d., pantoprazole, Zosyn, Flagyl, Cipro, Augmentin, Levaquin, potassium, amiodarone, and metered albuterol.
PHYSICAL EXAMINATION: Alert and oriented. Simple attention is intact. Speech is fluent and not hypomimic. He is able to give me a reasonably good history. I saw no discrepancies in his history giving from the chart. Language is fluent, and insight is good.
His cranial nerve examination is remarkable for psychotic pursuits. Otherwise, he has a symmetric face, mildly positive glabellar reflex, and fundi were poorly visualized.
Motor examination shows no cogwheeling, no tremor, minimal rigidity, mildly positive grasp and palmomental reflexes. Lower extremity reflexes are absent. Toes are down or nonreactive, and he has no cerebellar ataxia. Gait was not examined.
IMPRESSION: Mild Parkinson disease. Therapist reports he did fairly well with his ambulation and bed mobility today.
RECOMMENDATION: He was a bit lightheaded and this may be on the basis of his Sinemet. It is therefore reasonable to consider decreasing the dose since he has a very mild finding consistent with Parkinson; although, it may be at treated state right now and may be worse if we drop this dose.
The best thing to do is to try and see how he goes during his hospitalization here.
In terms of his dysphagia, it appears to be on the basis of global weakness, but there is a possibility that some of this is due to the Parkinson disease and abnormal coordination of his swallow. Unfortunately, that will only respond to adequate medication management and response.
We will continue to follow him and see how he does with his medication regimen. We have no other suggestions in his care for now.
