⚠️

DRAFT - Pending Review

This plan requires physician review before clinical use.

Tremor, Unspecified

VERSION: 1.1 CREATED: February 2, 2026 REVISED: February 2, 2026 STATUS: Revised per checker pipeline (v1.1)

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DIAGNOSIS: Tremor, Unspecified

ICD-10: R25.1 (Tremor, unspecified), G25.0 (Essential tremor), G25.1 (Drug-induced tremor), G25.2 (Other specified forms of tremor), G25.9 (Extrapyramidal and movement disorder, unspecified)

CPT CODES: 99213-99215 (E&M outpatient), 99221-99223 (E&M inpatient), 78830 (DaTscan), 70553 (MRI brain with/without contrast), 70551 (MRI brain without contrast), 84443 (TSH), 84439 (Free T4), 80053 (CMP), 82390 (Ceruloplasmin), 82607 (Vitamin B12), 95907-95913 (NCS/EMG), 95885 (EMG), 95816 (EEG), 70450 (CT head without contrast), 80307 (Drug screen), 82525 (24-hour urine copper)

SYNONYMS: Tremor, unspecified tremor, tremor evaluation, tremor workup, trembling, shaking, involuntary shaking, hand tremor, head tremor, voice tremor, action tremor, resting tremor, postural tremor, kinetic tremor, intention tremor, undifferentiated tremor, tremor NOS, new-onset tremor

SCOPE: Evaluation and diagnostic workup of undifferentiated tremor in adults. Covers the systematic approach to tremor classification (rest, postural, kinetic, intention, task-specific), differentiation of essential tremor, Parkinson tremor, enhanced physiologic tremor, drug-induced tremor, cerebellar tremor, Holmes (rubral) tremor, dystonic tremor, and psychogenic (functional) tremor. Includes DaTscan indications, laboratory workup (thyroid, Wilson disease, medication review), and empiric treatment while awaiting definitive diagnosis. Settings: ED, HOSP, OPD. Excludes definitive management of established diagnoses (see Essential Tremor, Parkinson's Disease, Drug-Induced Parkinsonism, Dystonia, Functional Neurological Disorder templates for ongoing management after diagnosis confirmed).

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DEFINITIONS: - Tremor: Involuntary, rhythmic, oscillatory movement of a body part produced by alternating or synchronous contractions of reciprocally innervated muscles - Rest Tremor: Tremor occurring in a body part that is completely supported against gravity and not voluntarily activated; classic for Parkinson's disease (4-6 Hz, pill-rolling) - Postural Tremor: Tremor occurring when voluntarily maintaining a position against gravity (e.g., arms outstretched); characteristic of essential tremor and enhanced physiologic tremor - Kinetic Tremor: Tremor occurring during voluntary movement; includes simple kinetic (during movement) and intention tremor (worsening as target is approached) - Intention Tremor: Subtype of kinetic tremor that increases in amplitude as the limb approaches a visual target (finger-to-nose); classic for cerebellar lesions - Task-Specific Tremor: Tremor occurring only during specific activities (e.g., writing, playing musical instrument) - Holmes Tremor (Rubral Tremor): Combination of rest, postural, and kinetic/intention tremor; low frequency (< 4.5 Hz), large amplitude; caused by midbrain/thalamic lesions disrupting both cerebellar and dopaminergic pathways - Dystonic Tremor: Irregular, jerky tremor occurring in a body part affected by dystonia; presence of a "null point" (position where tremor diminishes) - Enhanced Physiologic Tremor: Exaggeration of normal physiologic tremor (8-12 Hz) by reversible causes (anxiety, caffeine, medications, hyperthyroidism, hypoglycemia) - Functional (Psychogenic) Tremor: Tremor with features of variability, distractibility, and entrainment, inconsistent with organic tremor patterns

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TREMOR CLASSIFICATION FRAMEWORK:

Feature	Rest Tremor	Postural Tremor	Kinetic Tremor	Intention Tremor	Task-Specific
When present	Limb fully supported, relaxed	Maintaining position against gravity	During voluntary movement	Approaching target	Only during specific task
Frequency	4-6 Hz	6-12 Hz	4-8 Hz	3-5 Hz	Variable
Typical cause	Parkinson's disease	Essential tremor, physiologic	Essential tremor	Cerebellar lesion	Primary writing tremor
Amplitude	Moderate, may re-emerge	Low-moderate	Moderate	Increases at target	Variable

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
TSH (CPT 84443)	ROUTINE	ROUTINE	ROUTINE	-	Hyperthyroidism is a common reversible cause of enhanced physiologic tremor; hypothyroidism rarely causes tremor	Normal (0.4-4.0 mIU/L); abnormal TSH triggers free T4; hyperthyroidism identified directs treatment of underlying cause
Free T4 (CPT 84439)	ROUTINE	ROUTINE	ROUTINE	-	Order if TSH abnormal; confirms hyper- or hypothyroidism as cause of tremor	Normal; elevated confirms hyperthyroidism contributing to tremor
CMP (CPT 80053)	URGENT	ROUTINE	ROUTINE	-	Electrolyte derangements (hypoglycemia, hyponatremia, uremia, hepatic dysfunction) cause or worsen tremor	Normal; hypoglycemia, hyponatremia, liver failure, renal failure all produce tremor
Glucose (CPT 82947)	URGENT	ROUTINE	ROUTINE	-	Hypoglycemia is an acute reversible cause of tremor; hyperglycemia with diabetic neuropathy	Normal (70-100 mg/dL fasting); hypoglycemia triggers treatment and tremor resolves
CBC with differential (CPT 85025)	ROUTINE	ROUTINE	ROUTINE	-	General health assessment; infection screen; anemia workup	Normal; leukocytosis suggests infectious or inflammatory cause
Comprehensive medication reconciliation	STAT	STAT	ROUTINE	-	Drug-induced tremor is one of the most common causes; review ALL current medications including OTC, herbal, and supplements	Complete medication list; identify tremor-inducing agents (valproate, lithium, SSRIs, stimulants, bronchodilators, amiodarone, metoclopramide, antipsychotics)
Caffeine intake assessment	ROUTINE	ROUTINE	ROUTINE	-	Excessive caffeine is a leading cause of enhanced physiologic tremor; often overlooked	Quantify daily caffeine intake (coffee, tea, energy drinks, supplements); >400 mg/day causes significant tremor

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Serum ceruloplasmin (CPT 82390)	-	ROUTINE	ROUTINE	-	Wilson disease screening in patients <50 years or with atypical features (hepatic dysfunction, psychiatric symptoms, Kayser-Fleischer rings)	20-40 mg/dL; low (<20 mg/dL) triggers 24-hour urine copper and slit-lamp exam for K-F rings
24-hour urine copper (CPT 82525)	-	EXT	EXT	-	Wilson disease confirmation if ceruloplasmin low or borderline	<40 mcg/24h normal; >100 mcg/24h strongly suggestive of Wilson disease
Serum copper (CPT 82390)	-	ROUTINE	ROUTINE	-	Wilson disease evaluation alongside ceruloplasmin; copper deficiency causes neurological symptoms	Normal (70-140 mcg/dL); low total copper with low ceruloplasmin indicates Wilson disease
Liver function tests (CPT 80076)	-	ROUTINE	ROUTINE	-	Wilson disease screening; hepatic encephalopathy; medication hepatotoxicity	Normal; abnormal triggers evaluation for Wilson disease, hepatic tremor
Vitamin B12 (CPT 82607)	-	ROUTINE	ROUTINE	-	Deficiency causes tremor, neuropathy, and myelopathy contributing to movement disorder	>400 pg/mL; borderline (200-400) triggers methylmalonic acid; deficiency triggers supplementation
Drug levels (lithium, valproate, phenytoin, theophylline) (CPT 80178/80164/80185/80198)	URGENT	ROUTINE	ROUTINE	-	Drug toxicity is a common and reversible cause of tremor; supratherapeutic levels worsen EPS	Therapeutic ranges; supratherapeutic levels require dose adjustment or discontinuation
Drug/toxin screen (CPT 80307)	URGENT	ROUTINE	ROUTINE	-	Identify sympathomimetics, illicit substances (amphetamines, cocaine), or other toxins causing tremor	Negative; positive identifies offending agent for targeted management
Urine metanephrines/catecholamines	-	EXT	EXT	-	Pheochromocytoma presenting with tremor, hypertension, tachycardia, and diaphoresis	Normal; elevated triggers CT/MRI adrenals and endocrinology referral
Magnesium (CPT 83735)	URGENT	ROUTINE	ROUTINE	-	Hypomagnesemia contributes to tremor and neuromuscular excitability; common in alcoholism	Normal (1.7-2.2 mg/dL); low requires supplementation
ESR (CPT 85652) / CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	Inflammatory markers if autoimmune or paraneoplastic etiology suspected	Normal; elevated triggers further workup for inflammatory/autoimmune cause

1C. Rare/Specialized

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Heavy metal levels (mercury, lead, manganese, arsenic)	-	-	EXT	-	Occupational or environmental exposure causing tremor; manganese causes parkinsonism	Normal; elevated triggers toxicology consultation and chelation therapy
Anti-neuronal antibodies (paraneoplastic panel) (CPT 86255)	-	-	EXT	-	Autoimmune or paraneoplastic movement disorder presenting as tremor	Negative; positive triggers malignancy search and immunotherapy
Anti-GAD65 antibodies (CPT 86235)	-	-	EXT	-	Autoimmune movement disorder (stiff-person spectrum, cerebellar ataxia with tremor)	Negative; positive at high titers confirms autoimmune etiology
Genetic testing (LINGO1, FUS, ETM1/2, DYT genes)	-	-	EXT	-	Family history of tremor or dystonia; research interest; young-onset tremor	Informational; positive triggers genetic counseling
Serum ferritin and iron studies	-	-	EXT	-	Restless legs/periodic limb movements sometimes confused with tremor; iron deposition disorders	Normal; low ferritin (<50 mcg/L) requires supplementation; very high ferritin triggers iron overload evaluation
Cortisol level (CPT 82533)	-	-	EXT	-	Cushing syndrome with tremor and proximal myopathy	Normal; elevated triggers dexamethasone suppression test

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Comprehensive neurologic examination	STAT	ROUTINE	ROUTINE	-	At presentation; document tremor type, distribution, activation conditions, frequency, associated signs (bradykinesia, rigidity, dystonia, ataxia)	Characterize tremor (rest, postural, kinetic, intention, task-specific); identify associated neurologic signs; laterality and symmetry	None
Handwriting sample	-	ROUTINE	ROUTINE	-	At presentation and follow-up visits; compare over time	Large, tremulous writing (essential tremor) vs micrographia (Parkinson's); progressive change	None
Spiral drawing test (Archimedes spiral)	-	ROUTINE	ROUTINE	-	At presentation; objective assessment tool	Objective tremor severity rating; track progression or treatment response	None
Finger-to-nose testing	ROUTINE	ROUTINE	ROUTINE	-	At presentation	Dysmetria and intention tremor indicate cerebellar cause; past-pointing increases with action in intention tremor	None
CT head without contrast (CPT 70450)	STAT	STAT	-	-	STAT if acute onset tremor with other neurologic signs (weakness, ataxia, altered consciousness) suggesting structural lesion	Rule out hemorrhage, mass, hydrocephalus; does NOT adequately visualize posterior fossa or midbrain	None for non-contrast

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain without contrast (CPT 70551)	-	ROUTINE	ROUTINE	-	If structural cause suspected; atypical features; young onset; acute onset	Rule out midbrain/thalamic lesion (Holmes tremor), cerebellar lesion, basal ganglia pathology, Wilson disease (T2 basal ganglia changes), demyelination	MRI-incompatible implants, severe claustrophobia
MRI brain with and without contrast (CPT 70553)	-	ROUTINE	ROUTINE	-	If mass lesion, demyelination, or infection suspected	Midbrain lesion (Holmes tremor); cerebellar tumor/abscess; MS plaques; basal ganglia enhancement	MRI-incompatible implants; contrast allergy; GFR <30 for gadolinium
DaTscan (Ioflupane I-123 SPECT) (CPT 78830)	-	-	ROUTINE	-	Key study to differentiate essential tremor from Parkinson's disease when clinical features overlap; order when diagnostic uncertainty persists after clinical evaluation	Normal striatal uptake indicates essential tremor, enhanced physiologic tremor, drug-induced tremor, psychogenic tremor; reduced striatal uptake indicates Parkinson's disease, MSA, PSP, DLB	Pregnancy; iodine/shellfish allergy; hold interfering medications (bupropion, amphetamines, modafinil, cocaine) 2 weeks before
MRI with susceptibility-weighted imaging (SWI)	-	ROUTINE	ROUTINE	-	If Wilson disease or iron deposition suspected	Basal ganglia T2 hypointensity (iron deposition); "face of the giant panda" sign in Wilson disease (midbrain)	Per MRI contraindications
Accelerometry / Tremor analysis	-	-	EXT	-	Objective quantification of tremor frequency and amplitude; distinguish tremor types by frequency characteristics	ET: 4-12 Hz; physiologic: 8-12 Hz; PD rest: 4-6 Hz; cerebellar: 3-5 Hz; Holmes: <4.5 Hz; orthostatic: 13-18 Hz	None
EMG (CPT 95885)	-	-	EXT	-	If neuropathic tremor suspected; orthostatic tremor evaluation; distinguish tremor types	Rhythmic bursting pattern; high-frequency EMG bursts in orthostatic tremor (13-18 Hz); neuropathic tremor pattern	None significant
NCS/EMG (CPT 95907-95913)	-	ROUTINE	ROUTINE	-	If peripheral neuropathy suspected as contributing factor to sensory-mediated tremor	Sensory or sensorimotor neuropathy; demyelinating features (CIDP)	Anticoagulation (relative for EMG)

2C. Rare/Specialized

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
FDG-PET brain (CPT 78608)	-	-	EXT	-	Atypical parkinsonism suspected; distinguish PD from MSA, PSP, CBD	Characteristic metabolic patterns differ by diagnosis; hypometabolism in posterior cortex (DLB), frontal (PSP), asymmetric cortical (CBD)	Significant hyperglycemia; pregnancy
MIBG cardiac scintigraphy	-	-	EXT	-	Differentiate PD (reduced cardiac sympathetic innervation) from MSA or drug-induced parkinsonism (normal)	Reduced uptake indicates PD or DLB; normal indicates MSA, DIP, essential tremor	Drugs affecting cardiac norepinephrine uptake
Olfactory testing (UPSIT)	-	-	ROUTINE	-	Supportive test; olfactory dysfunction suggests underlying PD (present early) vs normal olfaction in ET or DIP	Impaired indicates PD, DLB; normal indicates ET, DIP, functional tremor	Nasal obstruction
Transcranial sonography	-	-	EXT	-	Substantia nigra hyperechogenicity assessment; supports PD diagnosis	Hyperechogenicity suggests PD; normal indicates ET, DIP	Inadequate temporal bone window
Polysomnography (CPT 95810)	-	-	EXT	-	REM sleep behavior disorder suggests underlying synucleinopathy (PD, DLB, MSA)	RBD present strongly supports underlying neurodegenerative parkinsonism	None
Slit-lamp ophthalmologic exam	-	ROUTINE	ROUTINE	-	Kayser-Fleischer ring detection for Wilson disease in patients <50 with low ceruloplasmin or liver disease	K-F rings present confirms Wilson disease highly likely	None

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3. TREATMENT

3A. Immediate Management (ED/Acute Setting)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Discontinue or reduce suspected causative medication	PO	Drug-induced tremor; temporal relationship between medication initiation and tremor onset	N/A :: PO :: once :: Identify and discontinue offending agent if safe; taper if abrupt withdrawal is dangerous (benzodiazepines, antiepileptics, antipsychotics); coordinate with prescribing physician	Active psychosis, seizure disorder, or condition requiring the medication without safe alternative	Symptom resolution timeline; withdrawal symptoms; rebound of treated condition	STAT	STAT	ROUTINE	-
Dextrose (for hypoglycemia)	IV	Hypoglycemia-induced tremor with blood glucose <70 mg/dL	25 g :: IV :: once :: Administer 50 mL of D50W IV push; recheck glucose in 15 minutes; repeat if glucose remains <70 mg/dL; transition to oral carbohydrates once able	None in emergent hypoglycemia	Blood glucose q15 min until >100 mg/dL; identify and treat underlying cause of hypoglycemia	STAT	STAT	-	-
Electrolyte correction (hyponatremia)	IV	Enhanced physiologic tremor from hyponatremia	0.9% NaCl :: IV :: continuous :: Normal saline or hypertonic saline per sodium deficit calculation; correct sodium no faster than 8-10 mEq/L per 24 hours to prevent osmotic demyelination	Hypervolemic hyponatremia (use fluid restriction instead)	Serum sodium q4-6h during correction; strict I/O monitoring; tremor resolution with correction	STAT	STAT	-	-
Magnesium sulfate (for hypomagnesemia)	IV	Hypomagnesemia-induced tremor and neuromuscular excitability	2 g :: IV :: once :: Administer 2 g IV over 1 hour; recheck magnesium in 4-6 hours; repeat 1-2 g IV if still low; transition to oral magnesium oxide 400-800 mg daily	Renal failure (dose adjust); heart block	Serum magnesium levels; deep tendon reflexes; respiratory rate	URGENT	URGENT	ROUTINE	-
Propranolol (empiric)	PO	Empiric symptomatic relief for functionally impairing tremor while diagnostic workup in progress; effective for postural and action tremor	20 mg :: PO :: BID :: Start 20 mg BID; titrate by 20 mg q3-7d based on response and tolerability; target 60-320 mg/day in divided doses; use LA formulation once optimal dose determined	Asthma/severe COPD; bradycardia (HR <50); second/third-degree AV block; decompensated heart failure; severe peripheral vascular disease; concurrent verapamil	HR, BP at each visit; bronchospasm; fatigue, depression; masks hypoglycemia in diabetics	-	ROUTINE	ROUTINE	-
Lorazepam (short-term)	PO/IV	Severe acute tremor causing significant distress or functional impairment; short-term bridge while definitive evaluation underway	0.5 mg :: PO/IV :: q8h PRN :: 0.5-1 mg PO/IV q8h PRN for severe tremor; limit to 48-72 hours acute use; not for chronic management due to dependence risk	Respiratory depression; severe hepatic impairment; myasthenia gravis; concurrent opioids (relative); elderly (fall risk)	Sedation, respiratory rate, fall risk; do NOT prescribe for chronic use	URGENT	URGENT	-	-

3B. Empiric Pharmacologic Treatment (Awaiting Diagnosis)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Propranolol (Inderal)	PO	First-line empiric for postural/action tremor pending diagnosis; effective for essential tremor and enhanced physiologic tremor	20 mg :: PO :: BID :: Start 20 mg BID; titrate by 20 mg q3-7d; target 60-320 mg/day divided BID-TID; Inderal LA 60-320 mg daily once stable dose determined	Asthma/severe COPD; bradycardia (HR <50); second/third-degree AV block; decompensated heart failure; severe peripheral vascular disease	HR, BP; bronchospasm; fatigue; depression; cold extremities; erectile dysfunction; do NOT stop abruptly (rebound tachycardia)	-	ROUTINE	ROUTINE	-
Primidone (Mysoline)	PO	Alternative first-line for action/postural tremor; use when propranolol is contraindicated or inadequate	12.5 mg :: PO :: QHS :: Start 12.5-25 mg QHS (ultra-low dose); titrate very slowly by 12.5-25 mg/week; target 250-750 mg/day in divided doses; initiation reaction (nausea, dizziness, sedation) common -- start very low	Porphyria; severe sedation to initial dose; pregnancy (teratogenic)	Sedation, ataxia, nausea (especially first dose -- warn patient); CBC periodically; cognitive effects in elderly	-	ROUTINE	ROUTINE	-
Gabapentin (Neurontin)	PO	Second-line for tremor when beta-blockers and primidone not tolerated or contraindicated	300 mg :: PO :: QHS :: Start 300 mg QHS; titrate by 300 mg q3-5d; target 900-1800 mg/day divided TID; max 3600 mg/day; adjust for renal function	Severe renal impairment (dose adjust); respiratory depression with opioids or CNS depressants	Sedation, dizziness, peripheral edema; renal function; suicidality (rare)	-	ROUTINE	ROUTINE	-
Topiramate (Topamax)	PO	Second-line for tremor; evidence for essential tremor	25 mg :: PO :: daily :: Start 25 mg daily; titrate by 25-50 mg/week; target 100-400 mg/day divided BID	Kidney stones; narrow-angle glaucoma; pregnancy (teratogenic); metabolic acidosis	Cognitive effects (word-finding difficulty, concentration); paresthesias; weight loss; kidney stones; metabolic acidosis	-	ROUTINE	ROUTINE	-
Clonazepam (Klonopin)	PO	Third-line for tremor; useful when anxiety is a major contributing factor; effective for orthostatic tremor	0.25 mg :: PO :: BID :: Start 0.25 mg BID; titrate by 0.25 mg q3-5d; target 0.5-4 mg/day divided BID-TID; use lowest effective dose	Respiratory insufficiency; severe hepatic impairment; myasthenia gravis; avoid abrupt discontinuation	Sedation, dependence, fall risk (especially elderly); cognitive impairment; limit duration; taper do not stop abruptly	-	ROUTINE	ROUTINE	-

3C. Etiology-Specific Treatment (When Cause Identified)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Levodopa/Carbidopa (Sinemet)	PO	PD tremor confirmed or strongly suspected based on clinical features and/or DaTscan; diagnostic and therapeutic trial	25/100 mg :: PO :: TID :: Start 25/100 mg TID with meals; titrate by 25/100 mg q1-2 weeks based on response; robust response supports PD diagnosis	Narrow-angle glaucoma; concurrent non-selective MAOIs; active psychosis (relative)	Nausea, orthostatic hypotension, dyskinesia (long-term); hallucinations; response to levodopa is diagnostically supportive of PD	-	ROUTINE	ROUTINE	-
Botulinum toxin (OnabotulinumtoxinA)	IM	Focal tremor refractory to oral medications; head tremor; voice tremor; dystonic tremor; hand tremor affecting function	50-100 units :: IM :: q3 months :: 50-100 units per affected limb for hand tremor; 40-400 units for head/cervical tremor; individualized by movement disorders specialist; effects onset 1-2 weeks, peak 4-6 weeks	Infection at injection site; myasthenia gravis; pregnancy	Weakness at injection site (dose-related); dysphagia with head/voice injections; repeat q3 months	-	-	ROUTINE	-
Methimazole	PO	Hyperthyroid tremor; first-line antithyroid agent for Graves disease causing tremor	10 mg :: PO :: daily :: Start 10 mg daily; titrate per thyroid function; typical range 5-30 mg daily; tremor resolves with euthyroid state; endocrinology co-management	Pregnancy first trimester (use PTU instead); prior agranulocytosis from antithyroid drugs; severe hepatic disease	Thyroid function tests q4-8 weeks initially; CBC (agranulocytosis risk -- instruct patient to report fever/sore throat immediately); LFTs	-	ROUTINE	ROUTINE	-
Propylthiouracil (PTU)	PO	Hyperthyroid tremor; use in first trimester pregnancy or when methimazole is contraindicated	100 mg :: PO :: TID :: Start 100 mg TID; titrate per thyroid function; typical range 100-200 mg TID; tremor resolves with euthyroid state; endocrinology co-management	Hepatotoxicity (black box warning); prior agranulocytosis from antithyroid drugs	Thyroid function tests q4-8 weeks initially; CBC (agranulocytosis risk); LFTs q1-3 months (hepatotoxicity -- black box); instruct patient to report jaundice, dark urine, abdominal pain	-	ROUTINE	ROUTINE	-
D-Penicillamine	PO	Wilson disease confirmed; first-line copper chelation therapy	250 mg :: PO :: daily :: Start 250 mg daily; increase by 250 mg q4-7d to target 1000-1500 mg/day divided QID; take on empty stomach 1 hour before meals; pyridoxine 25 mg daily supplementation required	Penicillin allergy (relative); renal impairment; blood dyscrasias; lupus-like syndrome history	24-hour urine copper; CBC q2 weeks for first 3 months then monthly; urinalysis (proteinuria); hepatologist co-management; neurologic monitoring for initial worsening (up to 50% of patients)	-	ROUTINE	ROUTINE	-
Trientine (Syprine)	PO	Wilson disease confirmed; use when D-penicillamine is not tolerated or contraindicated	250 mg :: PO :: TID :: Start 250 mg TID; titrate to 750-1500 mg/day divided TID; take on empty stomach 1 hour before meals; separate from iron supplements by 2 hours	Iron supplementation within 2 hours (chelates iron); pregnancy (relative -- risk-benefit)	24-hour urine copper q3-6 months; CBC; hepatic function; hepatologist co-management; fewer side effects than D-penicillamine	-	ROUTINE	ROUTINE	-
Amantadine	PO	Parkinsonian features suspected but not yet confirmed; mild symptomatic benefit; avoids levodopa commitment	100 mg :: PO :: daily :: Start 100 mg daily; increase to 100 mg BID after 1 week; max 300 mg/day; reduce dose if CrCl <50	Severe renal impairment (CrCl <15); seizure history (relative); livedo reticularis	Renal function; hallucinations (especially elderly); insomnia (avoid evening dosing); livedo reticularis; ankle edema	-	ROUTINE	ROUTINE	-

3D. Non-Pharmacologic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Caffeine reduction or elimination	Dietary	Enhanced physiologic tremor exacerbated by caffeine; all tremor types worsened by caffeine	N/A :: Dietary :: continuous :: Reduce caffeine intake gradually to avoid withdrawal headache; target <200 mg/day or elimination; educate on hidden caffeine sources (chocolate, energy drinks, medications)	None	Tremor severity with caffeine reduction; withdrawal symptoms (headache, fatigue for 1-2 weeks)	ROUTINE	ROUTINE	ROUTINE	-
Weighted utensils and adaptive equipment	Device	Functional impairment with eating, writing, or ADLs due to hand tremor of any etiology	N/A :: Device :: as needed :: Weighted utensils, stabilizing spoons (Liftware), weighted pens, two-handled cups, button hooks, rocker knives; OT assists with selection and training	None	OT assessment and follow-up; functional improvement	-	ROUTINE	ROUTINE	-
Wrist weights	Device	Reduce tremor amplitude during activities; kinetic and postural tremor	N/A :: Device :: as needed :: 1-2 lb wrist weights during functional activities; causes fatigue with prolonged use	None	Arm fatigue monitoring; not for prolonged continuous use	-	-	ROUTINE	-
Stress management and relaxation techniques	Behavioral	Stress, anxiety, and fatigue exacerbate all tremor types; anxiety is the primary driver in enhanced physiologic tremor	N/A :: Behavioral :: daily :: Deep breathing exercises, progressive muscle relaxation, mindfulness meditation, biofeedback; formal CBT if anxiety is prominent	None	Tremor severity correlation with stress levels; obtain formal psychiatric referral if anxiety disorder identified	-	ROUTINE	ROUTINE	-
Sleep hygiene optimization	Behavioral	Sleep deprivation and fatigue worsen all tremor types	N/A :: Behavioral :: continuous :: Target 7-9 hours sleep; consistent sleep schedule; avoid caffeine after noon; screen for sleep disorders (RBD in PD, OSA)	None	Sleep quality; if RBD suspected, refer for polysomnography	-	ROUTINE	ROUTINE	-
Alcohol avoidance counseling	Behavioral	Alcohol transiently suppresses essential tremor but is NOT a treatment; chronic alcohol causes cerebellar tremor; withdrawal causes severe tremor	N/A :: Behavioral :: continuous :: Educate that alcohol is NOT a treatment for tremor despite temporary relief; chronic alcohol worsens tremor long-term through cerebellar toxicity; screen for alcohol use disorder	None	Alcohol use screening (AUDIT-C); if alcohol use disorder identified, refer to addiction medicine	ROUTINE	ROUTINE	ROUTINE	-
Limit tremor-exacerbating activities	Behavioral	Avoid or modify activities that worsen tremor or where tremor causes safety risk	N/A :: Behavioral :: continuous :: Plan activities for times of day when tremor is least severe; use both hands for pouring; use straws for drinking; electronic devices over handwriting when possible	None	Functional impact assessment at each visit	-	ROUTINE	ROUTINE	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Neurology referral for tremor evaluation when etiology is uncertain, tremor is progressive, or associated neurologic signs present (bradykinesia, rigidity, ataxia, dystonia)	URGENT	URGENT	ROUTINE	-
Movement disorders specialist referral for diagnostic uncertainty after initial neurology evaluation, DaTscan interpretation, tremor refractory to first-line therapy, or interventional treatment evaluation (DBS, MRgFUS)	-	ROUTINE	ROUTINE	-
Occupational therapy for functional impairment with ADLs; adaptive equipment assessment; handwriting strategies; workplace modification	-	ROUTINE	ROUTINE	-
Physical therapy for balance and gait assessment if parkinsonian features or fall risk identified	-	ROUTINE	ROUTINE	-
Speech therapy if voice tremor identified affecting communication or swallowing	-	-	ROUTINE	-
Endocrinology referral if hyperthyroidism confirmed as tremor etiology for definitive thyroid management	-	ROUTINE	ROUTINE	-
Hepatology referral if Wilson disease suspected or confirmed for chelation therapy co-management	-	ROUTINE	ROUTINE	-
Psychiatry referral if functional (psychogenic) tremor diagnosed for integrated treatment approach; or if anxiety disorder is primary driver	-	ROUTINE	ROUTINE	-
Toxicology or occupational medicine if heavy metal exposure or environmental toxin suspected	-	-	ROUTINE	-
Ophthalmology (slit-lamp exam) if Wilson disease suspected and patient age <50 to evaluate for Kayser-Fleischer rings	-	ROUTINE	ROUTINE	-
Pharmacy consult for comprehensive medication reconciliation to identify all potential tremor-inducing agents including OTC, herbal, supplements	ROUTINE	ROUTINE	ROUTINE	-
Neuropsychology if cognitive concerns in addition to tremor (suggests neurodegenerative process)	-	-	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Return immediately for sudden worsening of tremor with new weakness, speech changes, vision changes, or difficulty walking (indicates stroke or structural brain lesion)	STAT	STAT	ROUTINE
Return immediately for high fever with severe rigidity and altered consciousness (indicates neuroleptic malignant syndrome if on antipsychotics)	STAT	STAT	ROUTINE
Tremor has many causes, most of which are treatable or manageable; an evaluation is needed to determine the specific cause before starting long-term treatment	ROUTINE	ROUTINE	ROUTINE
Bring a complete list of ALL medications (prescription, OTC, herbal, supplements) to every appointment as many common medications cause tremor	ROUTINE	ROUTINE	ROUTINE
Reduce or eliminate caffeine intake as this often significantly improves tremor regardless of the underlying cause	ROUTINE	ROUTINE	ROUTINE
Get adequate sleep (7-9 hours) and manage stress as fatigue and anxiety consistently worsen all types of tremor	-	ROUTINE	ROUTINE
Do not self-medicate with alcohol; while alcohol temporarily reduces essential tremor, it is not a treatment and chronic use causes permanent cerebellar damage with worsening tremor	ROUTINE	ROUTINE	ROUTINE
Keep a tremor diary noting when tremor is worst, what makes it better or worse, and any new symptoms to share with your neurologist	-	-	ROUTINE
Inform all healthcare providers about your tremor so they avoid prescribing medications that worsen it	ROUTINE	ROUTINE	ROUTINE
If a specific medication was identified as causing your tremor, do NOT restart it without neurologist approval	STAT	STAT	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Reduce caffeine to <200 mg/day or eliminate entirely; taper gradually over 1-2 weeks to avoid withdrawal headache	ROUTINE	ROUTINE	ROUTINE
Limit or avoid alcohol; not a treatment for tremor despite temporary relief	ROUTINE	ROUTINE	ROUTINE
Regular exercise (aerobic and strength training) improves overall neurologic health and reduces tremor severity	-	-	ROUTINE
Maintain regular sleep schedule; sleep deprivation worsens tremor	-	ROUTINE	ROUTINE
Stress reduction techniques (meditation, yoga, tai chi, biofeedback) reduce tremor exacerbation	-	-	ROUTINE
Avoid sympathomimetics (decongestants containing pseudoephedrine, diet pills, energy supplements) which worsen tremor	ROUTINE	ROUTINE	ROUTINE
Use adaptive equipment (weighted utensils, stabilizing devices) to maintain functional independence	-	ROUTINE	ROUTINE
Fall prevention measures if gait or balance affected (non-slip footwear, grab bars, adequate lighting, remove loose rugs)	-	ROUTINE	ROUTINE

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═══════════════════════════════════════════════════════════════ SECTION B: SUPPORTING INFORMATION ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Primary Differential by Tremor Type

Diagnosis	Tremor Type	Frequency	Distribution	Key Distinguishing Features	Tests to Differentiate
Essential tremor	Postural + kinetic (action tremor)	4-12 Hz	Bilateral hands (often asymmetric); head (titubational); voice	Duration >3 years; family history (~50%); alcohol responsive; NO bradykinesia, rigidity, or rest tremor; large tremulous handwriting	Clinical exam; DaTscan normal; response to propranolol/primidone
Parkinson's disease	Rest tremor (postural component with re-emergence)	4-6 Hz	Unilateral onset then bilateral; "pill-rolling" hands; chin/jaw	Bradykinesia (decrement); rigidity (cogwheel); postural instability; hyposmia; RBD; micrographia	DaTscan reduced uptake; clinical exam (MDS criteria); olfactory testing impaired
Enhanced physiologic tremor	Postural	8-12 Hz	Bilateral hands; low amplitude	Reversible cause present: anxiety, caffeine, medications, hyperthyroidism, hypoglycemia, fatigue; resolves when cause removed	TSH; medication review; caffeine assessment; resolves with trigger removal
Drug-induced tremor	Variable (postural, rest, or mixed depending on agent)	Variable	Bilateral, often symmetric	Temporal relationship to medication; valproate (postural); lithium (postural/intention); SSRIs (postural); antipsychotics (rest/postural); bronchodilators (postural)	Medication review; drug levels; improvement with dose reduction or discontinuation
Cerebellar tremor (intention)	Intention (kinetic, worse at target)	3-5 Hz	Ipsilateral to cerebellar lesion; limbs > proximal	Dysmetria; dysdiadochokinesia; nystagmus; ataxic gait; scanning speech; past-pointing on finger-to-nose	MRI brain (cerebellar lesion, atrophy); clinical exam for cerebellar signs
Holmes tremor (rubral)	Rest + postural + intention (all three)	<4.5 Hz	Unilateral; large amplitude; proximal + distal	Combination of ALL tremor types; very large amplitude; delayed onset after midbrain/thalamic lesion (stroke, demyelination, trauma); poor medication response	MRI brain (midbrain/thalamic lesion); history of prior brain injury/stroke
Dystonic tremor	Irregular, jerky, oscillatory	Variable (usually 4-7 Hz)	Focal; in body part affected by dystonia	Irregular amplitude and frequency; "null point" where tremor diminishes; associated dystonic posturing; tremor only without obvious dystonia ("tremor associated with dystonia")	Clinical exam (irregular tremor, null point, dystonic posturing); DaTscan normal; botulinum toxin response
Psychogenic (functional) tremor	Variable (any type)	Variable; changes with distraction	Any distribution; often bilateral	Variable frequency; entrainment (tremor adopts frequency of contralateral voluntary tapping); distractibility (tremor stops with cognitive tasks); sudden onset; inconsistent pattern; coactivation sign	Clinical exam (entrainment test, distraction, loading); DaTscan normal; neuropsychiatric evaluation
Orthostatic tremor	Postural (standing only)	13-18 Hz (very high)	Legs; relief with walking or sitting	Occurs ONLY when standing; sensation of unsteadiness; high frequency (often palpable but not visible); relief with sitting, walking, or leaning	Surface EMG showing 13-18 Hz rhythmic discharge; accelerometry
Wilson disease	Variable (postural, kinetic, wing-beating)	3-6 Hz	Proximal > distal; "wing-beating" tremor (arms abducted, elbows flexed)	Age <50; hepatic dysfunction; psychiatric symptoms; Kayser-Fleischer rings; mixed movement disorder (tremor + dystonia + parkinsonism)	Ceruloplasmin (low); 24h urine copper (elevated); slit-lamp exam (K-F rings); MRI (basal ganglia T2 changes)
Neuropathic tremor	Postural + kinetic	Variable	Distal; associated with neuropathy	Concomitant peripheral neuropathy (sensory loss, weakness, areflexia); IgM paraproteinemia common cause; CIDP	NCS/EMG (neuropathy); serum protein electrophoresis; anti-MAG antibodies
Hyperthyroidism	Enhanced postural	8-12 Hz	Bilateral hands; fine, rapid	Weight loss; palpitations; heat intolerance; lid lag; goiter; hyperreflexia; tachycardia	TSH (suppressed); free T4 (elevated)
Paraneoplastic tremor	Variable	Variable	Variable	Subacute onset; associated cerebellar signs or other paraneoplastic features; weight loss; smoking history	Paraneoplastic antibody panel; CT chest/abdomen/pelvis; PET-CT

Key Exam Maneuvers for Tremor Evaluation

Maneuver	What It Tests	Expected Finding
Arms at rest in lap, distraction with mental task (serial 7s)	Rest tremor (PD)	Rest tremor emerges or increases with distraction in PD
Arms outstretched, fingers spread (15-30 seconds)	Postural tremor (ET, physiologic)	Immediate onset postural tremor (ET); re-emergent tremor after latency (PD)
Finger-to-nose (repeatedly)	Intention tremor (cerebellar)	Worsening amplitude as finger approaches target
Rapid alternating hand movements	Dysdiadochokinesia (cerebellar)	Irregular rhythm and amplitude if cerebellar dysfunction
Handwriting sample and spiral drawing	Tremor characterization	Large tremulous (ET) vs micrographia (PD)
Contralateral voluntary rhythmic tapping during tremor observation	Entrainment (functional tremor)	Tremor frequency shifts to match voluntary tapping frequency indicates functional
Distraction (cognitive task, contralateral complex movement)	Distractibility (functional tremor)	Tremor stops or markedly reduces with distraction indicates functional
Standing with eyes open then closed (Romberg)	Orthostatic tremor assessment	Tremor in legs present ONLY on standing; patient reports unsteadiness rather than tremor
Search for "null point" in affected dystonic body part	Dystonic tremor	Tremor diminishes or stops in certain positions indicates dystonic tremor

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6. MONITORING PARAMETERS

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Tremor severity (clinical rating: FTM scale, Bain composite score, or spiral drawing)	-	ROUTINE	ROUTINE	-	Each visit; baseline and q3-6 months	Stable or improving with treatment	Worsening triggers reassessment of diagnosis; adjust treatment; order additional workup
Neurologic exam (look for emerging signs: bradykinesia, rigidity, ataxia, dystonia)	-	ROUTINE	ROUTINE	-	Each visit	No new neurologic signs developing	New bradykinesia/rigidity indicates PD evolving; new ataxia indicates cerebellar pathology; order DaTscan or MRI
Functional impact assessment (QUEST, ADL questionnaire)	-	-	ROUTINE	-	q6-12 months	Minimal functional impairment	Increasing functional impairment triggers treatment intensification; therapy referral; evaluate interventional options
Heart rate and blood pressure	-	ROUTINE	ROUTINE	-	Each visit if on propranolol or other beta-blocker	HR >50 bpm; SBP >90 mmHg	HR <50 or symptomatic bradycardia triggers dose reduction; SBP <90 triggers dose reduction or agent switch
Handwriting sample / spiral drawing	-	ROUTINE	ROUTINE	-	Each visit	Stable or improved	Progressive deterioration triggers diagnosis reassessment; possible PD evolving or treatment failure
TSH (if hyperthyroidism was the cause)	-	ROUTINE	ROUTINE	-	q4-8 weeks until stable, then q6-12 months	Normal (0.4-4.0 mIU/L)	Persistent hyperthyroidism triggers endocrinology management; tremor resolves with euthyroid state
Drug levels (if on tremor-inducing medications that cannot be discontinued)	-	ROUTINE	ROUTINE	-	Per drug-specific schedule	Therapeutic range	Supratherapeutic triggers dose reduction; correlate with tremor severity
Sedation and cognitive effects (if on primidone, gabapentin, benzodiazepines)	-	ROUTINE	ROUTINE	-	Each visit	Tolerable side effects; no cognitive impairment	Intolerable sedation or cognitive effects triggers dose reduction or agent switch
Wilson disease markers (ceruloplasmin, 24h urine copper) if on chelation therapy	-	ROUTINE	ROUTINE	-	q3-6 months	Improving copper levels; stable neurologic exam	Worsening triggers hepatology adjustment; neurologic monitoring for chelation-related neurological deterioration
Mood and anxiety assessment	-	ROUTINE	ROUTINE	-	Each visit	No significant depression or anxiety	Depression or anxiety triggers SSRI selection (choose agents that do not worsen tremor); psychiatry referral; note that tremor itself causes anxiety (bidirectional relationship)
Fall risk assessment	-	ROUTINE	ROUTINE	-	Each visit if gait involved	No falls	Recurrent falls triggers PT reassessment; home safety evaluation; assistive device

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7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home from ED	Tremor is chronic/slowly progressive without acute neurologic emergency; no new focal deficits; no concern for stroke or acute structural lesion; outpatient neurology follow-up arranged within 2-4 weeks; immediate metabolic causes addressed; patient educated on caffeine reduction and medication review
Outpatient neurology evaluation	Most patients; new-onset tremor without red flags; chronic tremor for diagnostic classification; referral within 2-4 weeks for routine evaluation
Urgent neurology referral (within 1-2 weeks)	Rapidly progressive tremor; tremor with new neurologic signs (bradykinesia, ataxia, weakness); age <50 with tremor and liver disease (Wilson disease concern); significant functional impairment
Admit to floor	Acute onset tremor with additional neurologic signs requiring expedited workup (MRI, DaTscan, labs); severe drug-induced tremor requiring monitored medication adjustment; Wilson disease with acute neurologic deterioration; tremor causing inability to perform ADLs (feeding, ambulation) without support
Movement disorders specialist referral	Diagnostic uncertainty after initial neurology evaluation; tremor refractory to first- and second-line medications; DaTscan interpretation needed; candidacy for interventional treatment (DBS, MRgFUS, botulinum toxin); suspected functional tremor requiring confirmation
DBS/MRgFUS evaluation	Medically refractory essential tremor with significant functional impairment; adequate cognition; no surgical contraindications; confirmed diagnosis (not for undiagnosed tremor)

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8. EVIDENCE & REFERENCES

Key Guidelines

Guideline	Source	Year	Key Recommendation
Consensus Statement on the Classification of Tremors	Bhatia et al. Mov Disord 2018	2018	Task Force of the International Parkinson and Movement Disorder Society; updated tremor classification system (Axis 1: clinical features; Axis 2: etiology)
AAN Practice Parameter: Therapies for Essential Tremor	Zesiewicz et al. Neurology 2011	2011	Propranolol and primidone Level A; topiramate Level B; botulinum toxin Level B for hand tremor
MDS Criteria for Essential Tremor Diagnosis	Bhatia et al. Mov Disord 2018	2018	Bilateral upper limb action tremor for >3 years; absence of other neurologic signs; "ET plus" category for soft signs
MDS Clinical Diagnostic Criteria for Parkinson's Disease	Postuma et al. Mov Disord 2015	2015	Bradykinesia required plus rest tremor or rigidity; supportive criteria and red flags

Landmark Studies and Key Evidence

Recommendation	Evidence Level	Source
Propranolol reduces essential tremor amplitude by 50-60%	Class I, Level A	Cochrane Review: Hedera et al. 2017
Primidone equally effective to propranolol for essential tremor; combination is synergistic	Class I, Level A	Koller & Vetere-Overfield. Neurology 1989
DaTscan differentiates essential tremor (normal uptake) from Parkinson's disease (reduced uptake) with >95% sensitivity	Class I, Level A	Benamer et al. Mov Disord 2000
Drug-induced tremor is among the most common causes of tremor; medication review is essential in all patients	Class II, Level B	Morgan & Sethi. Lancet Neurol 2005
Functional (psychogenic) tremor identified by entrainment and distractibility testing with high specificity	Class II, Level B	Schwingenschuh et al. Mov Disord 2011
Wilson disease must be excluded in all patients <50 years with new-onset tremor	Class III, Level C	EASL Clinical Practice Guidelines: Wilson Disease 2012
Orthostatic tremor is characterized by 13-18 Hz frequency on surface EMG; clonazepam first-line treatment	Class III, Level C	Hassan et al. Brain 2016
Holmes tremor (rubral) results from combined dopaminergic and cerebellar pathway disruption; poor response to medications	Class III, Level C	Raina et al. Neurol India 2016
Dystonic tremor distinguished by irregular amplitude and null point; botulinum toxin effective	Class II, Level B	Defazio et al. Mov Disord 2013
MRI-guided focused ultrasound (MRgFUS) effective for medically refractory essential tremor	Class I, Level A	Elias et al. N Engl J Med 2016
Deep brain stimulation of VIM thalamus effective for essential tremor and PD tremor refractory to medications	Class I, Level A	Schuurman et al. N Engl J Med 2000
Topiramate effective for essential tremor as second-line agent	Class I, Level B	Connor et al. Neurology 2008
Enhanced physiologic tremor resolves with removal of exacerbating factors (caffeine, medications, metabolic correction)	Class III, Level C	Deuschl et al. Mov Disord 1998
Botulinum toxin effective for ET hand tremor but limited by weakness	Class II, Level B	Brin et al. Neurology 2001
Task Force consensus: tremor evaluation includes classification by activation condition, body distribution, and frequency	Expert consensus	Deuschl et al. Mov Disord 1998

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NOTES

• Tremor is the most common movement disorder, affecting approximately 5% of the population over age 65
• Essential tremor and enhanced physiologic tremor are the two most common causes of tremor; Parkinson's disease is the most common cause of rest tremor
• A thorough medication review is the single most important initial step; drug-induced tremor is common and reversible
• The critical clinical distinction is between action tremor (suggests ET, physiologic, drug-induced) and rest tremor (suggests PD); some patients have both
• DaTscan is the key differentiating test when clinical features of ET and PD overlap; it does NOT distinguish PD from atypical parkinsonism (PSP, MSA, CBD)
• Wilson disease must be excluded in ALL patients under 50 years presenting with new tremor, especially with liver disease, psychiatric features, or mixed movement disorder
• Functional (psychogenic) tremor accounts for approximately 3-5% of tremor referrals; entrainment test is the most reliable bedside diagnostic maneuver
• Holmes tremor (rest + postural + intention) is pathognomonic for combined cerebellar and nigrostriatal pathway lesions in the midbrain/thalamus
• Orthostatic tremor is frequently misdiagnosed; diagnosis requires surface EMG showing characteristic 13-18 Hz frequency; patient reports "unsteadiness" rather than "tremor"
• Alcohol responsiveness is characteristic of essential tremor but is NOT a recommended treatment strategy and must not be encouraged
• Start propranolol or primidone as empiric treatment for functionally impairing postural/action tremor while awaiting diagnostic evaluation
• Propranolol and primidone are first-line; start primidone at very low doses (12.5 mg) to avoid initiation reaction
• DBS and MRgFUS are highly effective for medication-refractory essential tremor; VIM thalamus is the target

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CHANGE LOG

v1.1 (February 2, 2026) - Reordered lab table columns (Sections 1A/1B/1C) to standard format: Test | ED | HOSP | OPD | ICU | Rationale | Target Finding (C1) - Reordered imaging table columns (Sections 2A/2B/2C) to standard format: Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications (C2) - Added ICU column to Section 4A Referrals table (5 columns) (C3) - Applied proper Unicode section dividers (C4) - Reordered Section 6 Monitoring table columns to place venue columns after Parameter (C6) - Split "Methimazole or propylthiouracil" into separate rows with individual dosing in Section 3C (M1) - Split "D-Penicillamine or trientine" into separate rows with individual dosing in Section 3C (M2) - Added specific dosing for methimazole (10 mg daily) and PTU (100 mg TID) (M3) - Added specific dosing for D-penicillamine (250 mg daily titrated) and trientine (250 mg TID) (M4) - Replaced vague "Correct underlying metabolic derangement" with specific rows for dextrose, electrolyte correction, and magnesium sulfate in Section 3A (M5) - Removed directive language issues: replaced "consider", "may", "should" throughout with direct action statements (R1) - Updated version to 1.1 with REVISED date - Added change log entry documenting all revisions

v1.0 (February 2, 2026) - Initial template creation - Comprehensive 8-section format focused on EVALUATION of undifferentiated tremor - Full tremor classification framework (rest, postural, kinetic, intention, task-specific) - Detailed differential diagnosis table with 12 tremor etiologies including distinguishing features and tests - Key exam maneuvers table for bedside tremor characterization - DaTscan indications and interpretation guidance - Wilson disease screening protocol for patients <50 - Empiric treatment pathway (propranolol/primidone) while awaiting diagnosis - Etiology-specific treatments including levodopa trial for suspected PD - Non-pharmacologic interventions (caffeine reduction, adaptive equipment, stress management) - 15 evidence-based references with PubMed citation links - Settings: ED, HOSP, OPD

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APPENDIX A: Systematic Approach to Tremor Evaluation

Step 1: Classify the Tremor by Activation Condition

• Rest tremor: Arms fully supported in lap, patient distracted -- suggests PD
• Postural tremor: Arms outstretched -- suggests ET, enhanced physiologic, drug-induced
• Kinetic/Intention tremor: Finger-to-nose worsening at target -- suggests cerebellar lesion
• Combined (rest + postural + intention): -- suggests Holmes tremor (midbrain lesion)
• Task-specific: Only during writing, playing instrument -- primary writing tremor

Step 2: Determine Distribution and Symmetry

• Unilateral onset: Parkinson's disease; Holmes tremor; cerebellar lesion
• Bilateral, symmetric: Enhanced physiologic tremor; drug-induced; essential tremor (often asymmetric)
• Head tremor (titubational): Essential tremor (most common); cervical dystonia
• Voice tremor: Essential tremor; spasmodic dysphonia
• Chin/jaw tremor at rest: Parkinson's disease
• Legs on standing only: Orthostatic tremor

Step 3: Review Medications and Reversible Causes

• Tremor-inducing medications: Valproate, lithium, SSRIs/SNRIs, amiodarone, theophylline, bronchodilators, stimulants, antipsychotics, metoclopramide, cyclosporine, tacrolimus, corticosteroids
• Substances: Caffeine, alcohol withdrawal, nicotine, sympathomimetics
• Metabolic: Hyperthyroidism, hypoglycemia, hyponatremia, hypomagnesemia, hepatic encephalopathy, uremia

Step 4: Look for Associated Signs

• Bradykinesia + rigidity: -- Parkinson's disease or drug-induced parkinsonism
• Dysmetria + ataxia + nystagmus: -- Cerebellar pathology
• Dystonic posturing + null point: -- Dystonic tremor
• Variable frequency + entrainment + distractibility: -- Functional tremor
• Kayser-Fleischer rings + liver disease + young age: -- Wilson disease
• No other signs + bilateral action tremor + family history: -- Essential tremor

Step 5: Order Investigations by Priority

1. All patients: TSH, CMP, glucose, comprehensive medication review, caffeine assessment
2. If <50 years or atypical: Ceruloplasmin, copper, liver function, slit-lamp exam
3. If diagnostic uncertainty (ET vs PD): DaTscan
4. If structural lesion suspected: MRI brain
5. If orthostatic tremor suspected: Surface EMG
6. If neuropathic tremor suspected: NCS/EMG
7. If subacute onset with red flags: Paraneoplastic antibodies, B12, heavy metals

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APPENDIX B: DaTscan Decision Guide for Tremor Evaluation

When to Order DaTscan: - Clinical uncertainty between essential tremor and Parkinson's disease - Mixed tremor features (both postural and rest tremor) making clinical diagnosis unclear - Tremor with subtle signs that may or may not represent early parkinsonism - Need for diagnostic clarification before starting PD-specific treatment

When NOT to Order DaTscan: - Classic essential tremor with bilateral postural/action tremor, family history, no rest tremor, no bradykinesia - Classic Parkinson's disease with unilateral rest tremor, clear bradykinesia and rigidity - Obvious drug-induced tremor with clear temporal relationship - Enhanced physiologic tremor with identified reversible cause - Clear cerebellar tremor with MRI lesion

Interpretation:

DaTscan Result	Interpretation	Next Step
Normal bilateral striatal uptake	Essential tremor, enhanced physiologic tremor, drug-induced tremor, dystonic tremor, functional tremor, orthostatic tremor	Treat as ET or identified cause; no dopaminergic therapy
Reduced striatal uptake (asymmetric)	Parkinson's disease most likely; also possible in MSA, PSP, DLB, CBD	Movement disorders referral; levodopa trial; does NOT distinguish PD from atypical parkinsonism
Reduced striatal uptake (symmetric)	Atypical parkinsonism (PSP, MSA); or advanced PD	Movement disorders referral; further clinical and imaging evaluation

Medications to Hold Before DaTscan (2 weeks): - Bupropion - Amphetamines / methylphenidate - Modafinil - Cocaine - Phentermine - Note: Propranolol, primidone, benzodiazepines, anticholinergics do NOT interfere

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APPENDIX C: Tremor-Inducing Medications Quick Reference

Drug Class	Specific Agents	Tremor Type	Reversibility
Antiepileptics	Valproate, phenytoin (at toxic levels), carbamazepine (at toxic levels)	Postural, intention (if toxic)	Reversible with dose adjustment
Mood stabilizers	Lithium	Postural (fine at therapeutic; coarse at toxic)	Reversible with dose reduction
Antidepressants (SSRIs/SNRIs)	Fluoxetine, sertraline, paroxetine, venlafaxine, duloxetine	Fine postural tremor	Usually mild; dose-dependent
Antidepressants (TCAs)	Amitriptyline, nortriptyline	Postural tremor	Dose-dependent
Antipsychotics (typical)	Haloperidol, chlorpromazine, fluphenazine	Rest tremor (parkinsonian)	Reversible with discontinuation (weeks-months)
Antipsychotics (atypical)	Risperidone (dose-dependent), olanzapine	Rest tremor (parkinsonian)	Reversible with discontinuation
Antiemetics	Metoclopramide, prochlorperazine	Rest tremor (parkinsonian)	Reversible with discontinuation
Bronchodilators	Albuterol, salmeterol, theophylline	Postural tremor	Reversible; dose-dependent
Stimulants	Amphetamine, methylphenidate, modafinil	Postural tremor	Reversible
Cardiac	Amiodarone, procainamide	Postural tremor; intention	Amiodarone: tremor persists after discontinuation (long half-life)
Immunosuppressants	Cyclosporine, tacrolimus, corticosteroids	Postural tremor	Dose-dependent; reversible
Other	Caffeine, nicotine, thyroid hormones (excess), medroxyprogesterone	Enhanced physiologic tremor	Reversible

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This template has been validated through the checker/rebuilder pipeline (v1.1) and requires physician review before clinical deployment.