Evaluation of tremor

Physiologic tremor can be enhanced by several metabolic conditions and alcohol withdrawal. Diagnostic testing for these conditions should be performed urgently. Alcohol withdrawal tremors also need to be recognized and treated urgently.

Thyrotoxicosis

Symptoms include palpitations, heat intolerance, diaphoresis, weight loss, and anxiety. Thyroid function testing should be considered in every patient who presents with an action tremor. Treatment options are radioactive iodine therapy, antithyroid drugs, and surgery.

Pheochromocytoma

Symptoms include headache, sweating, and tachycardia. Patients often have hypertension. The tremor occurs due to excess catecholamines. This is typically evaluated by measuring urinary and plasma fractionated metanephrines and catecholamines. Treatment includes medical options (phenoxybenzamine, phentolamine) and surgical options (open or laparoscopic adrenalectomy).

Hypoglycemia

Symptoms include sweating, anxiety, tachycardia, and tremor. Patients may also experience fatigue, dizziness, visual disturbances, and confusion. Symptoms are generally seen as the plasma glucose level falls to <55 mg/dL (3 mmol/L). All patients may require supportive care with glucose and/or glucagon while awaiting definitive therapy for the underlying condition.

Alcohol withdrawal

Mild tremors may occur within hours after cessation of drinking. Continued alcohol withdrawal can lead to seizures, fever, and delirium with hallucinations, dehydration, and dangerous autonomic instability (delirium tremens). These usually occur 2 to 4 days after alcohol cessation but can happen as long as 10 days later. Alcohol withdrawal requires close monitoring and treatment. Benzodiazepines remain the cornerstone of treatment.