Tremor

Question 1

Probability diagnosis

Answer 1

Benign essential (familial) tremor

Senility

Physiological

Drugs: adverse effects, withdrawal

Parkinson disease (incl. drug-induced PD)

Anxiety/emotional

Alcohol

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• cerebral infarction → Parkinsonism

Infection:

• meningoencephalitis
• tertiary syphilis
• Cancer/tumour:
• cerebral tumour (frontal lobe)

Other:

• toxicity from organ failure (kidney, liver, lungs)

Question 3

Pitfalls (often missed)

Answer 3

Cerebellar disease

Multiple sclerosis

Alzheimer dementia

Uraemia of kidney failure

CO2 retention of respiratory failure

Hepatic failure

Rarities:

• hepatolenticular degeneration (Wilson disease)
• lesion of midbrain (red nucleus)

Question 4

Masquerades checklist

Answer 4

Drugs;

withdrawal e.g.

• opioids
• stimulants
• illicit agents
• benzodiazepines
• caffeine
• alcohol

adverse reactions e.g.

• sympathomimetics / agonists
• lithium
• phenothiazines
• valproate
• amiodarone
• alcohol

Thyroid/other endocrine:

• hyperthyroidism
• hypoglycaemia
• phaeochromocytoma

Question 5

Is the patient trying to tell me something?

Answer 5

Anxiety (esp. hyperventilation), conversion disorder (‘hysteria’).

Question 6

Key history

Answer 6

Nature of the tremor:

• resting
• intention
• postural (action)
• pill-rolling
• flapping (asterixis)
• hysterical
• mixed

Family hx of tremor

Evidence of cognitive changes or other neurological problems

Systems review: respiratory, cardiac, liver, kidneys

Drug history: prescribed, OTC, illicit drugs, alcohol, caffeine

Question 7

Key examination

Answer 7

General appearance and vital signs

Respiratory, cardiac, abdominal (esp. liver) and neurological examination

Question 8

Key investigations

Answer 8

FBE and ESR

thyroid function tests (?hyperthyroidism),

LFTs

pulse oximetry/blood gases

drug screen

MRI.

Question 9

Diagnostic tips

Answer 9

Essential tremor eased by a small quantity of alcohol.

Triad of essential tremor: postural or action tremor, head tremor, positive FHx.

Look for Parkinson tetrad: resting tremor, bradykinesia, rigidity, postural instability.

Look for cerebellar tetrad: intention tremor, dysarthria, nystagmus, ataxic gait.

Typical drugs that induce Parkinsonism are phenothiazine, butyrophenones, reserpine.