NRP/556 Week 3: Neurological Disorder Case, sample paper

The Coffee Cup Shakes, the Hand at Rest Does Not: Distinguishing Essential Tremor From Parkinson Disease in a 71-Year-Old Retired Watchmaker

[Student Name]

University of Phoenix

NRP/556: Adult and Geriatric Management II

Week 3 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Mr. A., a 71-year-old retired watchmaker, comes because his hands shake when he drinks coffee, signs checks or tries to fix watches, which he still does as a hobby. His brother was recently diagnosed with Parkinson disease, and Mr. A. is afraid he has it too. The shaking began about eight years ago and has slowly worsened. A glass of wine in the evening seems to help. His mother "had shaky hands." This paper describes how I distinguished his tremor.

Classifying Tremor

The International Parkinson and Movement Disorder Society consensus classifies tremor along two axes: clinical features, including activation condition, distribution and associated signs, and cause (Bhatia et al., 2018). Activation condition is the first question: rest tremor occurs when the body part is relaxed and supported against gravity, and action tremor occurs during voluntary muscle contraction, either holding a posture (postural) or moving (kinetic).

Examination

With Mr. A.'s hands resting in his lap, there is no tremor, even while he counts backward, a distraction that often brings out a rest tremor. Holding his arms outstretched, both hands show a fine, regular postural tremor, slightly more on the right. During finger-to-nose testing and when pouring water from one cup to another, the tremor increases (kinetic). His spiral drawing shows a regular, tremulous line in both hands. A slight side-to-side head tremor is visible, and his voice quavers slightly when he holds a note. Finger tapping and hand opening are fast and do not slow or shrink with repetition. Tone is normal in all limbs, including with activation. His gait shows normal arm swing and stride, and he turns in three steps. Facial expression and blink rate are normal.

His hands shook when they worked and rested quietly in his lap, which is the opposite of what his brother's did.

Essential Tremor

The consensus defines essential tremor as an isolated tremor syndrome of bilateral upper limb action tremor present for at least three years, with or without tremor in other locations such as the head or voice, and without other neurological signs such as parkinsonism (Bhatia et al., 2018). Mr. A. meets each criterion. Louis (2001) describes essential tremor as among the most common movement disorders in adults, often familial and frequently improved by alcohol, both features Mr. A. reports.

Why It Is Not Parkinson Disease

The Movement Disorder Society clinical diagnostic criteria require parkinsonism, defined as bradykinesia plus rest tremor, rigidity or both, as the essential first step (Postuma et al., 2015). Bradykinesia means slowness with a decrement in speed or amplitude on repeated movements. Mr. A. has no bradykinesia, no rest tremor and no rigidity, so he does not have parkinsonism. His tremor is bilateral and action-dominant, whereas Parkinson tremor is typically asymmetric and present at rest. His head and voice tremor are more characteristic of essential tremor.

Could Both Occur

Essential tremor and Parkinson disease can occasionally coexist, and some people with long-standing essential tremor later develop parkinsonian signs. I explain to Mr. A. that his examination shows no signs of Parkinson disease now and that we will watch for changes, such as slowness, stiffness or a tremor at rest.

Other Causes to Exclude

Enhanced physiological tremor from caffeine, anxiety, hyperthyroidism or medications can mimic essential tremor. Mr. A. drinks two cups of coffee a day and takes no tremor-causing medications such as lithium, valproate or bronchodilators. I check thyroid-stimulating hormone, which is normal.

Treatment

Treatment depends on disability. Louis (2001) identifies propranolol and primidone as the first-line drugs, each reducing tremor in many patients. Mr. A.'s tremor interferes with his hobby and with eating and writing. He has no asthma, heart block or depression, so propranolol is an option; I start propranolol extended-release 60 mg daily and titrate as tolerated, monitoring pulse and blood pressure. Nonmedication strategies include weighted utensils, using two hands for cups and avoiding caffeine before fine work. If medications fail and tremor is disabling, referral for deep brain stimulation or focused ultrasound can be considered.

Why the Examination Order Matters

I examined for rest tremor first, with his hands fully supported, and used mental distraction because rest tremor can be suppressed by attention. I then tested posture and movement. Bradykinesia was tested with repeated finger taps, hand opening and foot tapping, looking for progressive slowing or shrinking of movements, which is the essential feature of parkinsonism in the criteria (Postuma et al., 2015). Rigidity was checked at the wrists and elbows with and without having him move the opposite hand, which can bring out subtle rigidity.

What His Spiral Shows

Spiral drawing is a simple, repeatable measure of action tremor. His spirals will be kept in the chart and repeated at each visit, giving a visual record of change and of response to treatment. In Parkinson disease, handwriting tends to become small, a sign called micrographia, which his does not show.

Reassurance With Evidence

Mr. A.'s relief came from seeing the evidence himself. I showed him that his hands were still at rest, that his finger taps did not slow and that his tone was normal, explaining what each would look like in Parkinson disease. Specific reassurance is more convincing than a general statement that he is fine.

Family Implications

Essential tremor often runs in families. His mother's shaky hands suggest an inherited pattern, and his children may notice similar symptoms in later life. His brother's Parkinson disease does not mean that Mr. A. has it, although the two conditions are distinct and can occasionally occur in the same family.

Alcohol

Although alcohol reduces his tremor, I advise against using it as treatment because of the risks of dependence and falls, and because the effect is short-lived.

Impact on Daily Life

Essential tremor is sometimes dismissed as benign, but it can be disabling and socially embarrassing. Mr. A. has stopped eating soup in restaurants and avoids signing documents in public. Asking about these effects is part of deciding on treatment, since the goal is his function, not the amplitude of his tremor on examination.

Propranolol Precautions

Propranolol can slow the heart, lower blood pressure, cause fatigue and mask low blood sugar, and it should not be stopped abruptly. I check his baseline pulse, 72, and blood pressure, 134/80 mm Hg, and teach him to report dizziness or breathlessness.

Follow-Up

I will see Mr. A. in four weeks to assess response and side effects and examine him annually for any parkinsonian signs.

Conclusion

Mr. A.'s long-standing, bilateral action tremor of the hands with head and voice involvement, a family history and improvement with alcohol, with no rest tremor, bradykinesia or rigidity, meets the consensus definition of essential tremor and does not meet criteria for parkinsonism. The diagnosis, explained with his examination findings, relieved his fear, and treatment with propranolol and practical strategies addresses the disability that brought him in.

References

Bhatia, K. P., Bain, P., Bajaj, N., Elble, R. J., Hallett, M., Louis, E. D., Raethjen, J., Stamelou, M., Testa, C. M., & Deuschl, G. (2018). Consensus statement on the classification of tremors: From the Task Force on Tremor of the International Parkinson and Movement Disorder Society. Movement Disorders, 33(1), 75-87. https://doi.org/10.1002/mds.27121

Louis, E. D. (2001). Essential tremor. New England Journal of Medicine, 345(12), 887-891. https://doi.org/10.1056/NEJMcp010928

Postuma, R. B., Berg, D., Stern, M., Poewe, W., Olanow, C. W., Oertel, W., Obeso, J., Marek, K., Litvan, I., Lang, A. E., Halliday, G., Goetz, C. G., Gasser, T., Dubois, B., Chan, P., Bloem, B. R., Adler, C. H., & Deuschl, G. (2015). MDS clinical diagnostic criteria for Parkinson's disease. Movement Disorders, 30(12), 1591-1601. https://doi.org/10.1002/mds.26424