Trembling

A 65 year old lady presents with fine tremors of both hands for 2 years.

The tremors were postural in nature, more pronounced with stress, and absent at rest.

Her handwriting has worsened to the point where she is unable to write legibly anymore.

Her medical history is unremarkable and she is not on any medications.

Select Relevant Investigations
TSH + FT4

Performed

TSH: 1.0 mIU/L (0.4 – 4.0)
FT4: 15 pmol/L (8 - 27)
Liver Function Tests

Performed

Total bilirubin, ALT, AST, ALP, GGT, INR, S. Albumin: all within normal parameters.
Renal Functions

Performed

Blood urea: 15 mg/dL (3 - 20)
S. Creatinine: 0.6 mg/dL (0.5 - 1.2)
Nerve Conduction Studies

Performed

Nerve conduction studies of the upper limbs are completely normal.

Select Relevant Management
Propranolol
Gamma knife radiosurgery
Levodopa
Lithium