Unilateral

cerebellar
pathology

Intention

Rest

Parkinsons

Unilateral

Tremor

Postural + family history

Anxiety

Bilateral
Rest +
intention

Recent alcohol
withdrawal
Symptoms of
hyperthyroidism

Intention

Benign
essential
tremor
Anxiety
Alcohol
withdrawal
Hyperthyroidism
Bilateral
cerebellar
pathology

Figure 38.1 Flowchart for diagnosing the cause of a tremor

If the cause turns out to be neurological (e.g. Parkin

sons disease), remember to ask about the psychological
features (depression) and whether the patient has
support at home. These patients have an increased risk
of falls so addressing this issue in the history and also
in your discussion of management will be important.
Mentioning a multidisciplinary review (e.g. a physio
therapist and occupational therapist) will grab those
few marks for considering a holistic approach that are
earmarked for better candidates.

Parkinson-plus syndromes
To grab those extra few marks for a merit or distinction,
you should consider knowing the salient features of the
most common Parkinson-plus syndromes as well as
lithium toxicity:
Progressive supranuclear palsy: a Parkinsons-plus
syndrome in which patients exhibit asymmetrical Par
kinsonism with early falls (often backwards) and a ver

tical supranuclear gaze palsy. The latter is the result of

a failure to initiate vertical gaze above the level of the
brainstem nuclei. To confirm a pure supranuclear palsy,
vertical gaze can be elicited by assessing for the presence
of vestibular ocular reflexes by turning the patients
head down, with resultant upward eye deviation (the
upward eye deviation is possible despite the vertical
gaze palsy because the reflex does not require the supra
nuclear pathways).
Multiple system atrophy: early autonomic dysfunc
tion (e.g. postural hypotension), cerebellar signs
(DANISH dysdiadochokinesis, ataxia, nystagmus,
intention tremor, scanning dysarthria, heelshin test
positive).
Corticobasal syndrome: a very rare atypical parkin
sonian syndrome. It is classically unilateral with rapid
motor and cognitive decline. Patients develop apraxia
and alien hand phenomenon.
Lewy body dementia: early dementia is associ
ated with visual hallucinations and fluctuating
cognition.
Vascular Parkinsonism (multi-infarct dementia): in
this condition, there is a step-by-step decline. Cardio
vascular risk factors (hypertension, diabetes, hypercho
lesterolaemia) are apparent.