CASE 38 - Tremor

Question 1

Do you think I will get better?

Answer 1

I think your tremor will improve with medication, but I don’t know how long the improvement will last.

The tremor may be a sign of a larger movement disorder called Parkinson’s disease, and we need to do some additional evaluations to explore that possibility.

Question 2

Specific Qs:

Answer 2

1. Context.
2. Associated Sx ==> Falls, HAs, TIA sx, drooling, changes in voice or handwriting, difficulty with ADLs/IADLs, depression, constipation, rash etc.
3. Previous episodes.
4. Caffeine intake.
5. Alcohol use.

Question 3

PEx:

Answer 3

1. CV ==> A.
2. Chest ==> A.
3. Neuro ==> Mental status, CNs, Motor exam (including muscle tone), DTRs, cerebellar, gait, sensory exam.

Question 4

DDx:

Answer 4

1. Parkinson’s disease.
2. Essential tremor.
3. Physiologic tremor.
4. Midbrain lesion.
5. Drug-induced tremor.
6. Psychogenic tremor.
7. Wilson.
8. Hyperthyroidism.

Question 5

Workup:

Answer 5

1. MRI brain.
2. TSH.
3. Heavy metal screen.
4. Ceruloplasmin, slit lamp exam for Kayser-Fleischer rings, AST/ALT, CBC, 24h urinary copper, liver Bx.