Trembling

Nervous System & Special Senses


Step 1: View Clinicals

A 65 year old lady presents with fine tremors of both hands for 2 years.


The tremors were postural in nature, more pronounced with stress, and absent at rest.


Her handwriting has worsened to the point where she is unable to write legibly anymore.


Her medical history is unremarkable and she is not on any medications.


Step 2: Order Relevant Investigations

1. TSH + FT4

check

TSH: 1.0 mIU/L (0.4 – 4.0)

FT4: 15 pmol/L (8 - 27)

2. Liver Function Tests

check

Total bilirubin, ALT, AST, ALP, GGT, INR, S. Albumin: all within normal parameters.

3. Renal Functions

check

Blood urea: 15 mg/dL (3 - 20)

S. Creatinine: 0.6 mg/dL (0.5 - 1.2)

4. Nerve Conduction Studies

clear

Nerve conduction studies of the upper limbs are completely normal.

Step 3: Select Appropriate Management

1. Propranolol

check

2. Gamma knife radiosurgery

clear

3. Levodopa

clear

4. Lithium

clear