Hello there hello I'm doctor roberts I'm calling you doctor miller from 1 of the medical instructors it's a pleasure to meet you I'm good sir how are I'm just are you in the middle of or you've just produced I'm I'm just if you're in the middle of then I'd to come back no no I've had a pretty good initial oh that's good news to know that so I'm lucky I was hearing all about you from john that was why I come and see you in the past thank you that's excellent I'd be very pleased to do that could you just want me to run through what I had a little bit about it yeah and I read your gp record as well so tell me tell me okay so the reason it's actually very good with you've got to look at my body so I'm check my phone the worth of being in terms of sort of jumping out to to war yeah and sort of quite sort grossly but and and relying on things around for reasons tell me about that well he's well he's sort of the leg sending the instructions but he doesn't wanna do anything around it by he changed the instruction then he'd start to move do you feel like the capture from your instruction is delayed or is it that it's that the role has to be giving the wrong instruction I guess it's for the well the the right instruction to do but it it was the wrong 1 slightly I see thank you and then you know it's now I've I've gained some lot there within a minute june I've lost control of her which is completely new there and then then just just be in in bed you know you sort of do a certain kind of roll on the pillow to to get lined up with your pillow shuffle there's only so many like I can bend my back mhmm and I can bend my arms but other muscles like you you bummed tell me about your life in general did you ever hate me this is why I couldn't stand and how's your wife she's been fed over all that oh so I've cancer this time mhmm which is a short term around the half of our 30 outfit okay oh interesting what are things that digestive power as well is that all you're you're all on the work stuff you're checking for I'm doing a little bit of you're feeling thinning up and you feel like they're weight as well absolutely yeah I think I was really weak arms are like this at the boxer really strong 20 40 arms are are like this really strong go ahead and be weak arms are like this and your fingers are playing apart don't really push me together thumb to little finger you don't really pull it apart no it's weak I don't really yeah thumb to little finger I'm really weak thumb sorry to little again thumb to little finger that's fine and on your own I think just relax if you can I won't got you on I promise just test your sensation feeling a bit more here here yeah here yeah and here yeah so feel the same on both sides yeah alright so just test your feeling if there's vibration can you feel this vibrating yeah tell me when it stops do you feel it vibrating yeah you've got to use your sensation just now test your coordination can you your head like this yes perfect yes lift up toe and nose look present base so I'll show you now stop I'm gonna check a few of things though pop your finger to your nose very amazing you touch my finger and then I'll go to your lips 2 I think I don't know 2 and 4 very good close finger very good just look at the back of look at your eyes if that's alright and keep your eyes open and just follow my finger look at my finger over here uncomfortable at all extreme sufficient no you still need to keep your eyes open or is it just a bright light it's got a bright light got a a mound of dust in there oh sorry much much dust I'm just gonna send you a letter I already did the same thing good no you let's arrow in your legs can you lift this leg up good don't let me push it down that's good just lift it up don't let me push it down perfect and bring your hand into the bed good bend your knees up and again bend your knees up I'm in you're kicking me away yeah obviously come out and I will be definitely that's fine you're messing up now yeah let's just see down on me push down on the car pedal not the car pedal up towards your head just take a second just try to relax and let it be done that's fine just look down a little brisk any feeling on the bottom of your foot feeling yeah very good mhmm I'm gonna get a little of this for me putting your fingers together and then nice and open turn the other side in terms of coordination you lift this leg up into the first turn up to your knees heel to knee heel slide down your shin kick to my hand back up to your knees down here you apply it down your shin kick to your hand yep can you see you on your feet alright so as long as you don't know we've come to no the case it's probably not and your neuropsychiatric so just let me try that mhmm right what would you like breathing so this could be good enough could good to see it undertake but obviously taking the measurement process is also possible thank you for protecting my modesty sir gentleman's open I've a great job I'll be able to do the rest of your gown up once you're up doctor sorry doc the other 5 you saw yes can he go back to waiting room temporary it just needs to be but why sorry I didn't know you were waiting no so it's okay there's no medical reason that he needs to be in the no it's just the pressure yeah wounds I guess yeah a fit to sit will be optimal I guess I'll try to say you're getting just because of all the fat stuck but I know it's fat fine but there's nothing that needs to keep him in thank you well I'd like to you to stand by yourself my dear it feels like we're on a ship yeah he did wow it feels like he's on a ship feels like the room's spinning not not spinning yeah just ship mansion let's see a couple of steps then the scanner said they said it was normal but he didn't know he was using his imipril if that means alright not on old days mhmm some days usually you know it does you would you would like to rest up then do you need to take a step back before you sit down right yeah just gonna take a step back yeah we got you yeah we got you and then with your right leg and step back charlie hold tight for record hours bodyguard indeed yeah mhmm and roll down it's gonna be easier now than your legs to breathe yeah we don't want you to slip off and you're gonna get back up a little bit on with that I'm I'm trying I'm get better unfortunately yeah I'm I'm sure not what what's what's behind me but I'm trying to jump onto and there's this like trauma mattress that you know this puppy here which is ideally ideally yeah try to I've studied it for 7 hours today yes it's not not the most comfortable but no it's still the the carotene I think is a little more comfortable than a than a trolley yeah mhmm what kind of gp were you inner city gp and then sydney gp sydney yeah cool whereabouts in sydney so oh what do they call it macquarie centre macquarie centre I think you can eat something there my sister lives in I'm very empty sadly yeah yeah wow so I'm not in sadly but yeah yeah know where macquarie is yeah lovely spot oh yeah you don't fancy working there no no I would fancy it definitely a little bit too far through training to move really oh yeah maybe we're it's a sweet spot isn't it yeah maybe we're having a consultant wife that may be the old strange friends that suddenly they have to see every week in england yes and what can we do to help you be more comfortable back in your bed not not there's lots of things that could be going on normally I do is kind of sit down and jump on the bed and then swing my legs around let's see you then well I can't because it's too high so down and put the stand up and then and then bring the and then do the frog down I don't know what happened with they always turn up but they do whenever you're gonna arrive then that time turn his pants what have I it was good okay much nicer okay and it all started after you changed from sertraline to mirtazapine is it that's my we're all living with sertraline and indapamide so what changed on that day the switch from sertraline to mirtazapine and you also started indapamide they were on indapamide so they switched metazepine to sertraline in the press that's what you think might be causing this you were saying that's what you think causing the hyponatremia or which the was meant to be a short lived yeah and it certainly is your most recent ascidian is normal but it's also short lived because of the distance disability knee socks aren't they oops well it was a bit slippery I'm sorry I just don't want your feet to get cold neurologically examine you your tone does seem slightly increased on your particularly on your left but bilaterally in your arms and you do have some slight rigidity there associated with a tiny resting tremor yeah tiny tiny tiny resting tremor so there's always the possibility of something dopamine related that can be medication related or it can be idiopathic the neurologist to investigate that is very sensible given the concomitant incontinence I guess there's a potential for something like normal pressure hydrocephalus unless we ask that question either way there's not a huge amount of management I'm going to change over the life path that we're going down so we know quite a bit about dopaminergic it's a raised intracranial pressure hydrocephalus it's when some of the brain is affected and sort of turns into a vent track and cause you to become incontinent management is primarily focused on rehabilitation really but there's also some methods that they use to try and decrease the size some people have shunting to try and take something neither are great things to have could be wrong and I don't think I have something clearly pointing either way think there are possibilities and I think seeing a neurologist is worth it given what's going on with your mood and what you're experiencing prior to changing your medicine in terms of other tests I don't think there are any other tests that you need to have weakness so investigating for a neuropathy or a change in psychiatric medicine which might be sometimes that can make you feel weak I'll ask the physiotherapist to see you to do a full look does that sound like a reasonable plan going forward no thank you for your date on the file and would you agree that's your upcoming experiences and your thoughts are going to return to family no no great you I feel skeptical no you're great sexual so thank you for it no good I lost that before okay and did that happen yeah okay of algorithm because the problem with the problem is that it's likely to be so does have a better coverage test and possibly being on the brightness level around your left so it has a vast lack of pain mhmm monoclonal is slight slight resting tremor but it can be a strange decrease in the blood then a placenta the left bundle is a strange part of this classifying so examination findings lead pipe rigidity and very subtle cogwheeling on the right arm with slightly increased tone in the left arm also power 5 out of 5 throughout reflex is slightly brisk throughout normal sensation slight dis didokinesia bilaterally no other cerebellar signs lower limbs power normal tone increased bilaterally reflex is slightly brisk bilaterally throughout downgoing plantars normal coordination but not able to stand and not able to assess gait as patient feels like he's on a ship dizzy and not able to move legs well with not moving not lifting the foot on trying to take a step on general appearance he has an expressionless face and a monotone voice impression is neuropsychiatric presentation with evidence of increased tone raising the possibility for parkinsonism for further review by the neurology team other differential including reaction to medication changes with mirtazapine and so recommend review with the psych team also to ascertain whether this medicine could cause this kind of picture no no evidence of hydrocephalus normal sized ventricles on recent ct head so normal pressure hydrocephalus seems less likely in that context however the combination of neuropsychiatric symptoms poor mobility and incontinence does raise this as a possibility