John was a 70-year-old gentleman who loved long morning walks and tending to his yard. After working for nearly 50 years, he had come to enjoy his post-retirement life. On every Valentine’s Day, he held his wife’s hand and took a long evening stroll with her. Their walk concluded with a trip to the ice cream parlor on the corner. They had been married for 40 years and this was their favorite tradition on Valentine’s Day.
For the past three years, his wife had noticed that his walking was not quite the same. He had become slower and clumsier. Initially she thought that this was due to his age, but then his health gradually deteriorated to the point of concern. He had numerous falls resulting in rib fractures, a hip fracture, and even a hematoma around the brain. His wife noticed his forgetfulness and uncharacteristically slow thinking. After seeing five physicians and undergoing multiple imaging studies of his brain and spinal cord, he came to see me. He used a wheelchair and needed help with all of his daily activities. His wife lamented that he was not the same man she knew all these years.
As I examined him, I noticed that the strength in his legs was normal as well as his legs’ sensation. He was slow in his responses but still sharp-witted and the rest of the exam went on as normal. Then, I made him walk. As soon I saw him walk I knew what was ailing him. His gait was what we call a ‘magnetic gait’ whereby patients don’t lift their feet off of the ground; it’s as if there is a magnet stuck under their feet that is pulling them towards the ground. This is characteristic of a condition called ‘normal pressure hydrocephalus’ where there is an excess buildup of cerebrospinal fluid in the brain.
At the end of the interview John told me his only wish was to walk again so that he can take his wife out for an ice cream on Valentine’s Day. He then had a large volume spinal tap and about 40cc of spinal fluid was drained. Immediately following that, and to everyone’s amazement, his gait significantly improved and he was walking about ‘like the old days.’ This validated my initial suspicion of normal pressure hydrocephalus. He even had an MRI of his brain which corroborated the diagnosis, and finally a shunt was placed in his brain so that the excess cerebrospinal fluid could be drained out.
When I saw him about 3 months later he only needed a cane to walk. With a wide smile he told me that he finally took that evening stroll with his wife on Valentine’s Day and got their favorite treat: chocolate-cherry with sweet-n-tart cherries folded inside homemade dark chocolate Belgian ice cream! The use of technology has become pervasive and many times needed to make a diagnosis. But a good history and a careful exam, especially when technology gives conflicting answers, is still the best tool in a doctor’s bag. Regardless of the technological advances we make, medical histories and exams will remain an indispensable part of the practice of medicine.
Raghav Govindarajan, MD is a neurologist in Columbia, MO