CASE 22

DOORWAY INFORMATION

Opening Scenario
Charles Andrews, a 66-year-old male, comes to the clinic complaining of a tremor.

Vital Signs

BP: 135/90 mmHg

Temp: 98.6°F (37°C)
RR: 16/minute
HR: 70/minute, regular

Examinee Tasks
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.

Checklist/SP Sheet

PATIENT DESCRIPTION
Patient is a 66 yo M.

NOTES FOR THE SP

• Exhibit mild muscle rigidity in your wrists and arms—that is, when the examinee tries to move your wrists and
arms, stiffen them and move them slowly.
• Lean your back forward slightly and walk in small, shuffling steps.
• Exhibit a resting hand tremor (pill rolling) that disappears with movement.

CHALLENGING QUESTIONS TO ASK

“Do you think I will get better?”

SAMPLE EXAMINEE RESPONSE

“I think your tremor will improve with medication, but I don’t know how long the improvement will last. The
tremor may be a sign of a larger movement disorder called Parkinson’s disease, and we need to do more evalu-
ation to explore that possibility.”

Examinee Checklist
PRACTIC E CASES

ENTRANCE:
䡺 Examinee knocked on the door before entering.
䡺 Examinee introduced self by name.
䡺 Examinee identified his/her role or position.

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 Examinee correctly used patient’s name.
Examinee made eye contact with the SP.

HISTORY:
Examinee showed compassion for your illness.

 Question Patient Response

□ Chief complaint I have a tremor in this hand (points to right hand).

□ Location Only in the right hand.
□ Duration I noticed it about six months ago, but it seems to be getting
worse recently.
□ Context It shakes when I’m just sitting around doing nothing. It usually
stops when I hold out the remote control to change the
channel.
□ Alleviating factors None.
□ Exacerbating factors It seems more severe when I am really tired.
□ Associated symptoms (falls, headaches, No, I don’t think so. My wife says I’ve slowed down, but I think
TIA symptoms, drooling, changes in that’s just because I retired last year. (If asked what your wife
voice or handwriting, difficulty with means, say that she is frustrated because it is your job to push
ADLs/IADLs, depression, constipation, the grocery cart, but you can’t keep up with her in the store
rash, etc.) anymore.)
□ Prior history of similar symptoms Well, back in college I occasionally had a hand tremor after
pulling an all-nighter and drinking lots of coffee. The tremor
was in both hands, but it was worse in the right. It seemed faster
than the one I have now.
□ Caffeine intake One cup of coffee every morning. I used to drink three cups a
day, but I’ve cut back over the past few months.
□ Alcohol use None. Both of my parents were alcoholics, so I never touch it.
□ Past medical history High cholesterol, treated with diet. Asthma, treated with an
albuterol inhaler as needed.
□ History of head trauma No.
□ Family history My parents died in a car accident in their 40s, and my sister is
healthy.
□ Social history I am married and live with my wife.
□ Occupation Retired chemistry professor.
□ Exercise No, I’m really not very active anymore.
PRACTIC E CASES

□ Tobacco No.
□ Illicit drug use No.
□ Current medications Albuterol inhaler as needed. (If asked, say that you have not
used it in more than a year.)
□ Drug allergies No.

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Physical Examination:

䡺 Examinee washed his/her hands.

䡺 Examinee asked permission to start the exam.
䡺 Examinee used respectful draping.
䡺 Examinee did not repeat painful maneuvers.

嘼 Exam Component Maneuver

□ CV exam Auscultation
□ Pulmonary exam Auscultation
□ Neurologic exam Mental status, cranial nerves, motor exam (including muscle
tone), DTRs, cerebellar, gait, sensory exam

Closure:

䡺 Examinee discussed initial diagnostic impressions.

䡺 Examinee discussed initial management plans:
䡺 Follow-up tests.
䡺 Discussed possible need to compare an old handwriting sample with a present sample.
䡺 Physician support throughout the patient’s illness.
䡺 Examinee asked if the patient has any other questions or concerns.

Sample Closure:
Mr. Andrews, I am sorry to have to tell you this, but on the basis of your history and physical exam, it would ap-
pear that you have Parkinson’s disease. With medications your symptoms may improve, but eventually they will
return. One indicator of disease progression involves looking closely at your handwriting. Do you think you could
bring an old sample of your handwriting along with you on your next visit? You should also know that about 25%
of the time, patients will present with your symptoms and not have Parkinson’s. For this reason, I would like to
run a few tests, including some imaging studies of your head and some blood tests. Although we won’t have those
results before you leave today, I will print out a comprehensive patient pamphlet that will give you resources to
help answer your questions as they come up. I want you to know that I will be here to treat you and to help you
every step of the way. Do you have any questions for me?

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 USMLE PATIENT NOTE
STEP 2 CS
History

Physical Examination

Differential Diagnosis Diagnostic Workup

1. 1.

2. 2.

3. 3.

4. 4.
PRACTIC E CASES

5. 5.

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 USMLE PATIENT NOTE
STEP 2 CS

History
HPI: 66 yo M c/o right hand tremor for 6 months. It occurs at rest and seems to be getting worse recently. The
tremor is exacerbated by fatigue, and there are no alleviating factors (he does not drink alcohol). Reducing his
caffeine intake to 1 cup of coffee daily did not seem to help. He denies associated symptoms but does say that
his wife complains that he has “slowed down” since retiring last year. Specifically, he seems to be walking more
slowly recently (time course unspecified, but within the past year). He had a hand tremor when very fatigued
back in college, but it was bilateral and faster than his present tremor.
ROS: Negative except as above.
Allergies: NKDA.
Medications: Albuterol MDI prn (no use in past year).
PMH: High cholesterol, treated with diet. Mild asthma.
SH: No smoking, no EtOH, no illicit drugs. He is a retired chemistry professor, married and lives with his wife.
FH: Noncontributory.

Physical Examination
Patient is in no acute distress.
VS: WNL.
Chest: Clear breath sounds bilaterally.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Neuro: Mental status: Alert and oriented × 3. Cranial nerves: 2–12 grossly intact. Motor: Right hand resting
tremor, about 6 Hz, “pill rolling,” improves or disappears during purposeful action or posture. Mild muscle
rigidity in both wrists and arms, but no frank cogwheeling. Strength 5/5 throughout. DTRs: Symmetric 2+ in
all extremities. Cerebellar: Romberg, rapid alternating movements and heel-to-shin test normal and symmet-
ric. Gait: Bradykinetic, takes small steps. Walks with back slightly bent forward. Sensation: Intact to soft touch
and pinprick.

Differential Diagnosis Diagnostic Workup

1. Parkinson’s disease 1. TSH
2. Essential tremor 2. Heavy metal screen
3. Physiologic tremor 3. MRI—brain
4. Midbrain lesion 4. Ceruloplasmin, slit lamp examination for Kayser-
5. Drug-induced tremor Fleischer rings, AST/ALT, CBC, 24-hour urinary
copper, liver biopsy
6. Psychogenic tremor
7. Wilson’s disease
8. Hyperthyroidism
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 CASE DISCUSSION
Differential Diagnosis
• Parkinson’s disease (PD): This is the most common cause of resting tremor (i.e., it is evident with the affected
body part supported and completely at rest but improves or subsides with voluntary activity), although some pa-
tients with PD also have a postural-action tremor that is indistinguishable from essential tremor (ET, see be-
low). Tremor is usually low frequency (4–6 Hz), begins in one upper extremity, and may later involve the other
extremities as well. Leg tremor is more commonly due to PD than to ET. The face, lips, and jaw may be in-
volved, but in contrast to ET, PD does not produce head tremor. Along with the tremor, the patient’s bradykine-
sia and rigidity suggest PD.
• Essential tremor (ET): This is the most common neurologic cause of postural tremor (i.e., tremor that is apparent
when the arms are held outstretched) or action tremor (i.e., tremor that increases at the end of goal-directed ac-
tivity such as finger-to-nose testing). Approximately 50% of cases are familial. Tremor is usually high frequency
and often asymmetrically involves the distal upper extremity. The head, voice, chin, trunk, and legs can also be
involved. ET is not associated with other neurologic signs and is improved following the ingestion of small
amounts of alcohol. Differentiation from the classic resting tremor of PD is usually straightforward, as in this
case.
• Physiologic tremor: This refers to a very low amplitude, high-frequency (10–12 Hz) tremor present in normal in-
dividuals. The tremor is often not visible, but when enhanced by medications or other medical conditions, it is
the most common cause of postural and action tremors. Conditions that can enhance physiologic tremor in-
clude anxiety, excitement, sleep deprivation/fatigue, hypoglycemia, caffeine intake, alcohol withdrawal, thyro-
toxicosis, fever, and pheochromocytoma.
• Midbrain lesion: Midbrain injury due to stroke, trauma, or demyelinating disease is a rare cause of a solitary
asymmetric resting tremor.
• Drug-induced tremor: Many medications can enhance physiologic tremor, notably β-agonists (such as albuterol),
nicotine, theophylline, TCAs, lithium, valproic acid, and corticosteroids. Mercury and arsenic exposure may
also contribute to tremor. Neuroleptics and metoclopramide can cause drug-induced parkinsonism, but tremor
is often absent in these cases.
• Psychogenic tremor: This often manifests with varying frequency and either becomes more irregular or subsides
entirely when the patient is asked to perform a complex, repetitive motor task with the contralateral limb.
• Wilson’s disease: This can cause resting tremor (among other manifestations) but is not considered in patients
> 40 years of age.
• Hyperthyroidism: This is associated with fine tremor along with a variety of other classic signs and symptoms.

Diagnostic Workup
• TSH: To screen for hyperthyroidism.
• Heavy metal screen: To screen for mercury and arsenic toxicity via urine or blood tests.
• MRI—brain: To rule out a structural lesion, particularly in the midbrain or basal ganglia.
• Ceruloplasmin, slit lamp examination for Kayser-Fleischer rings, AST/ALT, CBC, 24-hour urinary copper, liver biopsy:
These tests comprise the screening tests (and diagnostic tests, in the case of liver biopsy) used to evaluate for sus-
pected Wilson’s disease. As noted above, the patient’s advanced age precludes consideration of Wilson’s disease
in this case.
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