Internal Medicine

P1: OXT/OZN/JDO P2: PSB

0521779407-E-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:10

560 Essential Tremor Excessive Daytime Sleepiness

■Blood & urine tests normal

■Brain imaging normal

differential diagnosis

■Drug-induced tremor (esp. beta-adrenergic agonists, caffeine, ste-

roids, tamoxifen, antiarrhythmics, valproic acid, cyclosporine, tacro-

limus) excluded by history

■Metabolic (eg, hyperthyroidism, electrolyte disturbance, hepatic or

renal disorders) differentiated clinically

■Degenerative disorders: Parkinson’s disease or atypical parkinson-

ism excluded clinically

■Structural & hypoxic ischemic injury: excluded by history & brain

imaging

management

■Limit caffeine intake

■Reassure pt that symptoms do not reflect anxiety disorder

specific therapy

Indications

■Tremor that significantly interferes w/ lifestyle

➣Propranolol

➣Primidone

➣Alprazolam

■For pts refractory to above treatments

➣Thalamotomy: stereotactic ventrolateral thalamotomy

➣Thalamic deep brain stimulator

follow-up

■Routine follow-up if undergoing therapy

complications and prognosis

■Symptoms progress gradually over decades

Excessive Daytime Sleepiness...........................

CHAD CHRISTINE, MD

history & physical

■Excessive daytime sleepiness

■Loud snoring, apneic episodes may occur during sleep (suggestive

of sleep apnea)

■Obesity is common in sleep apnea