Clinical Pearl of the Month – Tremor and Tremor Differentiation

Gerard Kiernan, MD, FAAFP, FHMClinical Pearls, Emergency Medicine, Family Medicine, Guideline Knowledge Check, Internal Medicine, Nurse Practitioner, Nursing RN/PN, Pediatric Medicine, Physician Assistant, Urgent Care

tremor - 55 year old woman with tremor

Tremor in a 55-year-old Woman

Tremor and Tremor Differentiation Clinical Pearls of Wisdom Q&A Case

Tremor consists of alternating contractions of agonist and antagonist muscles in an oscillating, rhythmic manner. Tremor may also be characterized based on distribution, frequency, amplitude, and related neurologic dysfunction.
The first step in the evaluation of a patient with tremor is to categorize the tremor based on its activation condition, topographic distribution, and frequency. The diagnosis of tremor is based on clinical information obtained from a thorough history and physical examination.

Tremor Case:

A 55-year-old woman complains that she has tremor that is embarrassing and more noticeable since it began several years prior. She finds that she cannot paint and draw as well as she used to because of the tremor.

Her father, she recalls, had a tremor as well, and it affected his handwriting. Her tremor started around age fifty.

She feels it is worse when she is stressed, and she has not noted any alleviating factors.

She is a non-drinker, non-smoker who has one cup of coffee a day.

Past medical history includes depression for which she takes sertraline, mild intermittent asthma treated with albuterol and hypertension treated with losartan.

She has not started any new medications in the past year.

Her vital signs are normal, as is the cranial nerve examination.

Speech is fluent with no dysarthria. Her gait is normal with no ataxia.

You ask her to reach out for your pen and note a roughly 8 Hz tremor, symmetrical in both arms.

You ask her to draw a spiral and note a wavy line in drawing. When arms are extended on table, supported, there is no tremor.


Of the following, which medication would be most reasonable to initiate for this patient with tremor?

Answer Options:





See the Answer:

About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

About Clinical Pearl of the Month:

Med-Challenger's Clinical Pearl Blog Series is a recurring segment of Med-Challenger's popular Medical Education BlogSubscribe for more free pearls of wisdom. Opt-out anytime.

About Med-Challenger:

Med-Challenger provides online medical education products and services to physicians, nurses, and other medical specialists as well as medical training programs and healthcare groups world-wide via its web-based medical education library and world-class assessment platform at

tremor diagnosis - intentional tremor, resting tremor, essential tremor

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