A 45-year-old Caucasian man comes to see you in the office. He is accompanied by his wife. They have noticed that he has shakiness of both hands for the past six months. The shakiness is limited only to his hands and has not progressed over time. It becomes much more pronounced when he tries to pick up things or attempts to eat or drink. On physical examination, you notice a constant tremor in both his hands, which becomes much more pronounced when his arms are outstretched. There is also a very subtle head tremor present. There is no rigidity or slowing of voluntary movements in the upper or lower extremities. His father had a similar problem in his 50s or 60s, but he is not sure what treatment he received at that time. His wife is extremely anxious and wants to know his prognosis.
The patient works as a carpenter and feels that he is unable to perform the fine motor tasks due to the tremor. Which of the following is the most appropriate next step in the management of this patient?

Question

A 45-year-old Caucasian man comes to see you in the office.  He is accompanied by his wife.  They have noticed that he has shakiness of both hands for the past six months.  The shakiness is limited only to his hands and has not progressed over time.  It becomes much more pronounced when he tries to pick up things or attempts to eat or drink.  On physical examination, you notice a constant tremor in both his hands, which becomes much more pronounced when his arms are outstretched.  There is also a very subtle head tremor present.  There is no rigidity or slowing of voluntary movements in the upper or lower extremities.  His father had a similar problem in his 50s or 60s, but he is not sure what treatment he received at that time.  His wife is extremely anxious and wants to know his prognosis.
The patient works as a carpenter and feels that he is unable to perform the fine motor tasks due to the tremor. Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The patient is suffering from a familial or benign essential tremor. Treatment for familial or benign essential tremor is not necessary in all patients and should be delayed as long as possible due to the need for indefinite treatment. The patient, however, has a significant disability due to the tremor that is affecting his ability to perform fine motor tasks with his hands. Beta-blockers are the most common first-line agents used in the treatment of benign essential tremors. Several studies have evaluated the efficacy of propranolol in reducing tremors and the disability associated with the tremor. (Choices A and B) The patient has symptoms that are affecting his work as a carpenter. He should be treated with pharmacotherapy at this point. Physical therapy does not improve the tremor in this condition and is not recommended. (Choices D and E) The patient does not have any signs or symptoms of Parkinson's disease; therefore, a carbidopa-levodopa combination or pramipexole is not indicated in this patient. Educational Objective: Beta-blockers are the first-line agents for symptomatic treatment of patients with benign essential or familial tremor.

A 45-Year-Old Caucasian Man Comes to See You in the Office. He