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Case 1 • 68 year old Mrs Smith is a retired school teacher. She lives alone, her husband passed away 7 years ago. She has an active social life and frequently visits her daughter in Brighton by car. She does not smoke or drink alcohol. She presents with a fairly acute onset of shaking of her hands and her head two months ago. This is affecting her handwriting, her voice is tremulous and eating and drinking is difficult. She feels it is gradually getting worse. She remembers her mother used to have shaking. There are no problems with walking and driving seems to be ok. She is using a topical cream for eczema and has no other medical problems. She is a little embarrassed when out for tea with her friends, she spilt most of her drink down her top, and so has now come to see you. • Examination shows she has a tremor whilst holding her arms outstretched, as well as head nodding/shaking. There is a normal gait and tone, and power. Cardiovascular and respiratory exam are normal. • How do you Proceed?
Case 1 • Blood tests; TFTs, LFTs, Renal function. • CT head • The results of these come back as normal. What’s your diagnosis?
Case 1 • Diagnosis- Essential tremor • The history in this case is characteristic of an essential tremor, with the tremor coming on with movement or when the affected body part is maintained in a position against gravity. The family history is often a clue as essential tremor is known to run in families. The involvement of the arms/ leg/ jaw or voice as may occur with head titubations, are also classical with an essential tremor. There is no test for this condition and diagnosis is mainly clinical however it is important to rule out other causes of the tremor. Alcohol is found to sometimes reduce the tremor, whilst stress, anxiety or heightened emotions can worsen the tremor. • How do you manage this lady?
Case 1 • Reassurance, symptom advice, decrease caffeine intake • Propanolol- 40 mg bd- tds • Primidone- 50 mg od, max 750 mg daily • A combination of propanolol and primidone can be tried, if no success specialist referral may be indicted where Gabapentin and Topiramate may be initiated. In some resistant cases patients may be referred for deep brain stimulation.
Case 2 • Case 2 • 78 year old Mr Rozputinski, presents with a sudden onset tremor which started 5 weeks ago. He can’t describe it but feels his walking is not the same- even using his stick he feels unsteady, he also feels dizzy. He suffers with osteoarthritis of his back, knees, and hips, and is taking a combination of NSAIDS, and co-codomol for this. He is also a known to have had a previous Myocardial Infarction 15 years ago and is also both a poorly controlled hypertensive as well as a Type 2 diabetic. He is taking metformin, Insulin, atenolol, amlodipine, perindopril, indapamide, and a statin. He has not been started on any new medication, and says he only drinks alcohol in moderate amounts. He lives with his wife, and due to his stubbornness she has not been able to persuade him to see the doctor until now. • Neurological examination reveals Nystagmus, a wide based gait, an intentional past pointing tremor. Romberg's is negative. He has no new features on cardiovascular, respiratory or ENT examination, and there is no postural drop in BP, though it is a little raised. • How do you proceed?
Case 2 • Bloods tests; TFTs, renal function, liver function, and fbc. • CT head • Refer to secondary care • These investigations are reported back as normal, what is your differential diagnosis?
Case 2 • Cerebellar ataxia secondary to vascular disease • This gentleman is an arteriopath, having had a previous MI, and at high risk of vascular complications with his uncontrolled hypertension and diabetes. He is presenting with cerebellar symptoms of nystagmus, wide based gait, and a tremor. It is likely he has had a cerebellar infarct, which may show up better on MRI scan but not CT head scan which is not known to be as good in imaging of the cerebellum. • Other differential diagnosis are as follows; • Multiple Sclerosis; Posterior fossa space occupying lesion; alcoholic cerebellar degeneration; hypothyroidism; abscess secondary to otitis media. • This man was referred to a neurologist; for diagnosis and management. This involved optimisation of vascular risk factors such as Hypertension/ cholesterol/ antiplatelets, also thiamine and alcohol reduction were advised.
Case 3 • 68 year old Mrs Vernon who is an infrequent attender and frightened of the doctors, has had a few falls mainly in her house. Her daughter visiting from the USA, insists she come to the doctors. Mrs Vernon is not worried about the falls and thinks this is just because she tripped and wasn’t being careful, she says her main problem is that she can not play piano in church anymore, as her hands are shaking. She has no significant past medical history and is not on any medication. • On examination she has a high BP, and a resting tremor of left hand. She also has increased tone in left upper and lower limbs, but no other neurological signs. • What is your diagnosis and how do you proceed?
Case 3 • This case is likely to be idiopathic Parkinson’s disease. She is orientated in time place and person. She has a resting tremor, which is distinctive of PD, as well as increased asymmetrical limb tone. She is not on any other medication and denies any other symptom. In PD the tremor is typically worse when stressed or tired, and if associated with the feeling that other people notice it. • Management involves referral to movement disorder clinic or to a neurological specialist. • In the meantime stop any neuroleptics/antihistamines/anti-emetics (e.g. metoclopramide) • Consider medication for PD in very symptomatic cases and if there is long wait for specialist. • Watch BP if started on levodopa / dopamine agonist medication, as these drugs are known to cause postural hypotension but also because postural hypotension can occur due to the disease itself.
Case 4 • A 55 year old man by the name of Mr Hurley develops a new tremor, leading to illegible hand writing. When asked he admits to a few falls. He has a past medical History of diabetes, and is on metformin. He was diagnosed with bipolar disease 20 years ago and is still on lithium. He was recently diagnosed with hypertension and started on ramipril. Examination shows a coarse tremor, micrographia, and a slight postural drop in BP. • How do you proceed?
Case 4 • Check Blood lithium levels. • Bloods for TFTs, Renal function, LFTs, vitamin B12 levels, short synacthen test. • Check drug, alcohol, caffeine history
Case 4 • This is a likely case of lithium toxicity, which can present with a tremor. In this case the lithium levels may have arisen secondary to renal impairment following initiation of Ramipril. • How do you manage this patient?
Case 4 • Avoid dehydration in patients on lithium, aim to correct lithium levels. • If no improvement in function after a couple of months refer to movement disorder specialist as a tremor caused by lithium toxicity can last for up to 18 months, even if the levels of lithium are corrected. • Consider DAT scan if progressive symptoms and lithium levels have normalised
