Essential Tremors

Casebank History
1

Prompt: You’re FY2 in GP.
Erwin Smith, a 40 year old man has presented with concerns.
Additional info: No significant previous illnesses.
Your task: Talk to the patient and address concerns.
Scenario GRIPS ODIPARA
What concern do you have - Dr. My hands have been shaking (both hands)
Since when - For some years now but it

has been more this past week.
Any things makes it worse or better - when I try to do things it happens especially
when Itry to play the Violin it starts shaking.
Any other thing - No DIFFERENTIALS
Ask about 4 cardinal signs of Parkinson’s
disease (rigidity, postural instability, bradykinesia and resting tremors)
Any head trauma
Do you feel cold when other feel hot (hypothyroidism) - No
Any problem with co-ordinating walking or balance (cerebellar ataxia) - No

Any Forgetfulness (lewy body dementia) - No
RED FLAGS
Differential body weakness, weight loss, lumps or bumps
PMAFTOSA
Any medical conditions - No On any medications - No
Allergies- No
Family history of similar condition - Yes/No
Psychosocial +Mood - Pt is a violinist and tremors have affected his job
DESA Smoking - No
Alcohol - No/Yes (alcohol helps with symptoms)

Recreational drug - No
EXAMINATIONS
Vitals, Neurological exam
DIAGNOSIS
Essential tremors - Essential tremor, also known as benign or familial tremor, is a
neurological (brain and nerves) disorder that causes involuntary shaking of parts of
the body.
Investigation: CBC, LFT, KFT, TFT, B12 assay.
Involve seniors
Refer to Neurology routinely to do brain
scans and rule out other possible causes of the tremors.

Tx - No curative treatment but there are medications that can reduce the severity if
it is affecting a patients life (prescribe this medication here as patient is a violinist and would need to control before playing).
1st line is propanolol.
Other medications: Botox, topiramate, gabapentin, pregabalin.
Supportive measures: Avoid caffeine, try relaxation techniques such as yoga, avoid stress and make sure you get plenty of sleep.
Support group, leaflet
Safety net: DVLA, worsening symptoms, low mood.

3 Likes
2

50-60 Years old.
Having tremors.
Bilateral. Violent.
Never had tremor before.
Concerned about Parkinson’s.

Odipara for tremors
Causes
Parkinson’s symptoms
Medications
Fever - previous medications
Stroke
TIA
MG

Alcohol makes it better?
Any other parts? Legs, hands, voice. Jaw,
Effects is very important. Don’t miss
Writing
Driving
Drinking

Examination. Neurological. Everything is normal. Cerebellar Examination normal. Cranial Nerve
Examination.

“All the Neuro symptom’s are normal except this tremor so you might be having a condition
called as Neurological Tremor”
Refer to Neuro. CT scans. MRI.
They’ll confirm. Medication called Propranolol or Topiramide. Botox is also an option.
“Worse in stresses”. Avoid caffeine. Stresses. Use heavy mug if shakiness while drinking.
Heavy cutlery. Problems with writing. Type. Relaxation. Yoga. Sleep.
Medication. If fails. Surgery is the option.

3

Here’s an organized version of your prompt:

Scenario:
You’re an FY2 in GP. Erwin Smith, a 40-year-old man, has presented with concerns.
Additional Information:

  • No significant previous illnesses.

Task:

  • Talk to the patient and address concerns.

GRIPS and ODIPARA Approach

Concerns:

  • Patient: “My hands have been shaking (both hands).”

Duration:

  • Since when: “For some years now, but it has been more noticeable this past week.”

Triggers:

  • What makes it worse or better: “When I try to do things, especially when I play the violin, it starts shaking.”

Other symptoms:

  • Any other concerns: “No.”

Differential Diagnosis

  • Ask about 4 cardinal signs of Parkinson’s disease (rigidity, postural instability, bradykinesia, resting tremors).
  • Any history of head trauma?
  • Do you feel cold when others feel hot (hypothyroidism)?
    • Patient: “No.”
  • Any problems with coordination, walking, or balance (cerebellar ataxia)?
    • Patient: “No.”
  • Any forgetfulness (Lewy body dementia)?
    • Patient: “No.”

Red Flags

  • Differential body weakness?
  • Weight loss?
  • Lumps or bumps?

PMAF TOSA (Past Medical, Allergy, Family, Tobacco, Occupational, Social, Alcohol)

  • Medical Conditions: None.
  • Medications: None.
  • Allergies: None.
  • Family history of similar condition: Yes/No.
  • Psychosocial: Patient is a violinist, and tremors have affected his job.

DESA (Drugs, Ethanol, Smoking, Alcohol)

  • Smoking: No.
  • Alcohol: No/Yes (Alcohol helps with symptoms).
  • Recreational drugs: No.

Examination

  • Check vitals.
  • Conduct a neurological exam.

Diagnosis

  • Essential Tremors:
    • Essential tremor, also known as benign or familial tremor, is a neurological disorder that causes involuntary shaking of parts of the body.

Investigations

  • CBC, LFT, KFT, TFT, B12 assay.
  • Involve seniors.
  • Refer to Neurology routinely to do brain scans and rule out other causes.

Treatment

  • No curative treatment, but there are medications to reduce severity if it affects the patient’s life.
  • As the patient is a violinist, 1st line treatment is propranolol.
  • Other options: Botox, topiramate, gabapentin, pregabalin.

Supportive Measures

  • Avoid caffeine.
  • Try relaxation techniques like yoga.
  • Avoid stress, ensure plenty of sleep.

Support and Safety

  • Support group.
  • Provide a leaflet.
  • Safety net:
    • Inform DVLA if driving is affected.
    • Watch for worsening symptoms or low mood.

This version organizes the case flow for your PLAB 2 preparation, based on the GP setting.

4

The only complaint of the guy was tremors in hands. Thats all. That too while playing violin and he was a professional violinist 62 years old. nothing was significant in the history
No family history of any neurological disorders, non smoker, no hx of alcohol and wasn’t taking any regular meds.

Task-specific tremors are involuntary, rhythmic muscle contractions that occur only during specific, goal-oriented tasks, such as writing, playing a musical instrument, or typing. These tremors typically do not occur at rest and are triggered by particular movements or actions. Below are key points about task-specific tremors:Types of Task-Specific Tremors:Primary Writing Tremor (PWT): A tremor that occurs specifically when writing.Musician’s Tremor: A tremor affecting musicians, which may occur while playing an instrument.Typing Tremor: A tremor that appears during activities like typing.Causes:Often idiopathic (unknown origin).Can be associated with dystonia, especially in the case of musician’s or writer’s cramp.May be influenced by genetic factors or specific repetitive tasks that stress fine motor skills.Less commonly, it can be related to neurological conditions like Parkinson’s disease or essential tremor, though task-specific tremors usually occur in isolation.Diagnosis:Clinical evaluation: The tremor is noted only during specific tasks, not at rest or during other actions.Electromyography (EMG) may be used to study muscle activity.Exclusion of other causes: Ruling out conditions like essential tremor, cerebellar disorders, and other movement disorders is essential.Management:Botulinum toxin injections: Used in cases of dystonic tremors like writer’s cramp.Medications: Beta-blockers or anticholinergics may help in some cases, though they are not always effective.Physical therapy and task-specific retraining.Ergonomic changes to the task (e.g., altering the way an instrument is held or changing writing posture).These tremors can be disabling depending on the affected task, making early identification and management crucial, especially for individuals who rely on fine motor skills in their profession.