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Probability diagnosis

Benign essential (familial) tremor



Drugs: adverse effects, withdrawal

Parkinson disease (incl. drug-induced PD)



Serious disorders not to be missed


  • cerebral infarction → Parkinsonism


  • meningoencephalitis

  • tertiary syphilis


  • cerebral tumour (frontal lobe)


  • toxicity from organ failure (kidney, liver, lungs)

Pitfalls (often missed)

Cerebellar disease

Multiple sclerosis

Alzheimer dementia

Uraemia of kidney failure

CO2 retention of respiratory failure

Hepatic failure


  • hepatolenticular degeneration (Wilson disease)

  • lesion of midbrain (red nucleus)

Masquerades checklist

Drugs (withdrawal e.g. opioids, stimulants, illicit agents, benzodiazepines, caffeine, alcohol; adverse reactions e.g. sympathomimetics, ® agonists, lithium, phenothiazines, valproate, amiodarone; alcohol) Thyroid/other endocrine: (hyperthyroidism, hypoglycaemia, phaeochromocytoma)

Is the patient trying to tell me something?

Anxiety (esp. hyperventilation), conversion disorder (‘hysteria’).

Key history

  • Nature of the tremor: resting, intention, postural (action), pill-rolling, flapping (asterixis), hysterical, mixed

  • Family history of tremor

  • Evidence of cognitive changes or other neurological problems

  • Systems review: respiratory, cardiac, liver, kidneys

  • Drug history: prescribed, OTC, illicit drugs, alcohol, caffeine

Key examination

  • General appearance and vital signs

  • Respiratory, cardiac, abdominal (esp. liver) and neurological examination

Key investigations

According to above:

  • FBE and ESR

  • thyroid function tests (?hyperthyroidism), LFTs, pulse oximetry/blood gases

  • drug screen

  • MRI.

Diagnostic tips

  • Essential tremor eased by a small quantity of alcohol.

  • Triad of essential tremor: postural or action tremor, head tremor, positive family history.

  • Look for Parkinson tetrad: resting tremor, bradykinesia, rigidity, postural instability.

  • Look for cerebellar tetrad: intention tremor, dysarthria, nystagmus, ataxic gait.

  • Typical drugs that induce Parkinsonism are phenothiazine, butyrophenones, reserpine.

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