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Gradually progressing tremor of right hand
A 76-year-old architect developed a gradually progressing tremor of the right hand about 18 months ago,
that was especially noticeable when he walked or sat watching television at night. Over the following
months, the tremor became more conspicuous and, at times, would interfere with his writing. One year
later, he began to drag his right leg while walking. Examination at this time showed a soft-spoken,
pleasant, rather impassive man with a staring expression. There was an obvious tremor of the right
hand. There was some rigidity in all limbs, more marked on the right than the left, with cogwheeling at
the right wrist and mild rigidity in the arms. There was no focal weakness, but he seemed slow with the
right hand, and could not perform rapid alternating movements well. There was no significant reflex
asymmetry, and no sensory deficit. Plantar responses were flexor bilaterally
Gradually progressing tremor of right hand
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about his condition and about any proposed
therapy?
Case 42
A 76-year-old architect developed a gradually progressing tremor of the right hand about 18 months ago,
that was especially noticeable when he walked or sat watching television at night. Over the following
months, the tremor became more conspicuous and, at times, would interfere with his writing. One year
later, he began to drag his right leg while walking. Examination at this time showed a soft-spoken,
pleasant, rather impassive man with a staring expression. There was an obvious tremor of the right
hand. There was some rigidity in all limbs, more marked on the right than the left, with cogwheeling at
the right wrist and mild rigidity in the arms. There was no focal weakness, but he seemed slow with the
right hand, and could not perform rapid alternating movements well. There was no significant reflex
asymmetry, and no sensory deficit. Plantar responses were flexor bilaterally
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about his condition and about any proposed
therapy?