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March 2015

All My Husband Needed Was a Good Physical Examination

Author Affiliations
  • 1Intersocietal Accreditation Commission, Ellicott City, Maryland
JAMA Intern Med. 2015;175(3):340. doi:10.1001/jamainternmed.2014.7183

My husband had been experiencing tremor in his hands for approximately 2 years. He is 69 years old, had worked for many years for a telecommunications company, and is now retired. The tremors come and go unexpectedly. One night they flared up when he was carving a ham. Sometimes he needed 2 hands to hold a cup of coffee in the morning, and the tremors show up when he writes. We were afraid that he had Parkinson disease.

We went to our primary care physician whom we have known for a long time. He ordered a dopamine transporter (DAT) scan at a local hospital. This required injecting a radiopharmaceutical agent in the veins in a procedure called SPECT (single-photon emission computed tomographic) imaging.

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    1 Comment for this article
    The patient needed a good neurologist, not a DaT scan
    David L. Keller, MD | Internist with Parkinson's disease
    The clinical vignette is a classic story of bad utilization of a test which is ordered far more often than it should be. A good neurologist's history and exam should distinguish nearly all cases of essential tremor (ET) from Parkinson's disease (PD). As these diseases progress, they become more obviously different in their divergent symptoms and response to therapeutic trials of levodopa versus propranolol (the former treats PD, the latter ET). There is no advantage to early diagnosis in either case, since neither condition has a disease-altering treatment available yet. Lastly, in addition to being expensive and "unclear", the dopamine-transporter "nuclear" medicine scan concentrates most of the injected dose of ionizing radiation exactly where the PD patient can least afford to lose more dopamine-producing cells: the basal ganglia. The DaT scan should never be ordered by a non-neurologist, and a PD patient should never consent to this harmful test unless it will make a significant difference to his treatment (and NEVER at the behest of a disability insurance examiner).