DAVID S. DENNIS

100 WEST CONVERSE ST.

WEIMAR, TX. 78962

AGE:4x

DOB: 08-14-19xx

DATE OF DX: 01-18-20xx

LOCATION: METHODIST HOSPITAL

                6565 Fannis St

                HOUSTON, TX 77210

PROVIDER:

DR. CHARLES KERTZMAN SR.,Ph.D.

NEUROLOGY / MOVEMENT DISORDERS SPECIALIS

DIAGNOSIS GIVEN BY DR. CHARLES KERTZMAN SR.,Ph.D.:

(1) MULTIPLE SYSTEM ATROPHY WITH ORTHOSTATIC HYPOTENSION. (ORTHOSTATIC DECREASE OF BLOOD PRESSURE WITHIN 3 MIN. OF STANDING BY AT LEAST 30MM HG SYSTOLIC OR 15MM HG DIASTOLIC)

TILT TABLE RESULTS:

DAVID'S AVERAGE TILT TABLE RESULTS WERE A DROP OF 32MM HG SYSTOLIC, AND 22MM HG DIASTOLIC DROP WITHIN 3 MIN. (1-18-2008)

(2) HEARING IMPAIRED. (RIGHT EAR HEARING LOSS IS 130dBA / LEFT EAR HEARING LOSS IS 125dBA). THIS HEARING LOSS IS CAUSED BY ATROPHY OF DAVID'S TEMPORAL LOBES AS SEEN ON 1-18-2008 PET SCAN. (ABR AND PET SCAN WERE GIVEN TO DAVID ON 1-18-2008). LEGALLY DEAF AS DEFINED BY SOCIAL SECURITY IS 90dBA HEARING LOSS IN BEST EAR.

ADDITIONAL INFORMATION CONFIRMING PROBABLE DIAGNOSIS OF MSA:

** PRESYNAPTIC NIGROSTRIATAL DOPAMINERGIC DENERVATION ON PET SCAN. (NIGROSTRIATAL DYSFUNCTION IS A STRONG INDICATION OF SHY DRAGER SYNDROME). ALSO PET SCAN RESULTS SHOWED REDUCED 18F-6-FLUORODA UPTAKE INDICATING NIGROSTIATAL DYSFUNCTION. (THIS IS 2 AREAS OF PROOF AS SHOWN ON PET SCAN THAT DAVID INDEED HAS PROBABLE MULTIPLE SYSTEM ATROPHY DISEASE).

DAVID DENNIS IS DOMINANT MSA-P, MAKING HIS DIAGNOSIS CATEGORY AS PROBABLE MSA-P. PATIENTS WITH MSA-P SHOW MORE SEVERE AND WIDESPREAD COGNITIVE DYSFUNCTIONS THAN PATIENTS WITH MSA-C (CEREBELLAR ATAXIA). OUR MAYO CLINIC STUDIES ALSO INDICATE THAT COGNITIVE DYSFUNCTIONS IN PATIENTS WITH MSA-P MAY BE ASSOCIATED WITH PREFRONTAL BRAIN INVOLVEMENT.

DAVID DENNIS'S DIAGNOSIS IS BASED OFF THESE TESTS:

(1) (VEP): VISUAL EVOKED POTENTIALS. RESULTS SHOWED DOUBLE VISION, AND BLURRED VISION. (THIS IS CALLED VISUAL DISTURBANCE).

(2) (ENG): ELECTRONNYSTAGOGRAPHY WAS UTILIZED ON MR. DENNIS. RESULTS SHOWED DIZZINESS AND BALANCE PROBLEMS.

(3) (PET): POSITRON EMISSION TOMOGRAPHY. RESULTS SHOWED 2 MAJOR INDICATIONS OF SHY DRAGER SYNDROME. MR. DENNIS SHOWED REDUCED 18F-6-FLUORODA UPTAKE INDICATING NIGROSTRIATAL DYSFUNCTION. MR. DENNIS'S PET SCAN ALSO SHOWED PRESYNAPTIC NIGROSTRIATAL DOPAMINERGIC DENERVATION.

ATROPHY ON PET SCAN OF PUTAMEN, MIDDLE CEREBELLAR PEDUNCLE, PONS, AND CEREBELLUM. (ALL AREAS ARE SHOWING SHRINKAGE SIGNS. **THIS CAN BE MISSED ON CT AND MRI TEST SCANS.

(4) (ABR): AUDITORY BRAIN-STEM RESPONSE. TEST RESULTS SHOW: RIGHT EAR HEARING LOSS IS MEASURED AT 130dBA. LEFT EAR HEARING LOSS IS MEASURED AT 125dBA. (LEGALLY DEAF IS 90dBA IN BEST EAR.) ** THRESHOLD OF PAIN STARTS AT 125dBA.

DAVID'S LOSS OF HEARING IS CAUSED BY ATROPHY IN THE TEMPORAL LOBES AS SEEN ON PET SCAN. (ALSO ATROPHY IN THE BRAINSTEM ENOUGH FOR LOSS OF HEARING).**MORE DETAILS ON TEMPORAL LOBES ARE LISTED BELOW.

(5) VALSALVA TEST WAS NOT NORMAL. (STEADY PRESSURES WERE OBTAINED ON BOTH HEARTBEAT, AND BLOOD PRESSURE). NORMAL RESULTS WOULD HAVE SHOWN INCREASED BLOOD PRESSURE AND HEARTBEAT.

(6) PLATFORM TABLE BLOOD PRESSURE TEST. THIS TEST WAS HELPFUL WITH THE DIAGNOSIS OF ORTHOSTATIC HYPOTENSION. RESULTS SHOWED DECREASED BLOOD PRESSURE WHILE STANDING.

(7) AUTONOMIC FAILURE INVOLVING URINARY INCONTINENCE. MR. DENNIS HAS INABILITY TO CONTROL THE RELEASE OF URINE FROM THE BLADDER. (WHEN HE EMPTIED HIS BLADDER WE STILL MEASURED 225 ML STILL LEFT IN BLADDER WHEN GIVEN THE ULTRASOUND). URINARY RETENTION AND INCONTINENCE RELATED PROBLEMS.

PATIENT DAVID DENNIS'S SYMPTOMS BEGAN ON JUNE 23, 2007 WITH URINARY RETENTION, RIGHT SIDE WEAKNESS, AND SEVERE HEADACHES FROM NECK AND SHOULDER PAINS. (OFTEN THESE ARE STARTING SYMPTOMS OF MULTIPLE SYSTEM ATROPHY. AS A SHORT TIME PASSED BY MR. DENNIS NOTICED HIS RIGHT HAND TREMOR STARTED, AND LATER ALL HEARING WAS LOST.

OTHER SYMPTOMS FOR MR. DENNIS:

INSTABILITY & BRADYKINESIA. (NEEDS CANE FOR SUPPORT AT THIS TIME).

RAPID PROGRESSIVE PARKINSONISM.

RIGHT SIDE TREMEXTRAPYRAMIDAL PARKINSONISM SUCH AS; RIGIDITY, POSTURAL, TREMOR.

COORDINATION PROBLEMS. (CEREBELLAR OCULOMOTOR DYSFUNCTION).

HYPOMETABOLISM ON PET SCAN IN PUTMAN, BRAINSTEM, AND CEREBELLIUM.

SPEECH. (LOW VOLUME, SLURRED, REPETITIOUS)

GENERALIZED LEG WEEKNESS.

DEMENTIA. (LONG-TERM MOSTLY)

CONSTIPATION. (BOWL DYSFUNCTION)

URINARY RETENTION. (BLADDER DYSFUNCTION)

GAIT ATAXIA

PRESYNAPTIC NIGROSTRIATAL DOPAMINERGIC DENERVATION ON PET SCAN.

*** INFORMATION ON CAUSE OF HEARING LOSS: TEMPORAL LOBE ATROPHY***

(ATROPHY IN TEMPORAL SEEN ON 1-18-2008 PET SCAN):

TEMPORAL LOBE INFORMATION:

EIGHT PRINCIPLE SYMPTOMS OF TEMPORAL LOBE DAMAGE. (1) DISTURBANCE OF AUDITORY SENSATION AND PERCEPTION. (2) DISTURBANCE OF SELECTIVE ATTENTION OF AUDITORY AND VISUAL INPUT. (3) DISORDERS OF VISUAL PERCEPTION. (4) IMPAIRED ORGANIZATION AND CATEGORIZATION OF VERBAL MATERIAL. (5) DISTURBANCE OF LANGUAGE COMPREHENSION. (6) IMPAIRED LONG-TERM MEMORY. (7) ALTERED PERSONALITY AND AFFECTIVE BEHAVIOR. (MOOD SWINGS). (8) ALTERED SEXUAL BEHAVIOR.

PROGNOSIS:

THERE IS NO REMISSION. THERE IS NO CURE. PROGNOSIS IS: DEATH IN 6-10 YEARS.

MSA IS GRADUALLY PROGRESSIVE AND USUALLY FATAL. MSA IS ASSOCIATED WITH DETERIORATION AND SHRINKAGE OF PORTIONS OF THE BRAIN. (CEREBELLUM, BASAL GANGLIA, AND BRAINSTEM).

THERE IS NO KNOWN CAUSE FOR THE DISEASE. TREATMENT OF MULTIPLE SYSTEM ATROPHY INVOLVES A COMBINATION OF MEDICINE, SPECIALIZED EQUIPMENT, AND THE USE OF THERAPISTS TO MANAGE INDIVIDUAL SYMPTOMS. YOUR TREATMENT WILL USUALLY BE MANAGED BY A NEUROLOGIST OR PHYSICIAN WHO SPECIALIZES IN MOVEMENT DISORDERS OR AUTONOMIC DISORDERS.

I understand this is a devastating diagnosis to receive, and I am sorry I could not give a more optimistic prognosis. Symptoms however, can be controlled or made somewhat better. The target for your health care should be the maintenance of your quality of life through the relief of suffering, and this is best achieved through close contact with your GP.

Dr. Charles Kertzman Sr.,Ph.D.
Neurology / Movement Disorders Specialist