A 44-year-old man comes to the office due to hand tremors. The patient first noticed the tremor 2 years ago, and it has gradually worsened. He feels well most of the time, but his hands shake uncontrollably with activities such as pouring drinks or writing notes. The symptoms are most pronounced during stressful situations such as office meetings, and he keeps his hands tightly squeezed together or hidden below the table. He has had no arm stiffness, leg symptoms, or difficulty walking, but his wife has noticed that the patient occasionally keeps nodding his head while talking. Physical examination shows obvious tremors of outstretched hands that worsen during finger-nose testing. Which of the following additional factors is most likely to be present in this patient's medical history?

Question

A 44-year-old man comes to the office due to hand tremors.  The patient first noticed the tremor 2 years ago, and it has gradually worsened.  He feels well most of the time, but his hands shake uncontrollably with activities such as pouring drinks or writing notes.  The symptoms are most pronounced during stressful situations such as office meetings, and he keeps his hands tightly squeezed together or hidden below the table.  He has had no arm stiffness, leg symptoms, or difficulty walking, but his wife has noticed that the patient occasionally keeps nodding his head while talking.  Physical examination shows obvious tremors of outstretched hands that worsen during finger-nose testing.  Which of the following additional factors is most likely to be present in this patient's medical history?

Quizplus · Accepted Answer

11ec160b_39e3_6d43_9249_135559858627_MD0001_00 This patient has a worsening tremor of his distal upper extremities that becomes more pronounced with extension of his arms and at the end of an intended action (finger-to-nose test). In association with a head tremor (eg, repetitive nodding) and absence of other neurologic manifestations, this is most consistent with essential tremor (ET). ET is often hereditary and can be passed in an autosomal dominant fashion, so a family history of tremor supports the diagnosis. Although features of ET are highly variable, it most often affects the wrists and hands, especially when the arms are extended. It worsens with movement (ie, action tremor) and improves, but may not completely abate, at rest. Although ET is not typically unilateral, it may be asymmetric. It can also affect the head and voice, but it generally spares the trunk and legs and is not associated with other neurologic manifestations. Although ET does not shorten life, it is slowly progressive and may cause patients significant social embarrassment and impair activities of daily living. (Choice A) ET classically improves with, rather than is exacerbated by, alcohol use. (Choices B and E) Secondary parkinsonism can be induced by MPTP (a toxic substance that destroys dopaminergic neurons in the substantia nigra) or by the use of dopamine D2 receptor blocking drugs (eg, antipsychotics, antiemetics). Patients can have tremor, but it is typically most prominent at rest and improves with action. The tremor is also accompanied by other parkinsonian features such as rigidity, postural instability, and gait disturbances. (Choice D) Previous head trauma can predispose to a wide range of neurologic sequelae, particularly headaches, seizures, and dementia. However, the development of isolated ET due to head trauma would be rare. Educational objective: Essential tremor most often presents as a tremor of the hands that is suppressed at rest, exacerbated by outstretched arms, and more pronounced during goal-directed movements. It is often hereditary (autosomal dominant) and can be associated with a head tremor, but it is not associated with other neurologic symptoms.

A 44-Year-Old Man Comes to the Office Due to Hand