DEAR DR. ROACH: I am a 70-year-old white male. I work full time as a veterinarian, teach two aerobics classes and take a weekly class for strength training. In the past three weeks, I have fallen twice -- once just walking in the airport. It was sudden and scary. Over the past five to six months I have noticed a loss of balance greater than what I could blame on past injuries and surgeries. When standing still, I am constantly fighting for balance, and feel like I will tip over. After yesterday's fall, I researched balance issues, and Parkinson's disease seems to be a common cause. I tried doing the "balance beam" test and failed miserably. I will be seeing my primary doctor in a few weeks, and this will be a topic of conversation. What other conditions should I be considering as possible causes for the increased loss of balance? I dread the thought of falling and injuring myself so that I can't work. -- J.F.
ANSWER: A progressive loss of balance needs evaluation. There are many causes (my textbook lists over a hundred, and although Parkinson's disease can cause instability and falls, it usually does not do so until relatively late in its progression. Your symptoms are more concerning for ataxia, a type of loss of motor control that often comes from disorders of the cerebellum, a large structure in the base of the brain that controls coordinated movement.
I would not wait a few weeks to see your primary doctor: I would see your doctor sooner, or go directly to a neurologist.
DEAR DR. ROACH: I have something to say to health care providers: Please do a physical exam on your patients. I have taken my dad to many appointments, and all the doc does is chit-chat, pat and send him away. I have no idea what is written in their notes. I had to make one doctor look at his feet a couple of years ago, but he did a poor exam. In the past three months, my father has been to two geriatricians, one gait doctor, a nurse practitioner and a host of physical therapists, in part for this gait disorder. No one examined his feet or tested his sensation -- so I did. He has greatly diminished sensation; long, infected nails; painful calluses; and three toes with open areas of infections between them. Twice, his hemoglobin has dropped, with no resultant GI exam of any sort. He has been on medication that can cause neuropathy for years, but no one has monitored that.
Doctors, your clinical judgment needs to be supported by a physical exam. With limited time for visits, health care providers must make time for both. Patients, insist on an exam! -- L.T.C.
ANSWER: I agree with you. I know many doctors do not do a regular exam, and I can't defend this. It's true that the history most often leads to the diagnosis, but the physical is important for everybody -- especially older and sicker patients. Doctors may be friendly, but in the office, our patients are our patients, not our friends. That means taking clothes off and doing an appropriate examination. It also means keeping an unbiased ear open for concerns and acting on them. We like to say that everything is OK, but sometimes it isn't, so knowing when to look further is a critical skill.
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