Neurology Question 25

A 54-year-old man is seen for follow-up evaluation of a tremor in his upper extremities that has been present since age 20 years. The tremor was mild for many years and did not interfere with his work but has become more prominent in recent years. He has difficulty writing and using utensils during meals. He has no associated slowness, stiffness, or change in gait. The patient started a trial of propranolol, which provided better control of the tremor, but after a few months, the tremor again worsened. He has subsequently been taking clonazepam without significant relief of symptoms. Alcohol, which the patient uses infrequently, temporarily diminishes the tremor. He also has kidney stones and glaucoma. His father and two sisters have a similar tremor.

On physical examination, vital signs are normal. A persistent large-amplitude tremor of the upper extremities is noted when the patient holds his arms in an outstretched position and during finger-to-nose testing. The tremor is bilateral and absent at rest. Tandem gait cannot be performed, but gait is otherwise normal.

Which of the following is the most appropriate next step in treating this patient's tremor?

A  Botulinum toxin

B  Deep brain stimulation

C  Levodopa

D  Primidone

E  Topiramate

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