Tremor

Question 1

Patient presents with tremor.

Impression/DDx/Goals

Answer 1

Impression:
Vague and non-specific presentation. Would require thorough assessment to rule out key differentials:
- Parkinson’s disease - resting ‘pill-rolling’, resolving with
- Thyrotoxicosis
- Hypoglycemia
- Alcohol withdrawal/Wernicke’s encephalopathy
- Multiple sclerosis
- Cerebellar tremor - MS, stroke, alcohol/drug related damage, malignancy, infection
- Lewy body dementia
- Wilson’s disease
- Chronic disease (asterixis) → liver failure, respiratory failure, renal failure
Common
- Essential tremor
- Enhanced physiological tremor

Goals of management:

• Rule out red flag differentials
• Initiate appropriate management

Question 2

Tremor - History

Answer 2

History

• Sx: characterise actual sx of tremor (intention, resting, etc) RED FLAG: parkinsons (bradykinesia, tremor/rigidity, personality/emotional changes, anosmia, autonomic dysfunction etc)
• Intention vs resting
• Fam Hx: resting tremor, other neurological
• SNAP: focus on alcohol history

Question 3

Tremor - Examination

Answer 3

Examination:

• Neurological examination: cranial, UL, LL, gait
• Cerebellar tests
  - Dysdiadokokinesis
  - Ataxia
  - Nystagmus
  - Intention tremor
  - Slurred/staccato speech
  - Hypotonia
• Abdominal/gastro

Question 4

Tremor - Investigations

Answer 4

Investigations:

• Bedside → BSL, BP
• Bloods → TFT, LFTs (alcohol withdrawal, wilson’s disease)
• Imaging → MRI brain

Question 5

Tremor - Management

Answer 5

Dependent on aetiology

• Parkinsons: Trial dopamine therapy → Levodopa+carbidopa are first line
• Essential tremor → beta blockers (propranolol)