A 64-year-old man comes to the physician because of a tremor. He first began experiencing a tremor in his right hand two years ago that gradually has involved his left hand. The tremor worsens when he drinks from a glass of water or tries to tie his shoes. His other medical problems include hypertension treated with lisinopril. He does not smoke cigarettes, but drinks occasionally and mentions that his tremor improves with a glass of wine. His father died of old age and had a "movement problem" in his later years. His mother died of breast cancer. He currently lives alone.
His blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 12/min. At rest, he appears comfortable sitting on the examination table. His heart and lung examinations are within normal limits. He is alert and oriented to person, place, and time. He has 5/5 muscle strength in all extremities and has no obvious resting tremor. When asked to touch his finger to his nose, a tremor is present that increases when his finger touches his nose. His head also appears to have a mild tremor as he stands up that decreases once he sits down. His gait appears to be normal.
Which of the following is the most likely diagnosis?

Question

A 64-year-old man comes to the physician because of a tremor.  He first began experiencing a tremor in his right hand two years ago that gradually has involved his left hand.  The tremor worsens when he drinks from a glass of water or tries to tie his shoes.  His other medical problems include hypertension treated with lisinopril.  He does not smoke cigarettes, but drinks occasionally and mentions that his tremor improves with a glass of wine.  His father died of old age and had a "movement problem" in his later years.  His mother died of breast cancer.  He currently lives alone.
His blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 12/min.  At rest, he appears comfortable sitting on the examination table.  His heart and lung examinations are within normal limits.  He is alert and oriented to person, place, and time.  He has 5/5 muscle strength in all extremities and has no obvious resting tremor.  When asked to touch his finger to his nose, a tremor is present that increases when his finger touches his nose.  His head also appears to have a mild tremor as he stands up that decreases once he sits down.  His gait appears to be normal.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's presentation is consistent with an essential tremor (ET), which is the most common cause of postural or action tremors. Resting tremors change with movement and can involve the head and limbs, whereas action tremors remain unchanged with movement. Essential tremors can be familial or occur sporadically with an unclear etiology. Patients typically present with an action tremor (does not occur at rest) without other focal neurological signs. Essential tremor can have varying degrees of amplitude and is evident when the arm is outstretched with an increase in the tremor at the very end of goal-directed movement (e.g., drinking from glass, finger to nose testing). However, there can also be head involvement without dystonia. Treatment usually involves propranolol or primidone. (Choice A) Cerebellar stroke causing a tremor is usually associated with ataxia and dysmetria, which are not seen in this patient. Also, a cerebellar tremor tends to increase steadily as the hand approaches the target, rather than at the end of goal-directed movement, as seen in this patient. (Choice C) Hyperthyroidism usually causes a more acute onset of high frequency and low amplitude tremors than ET. However, this patient does not have other manifestations of hyperthyroidism, such as tachycardia or weight loss. (Choice D) Multiple sclerosis can present with spasticity in the legs, but not usually with a tremor as seen in this patient. (Choice E) Parkinson's tremor is the most common cause of a resting tremor that usually occurs in the legs and hands and decreases with voluntary movement. Educational objective: Essential tremor is the most common action tremor and occurs more commonly with advancing age. It usually involves the hands and arms and worsens at the end of goal-directed movements. Treatment usually includes propranolol or primidone. __________ References: Treatment of patients with essential tremor. (http://www.ncbi.nlm.nih.gov/pubmed/21256454) Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology. (http://www.ncbi.nlm.nih.gov/pubmed/15972843)

A 64-Year-Old Man Comes to the Physician Because of a Tremor