Question of the Week # 323

323)  A 65 year old man is evaluated in your office for slowly progressing involuntary shaking movements in his hands. He noticed these movements about 10 months ago which have slightly worsened now.  Occasionally, he was told by his wife that his head shakes as well. The movements have led him to feel socially embarrassed because they are worse when he attempts to write or hold a cup of coffee or fasten a shirt button. He denies any tremors in his legs. He denies any problems with his gait or muscle pain or stiffness. He reports drinking wine on daily basis since the tremors have started because he thinks alcohol appears to improve the tremors. He denies using any medications. There is no family history of tremors or seizures. On examination, he appears comfortable. Tremors are visible bilaterally with his arms outstretched and they are increased when asked to hold a cup filled with water. His handwriting is large and tremulous. Gait is normal with normal arm-swing. There are no other neurological deficits. Routine chemistry panels including TSH and Liver function tests are normal. Which of the following is the most appropriate next step in management?

A)  MRI brain with contrast

B) Vitamin B12 level

C) Trial of Dopamine Agonist

D) Initiate Propranolol Therapy

E) Serum Cerulopalsmin level

F) Start oral Primidone

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