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Tremor 01

Topic: Behavior

Created on Saturday, December 30 2006 by jdmiles

Last modified on Sunday, November 16 2008.

A very old man is seen in clinic by his Neurologist. He complains of more than 2 years of worsening tremor.
The tremor is worse in the right hand. It improves slightly when he uses the hand to perform a task. He has no cognitive symptoms.
He drinks 6 40-oz beers every night. When he does, he notices no change in the tremor.
There is no significant family history.
He is currently on medications for genital herpes, COPD, and tinea pedis.
Significant findings on physical exam are shown in the image above.
Of the following options, which medication would make the best choice as empiric treatment for this tremor?

A) Pyridostigmine

B) Trihexyphenidyl

C) Glatiramer

D) Valproic acid

E) Dexamethasone

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This question was created on December 30, 2006 by jdmiles.
This question was last modified on November 16, 2008.

ANSWERS AND EXPLANATIONS

A) pyridostigmine

This answer is incorrect.

By history and exam, this patient's tremor appears Parkinsonian: it is worse at rest, it is asymmetrical, has a pill-rolling quality, and does not improve with ethanol intake. Pyridostigmine is not indicated in the treatment of Parkinsonsim. Pyridostigmine is a cholinergic agent, and is indicated in the treatment of myasthenia gravis. (See References)


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B) trihexyphenidyl

This answer is correct.

By history and exam, this patient's tremor appears Parkinsonian: it is worse at rest, it is asymmetrical, has a pill-rolling quality, and does not improve with ethanol intake. Trihexyphenidyl is indicated in the treatment of Parkinson disease. Trihexyphenidyl is an anticholinergic agent, and as such reduces the effects of acetylcholine post-synaptic to striatal neurons. It will reduce tremor and rigidity, but has no effect on bradykinesia. (See References)


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C) glatiramer

This answer is incorrect.

By history and exam, this patient's tremor appears Parkinsonian: it is worse at rest, it is asymmetrical, has a pill-rolling quality, and does not improve with ethanol intake. Glatiramer is not indicated in the treatment of Parkinsonsim. Glatiramer is an anti-MS agent, and is indicated in the treatment of multiple sclerosis. (See References)


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D) valproic acid

This answer is incorrect.

By history and exam, this patient's tremor appears Parkinsonian: it is worse at rest, it is asymmetrical, has a pill-rolling quality, and does not improve with ethanol intake. Valproic acid is not indicated in the treatment of Parkinsonsim. Valproic acid is an antiepileptic drug, and is indicated in the treatment of epilepsy or migraine. (See References)


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E) dexamethasone

This answer is incorrect.

By history and exam, this patient's tremor appears Parkinsonian: it is worse at rest, it is asymmetrical, has a pill-rolling quality, and does not improve with ethanol intake. Dexamethasone is not indicated in the treatment of Parkinsonsim. Dexamethasone is a steroid.. (See References)


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References:

1. Rao, G., Fisch, L., Srinivasan, S., D\'Amico, F., Okada, T., Eaton, C., and Robbins, C. (2003). Does this patient have Parkinson disease? JAMA, 289(3):347-353. (PMID:12525236)
2. Shannon, K.M. (2004). Movement Disorders. In Bradley, W.G., Daroff, R.B., Fenichel, G.M., and Jankovic, J. (Eds.). Neurology in Clinical Practice, 4th Edition. Butterworth Heinemann, Philadelphia. Pp. 2131-2140. (ISBN:0750674695)	Advertising:
3. Fahn, S., and Przedborski, S. (2000). Parkinsonism. In Rowland, L.P. (Ed), Merritt\'s Neurology, 10th Edition. Lippincott Williams & Wilkins, Philadelphia. Pp. 679-693. (ISBN:0683304747)	Advertising:
4. Cochran, E.J. (2005). Neurodegenerative Diseases. In Prayson, R.A., and Goldblum, J.R. (Eds.). Neuropathology. Elsevier Churchill Livingstone, Philadelphia. Pp. 232-243. (ISBN:0443066582)	Advertising:
5. Aminoff, M.J. (2001). Parkinson\'s Disease and Other Extrapyramidal Disorders. In Braunwald, E., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., and Jameson, J.L. (Eds.). Harrison\'s Principles of Internal Medicine, 15th Edition. McGraw Hill. New York. (ISBN:0070072728)	Advertising:
6. Victor, M., and Ropper, A.H. (2001). Adams and Victor\'s Principles of Neurology, 7th Edition. McGraw-Hill, New York. Pp. 1128-1137. (ISBN:0070674973)	Advertising:
7. Pierantozzi, M., Pietroiusti, A., Brusa, L., Galati, S., Stefani, A., Lunardi, G., Fedele, E., Sancesario, G., Bernardi, G., Bergamaschi, A., Magrini, A., Stanzione, P., and Galante, A. (2006). Helicobacter pylori eradication and L-dopa absorption in patients with PD and motor fluctuations. Neurology, 66(12): 1824-1829. (PMID:16801644)


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behavior
Tremor 01
Question ID: 12300600
Question written by J. Douglas Miles, (C) 2006-2009, all rights reserved.
Created: 12/30/2006
Modified: 11/16/2008
Estimated Permutations: 0