Neurologist exam this morning, 1/9/2020, review:
I was diagnosed 2012
Bedtime C/L 50-200 ER: Because it is ER, I take with or w/o food.
5 x day C/L 25 - 100 IR: 6:30, 9:30, 12:30, 3:30, 6:30
B1 (8 am 2g, and 12:30 pm 2g) vitamin B1 as thiamine HCL. 500mg, easy swallow capsules
Assessment and Plan:
1. Parkinson’s disease – This very pleasant 72-year-old gentleman who has at least an eight year history of tremor specific Parkinson disease H and Y stage II has overall done very well in his clinical course. However, I think that we could try to work on medical treatment of his tremor. At this time (referring to thirty days earlier) taking no more than four hundred mg total of carbidopa levodopa separated by 12 hours. Have spoken to husband and wife that levodopa definitively most helpful with tremor over any other dopamine agonist or amantadine and that we await for him to optimize this first. (see current/optimization dose recommendation at beginning of this note). Additionally, his disease type would also respond very well to DBS (considering that levodopa is effective for his tremor)
Encouraged to take 50/200 ER at his usual bedtime of about 10:30 at night explaining to him that it would be better physiologically for him to not go 12 hours without C/L. As an alternative, did suggest that he could take short acting C/L if he gets up in the early morning to go to the bathroom and then goes back to bed.
2. REM sleep behavior disorder – We spoke today about the fact that he has somewhat violent dreams at night. We talked about the use of melatonin. To take 10mg of melatonin about 6:30 when he takes his evening dose of C/L. After a week they do not see an improvement in this, they are going to get in touch with me and we will try clonazepam.
3. Neuropathy – patient complains of numb toes. Is already taking supra tx doses of B1. All labs that we ordered in between this visit and last including ESR, CRP, SPEP, ANA, vitamin B12 and folate have returned normal. Thyroid function had been tested prior to this visit was normal. Suggest that this is likely idiopathic especially since it has been ongoing for some time. Explained to family about this and offered handout on this very unfortunate common condition. Suggested vitamin D3 supplementation 2000 IU to 4000 IU daily. Also emphasized that supratherapeutic doses of D3 can be harmful.