A 73-year-old woman comes to the physician for routine follow-up and medication refill. She has experienced an acute onset of hand shaking over the last couple of weeks. It has significantly affected her daily activities, especially pouring tea and knitting. She has no chest pain, anxiety, shortness of breath, lower-extremity edema, or weight loss. She has had no recent falls. The patient has taken atenolol and hydrochlorothiazide for hypertension for many years but ran out of medications about a month ago and has not renewed them until today.
Her blood pressure is 152/76 mm Hg and pulse is 85/min. Her thyroid gland is not enlarged. There is a 2/6 ejection type systolic murmur at the right upper sternal border. A mild tremor of outstretched hands is seen bilaterally. Romberg maneuver is negative for any signs. Gait is normal.
Which of the following is the most likely diagnosis?

Question

A 73-year-old woman comes to the physician for routine follow-up and medication refill.  She has experienced an acute onset of hand shaking over the last couple of weeks.  It has significantly affected her daily activities, especially pouring tea and knitting.  She has no chest pain, anxiety, shortness of breath, lower-extremity edema, or weight loss.  She has had no recent falls.  The patient has taken atenolol and hydrochlorothiazide for hypertension for many years but ran out of medications about a month ago and has not renewed them until today.
Her blood pressure is 152/76 mm Hg and pulse is 85/min.  Her thyroid gland is not enlarged.  There is a 2/6 ejection type systolic murmur at the right upper sternal border.  A mild tremor of outstretched hands is seen bilaterally.  Romberg maneuver is negative for any signs.  Gait is normal.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's presentation is consistent with essential or benign tremor. Essential tremor (ET) is autosomal dominant and usually presents in the 5th or 6th decade of life. Most patients have a positive family history. The tremor usually involves the hands or arms but can also affect the head (eg, "yes-yes" or "no-no" tremors), voice, chin, trunk, and legs. Alcohol consumption usually improves ET. Tongue or jaw involvement is more common in idiopathic Parkinson's disease than in ET. Unlike resting tremor of Parkinson's disease, ET is induced by action or posture. The tremor is more pronounced when the arms are held outstretched (postural tremors) and increased during goal-directed movements (eg, drinking from a glass or finger-to-nose testing). Severe and disabling ET can be treated with propranolol or primidone. Although both are equally effective, propranolol is favored due to the better side effect profile. Patients with history of asthma or bronchospasm can use selective beta-1 adrenergic blocker (eg, atenolol) as alternate therapy. Combination therapy with beta blockers and primidone may be used in some patients not responding to monotherapy. This patient likely had ET that was responding to the atenolol given for hypertension. Once she stopped her atenolol, the ET became clinically apparent. (Choice A) Beta blocker therapy withdrawal can present with headache, palpitations, sweating, and postural hand tremors. However, these symptoms typically occur acutely within 24-36 hours following discontinuation of therapy. This patient's symptoms have continued for many weeks, making beta blocker withdrawal unlikely. (Choice B) Cerebellar strokes typically cause intention tremor, which increases in severity as the hand gets closer to its target. This is in contrast to ET (seen in this patient), which usually remains constant throughout movement or increases only at the end of the movement. This patient also has no other cerebellar signs (eg, wide-based and ataxic gait). (Choice D) Hyperthyroidism can lead to a fine postural tremor. However, this patient's absence of other hyperthyroid symptoms (eg, excessive weight loss, palpitations, anxiety, restlessness, heat intolerance) makes this less likely. (Choice E) The absence of a resting tremor and bradykinesia makes the diagnosis of idiopathic Parkinson's disease less likely. Parkinson's patients also have a narrow-based and shuffling gait. Educational objective: Essential tremor is an autosomal dominant tremor induced by action or posture. It tends to affect the upper extremities but can also occur in the head, voice, chin, and legs. Treatment involves the use of beta blockers (eg, propranolol) or primidone. __________ References: Benefits and risks of pharmacological treatments for essential tremor. (http://www.ncbi.nlm.nih.gov/pubmed/12735785)

A 73-Year-Old Woman Comes to the Physician for Routine Follow-Up