Essentials Of Differential Diagnosis Pdf Free Download [NEW]

Clinical challenges: There is no single diagnostic test for feline acromegaly - a confident diagnosis relies on a combination of clinical signs, feline growth hormone and insulin-like growth factor 1 levels, and intracranial imaging. Additionally, the ideal treatment protocol has yet to be established. Currently, radiotherapy is considered by many to be the best treatment; however, costs, the need for multiple anaesthetics, and the often delayed and unpredictable treatment response represent serious limitations of this modality. Previously, medical treatment has proven unsuccessful. Recent studies provide some evidence in favour of, and some against, the use of newer long-acting somatostatin analogue preparations in a proportion of acromegalic cats.

Although patients with Parkinson's disease display tremor, rigidity, bradykinesia, postural abnormalities, and other typical clinical manifestations, still many patients were with atypical clinical manifestations or showed only a symptom. The diagnosis of PD and its differentiation from other types of tremor such as ET and EPT are frequently difficult. Especially in early disease stages it remains problematic. Postural tremor may be the isolated or predominant symptom in early stages of PD, in which rest tremor, bradykinesia, rigidity, and postural stability may be slight or inexistent [8].

Essentials Of Differential Diagnosis Pdf Free Download

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Now, the differential diagnoses of PD, ET, and EPT are still mostly based on clinical phenomena. The accurate diagnosis of tremor is of fundamental importance to both patients and clinicians because assessment of prognosis and treatment selection depend on tremor type. It is crucial to the success of therapeutic trials [8].

Chapters feature a comprehensive assessment of special populations, including patients with disabilities; pediatric, pregnant, and elderly patients; and transgendered and veteran populations, as well as differential diagnosis guidance in tabular format. Chapters are further enhanced with illustrations, images, and case studies that demonstrate clinical reasoning and application of principles to practice. A robust ancillary package includes an instructor manual, discussion questions, multiple-choice questions, and PowerPoint slides.

Tremor is an involuntary, rhythmic, oscillatory movement of a body part. It is the most common movement disorder encountered in primary care. The diagnosis of tremor is based on clinical information obtained from the history and physical examination. The most common tremors in patients presenting to primary care physicians are enhanced physiologic tremor, essential tremor, and parkinsonian tremor. All persons have low-amplitude, high-frequency physiologic tremors at rest and during action that are not reported as symptomatic, but can be enhanced by anxiety, medication use, caffeine intake, or fatigue. Features consistent with psychogenic tremor are abrupt onset, spontaneous remission, changing tremor characteristics, and extinction with distraction. Other types of tremor include cerebellar, dystonic, and drug- or metabolic-induced. The first step in evaluating a patient with tremor is to categorize the tremor based on its activation condition, topographic distribution, and frequency. Resting tremors occur in a body part that is relaxed and completely supported against gravity. Action tremors occur with voluntary contraction of a muscle and can be further subdivided into postural, isometric, and kinetic tremors. The most common pathologic tremor is essential tremor, which affects 0.4% to 6% of the population. In one-half of cases, it is transmitted in an autosomal-dominant fashion. More than 70% of patients with Parkinson disease have tremor as the presenting feature. This tremor is typically unilateral, occurs at rest, and becomes less prominent with voluntary movement. If there is diagnostic uncertainty, single-photon emission computed tomography can be used to visualize the integrity of the dopaminergic pathways in the brain, and transcranial ultrasonography may be useful to diagnose Parkinson disease.

Essential tremor affects 0.4% to 6% of the population.4 In about one-half of cases, it is transmitted in an autosomal-dominant fashion.8 Although essential tremor can manifest by early adulthood, most patients do not present for treatment until 60 to 69 years of age because it tends to progress slowly. Sometimes called benign essential tremor, essential tremor often causes social embarrassment, and up to 25% of those affected retire early or modify their career path.4,8,9 Importantly, 30% to 50% of those initially diagnosed with essential tremor eventually receive an additional tremor diagnosis or a different diagnosis entirely after further evaluation.12

The diagnosis of essential tremor is clinical, based on classic symptoms and tremor features.2 Persons with essential tremor typically have no other neurologic findings; therefore, it is sometimes considered a diagnosis of exclusion.13 A video of this tremor is available at =xVRKO-Sz0x4amp;&NR=1.

The diagnosis of tremor is generally based on clinical information obtained from the history and physical examination.17 Although there is overlap and variability among tremor syndromes, the intrinsic features of the tremor usually provide key diagnostic clues (Figure 118; Table 418). The first step is to categorize the tremor based on its activation condition, topographic distribution, and frequency. The activation condition should be described as resting, kinetic (or intention), postural, or isometric. The examiner can have the patient sit with his or her hands in the lap to check for rest tremor. A sequential test for postural and kinetic tremors can involve the patient stretching his or her arms and hands out, followed by a simple finger-to-nose test.2,3 A resting tremor is virtually pathognomonic for parkinsonism, whereas an intention tremor often indicates a cerebellar lesion.11 Frequency is generally classified as low (less than 4 Hz), medium (4 to 7 Hz), or high (more than 7 Hz). The topographic distribution of the tremor (e.g., limbs, head, voice) can also provide useful information. For example, a high-frequency tremor involving the head is more likely to be essential tremor than parkinsonian tremor.2,3

Caffeine intake and fatigue are often exacerbating factors in essential tremor with few alleviating factors. Associated conditions and diseases should be identified. For example, fatigued muscles from sleep disorders amplify physiologic tremor, and polyneuropathy from lack of innervations causes small involuntary movements that may be interpreted as tremor. A family history of neurologic disease or tremor suggests a genetic component, which is common in essential tremor. A medication history should be obtained to rule out drug-induced tremor. Patients should be screened for drugs of abuse as well as alcohol overuse and withdrawal because these can cause tremor. Conversely, small amounts of alcohol (30 to 60 g) can temporarily relieve essential tremor and can be a historical clue to the diagnosis.2,3

The diagnosis of tremor in children is challenging because of myriad potential causes, such as Wilson disease, fragile X syndrome, nutritional deficiencies (e.g., vitamin B12), heavy metal poisoning, and essential tremor. Almost one-half of children with traumatic brain injury experience tremor for up to 18 months.26 All childhood tremors are potentially serious and should prompt an in-depth investigation to clarify the cause; patients should be promptly referred to a neurologist.27

Although the diagnosis of tremor remains primarily clinical, certain imaging modalities can help differentiate some causes of tremor. Noncontrast magnetic resonance imaging and computed tomography can rule out secondary causes of tremor (e.g., multiple sclerosis, mass lesion, stroke) when the history and physical examination are suggestive of a structural cause, or in parkinsonism with atypical features or that is refractory to levodopa.28

If there is diagnostic uncertainty, single-photon emission computed tomography (SPECT) using ioflupane (123I-FP-CIT SPECT or DaTSCAN), in addition to subspecialty consultation, can be useful for distinguishing Parkinson disease from essential tremor, and to a lesser extent from drug-induced tremor, dystonic tremor, psychogenic tremor, or unilateral postural tremor.29,30 When assessing for dopamine transporter dysfunction, 123I-FP-CIT SPECT was 78% sensitive and 97% specific, with a positive likelihood ratio of 26 and a negative likelihood ratio of 0.23 in one case series of 99 patients with suspected Parkinson disease.31 A positive test can therefore rule in a diagnosis of Parkinson disease within three years; however, it is not superior to clinical assessment in the diagnosis of Parkinson disease,29 and its specific clinical use remains unclear.32

Transcranial ultrasonography can also predict Parkinson disease by revealing hyperechogenicity of the substantia nigra. A European study of 49 patients in a neurology clinic demonstrated that ultrasonography compared favorably vs. 123I-FP-CIT SPECT for sensitivity (90% vs. 97%), specificity (60% vs. 70%), positive predictive value (77% vs. 82%), and negative predictive value (80% vs. 93%) for the diagnosis of Parkinson disease. Operator inexperience and limited fusion imaging technology, as well as conflicting results from several clinical studies, limit the use of transcranial ultrasonography.33

Berardelli A, Wenning GK, Antonini A, et al. EFNS/MDS-ES/ENS [corrected] recommendations for the diagnosis of Parkinson's disease [published correction appears in Eur J Neurol. 2013;20(2):406]. Eur J Neurol. 2013;20(1):16-34.

processing.... Drugs & Diseases > Neurology Essential Tremor Differential Diagnoses Updated: Feb 24, 2023 Author: Natalya V Shneyder, MD; Chief Editor: Selim R Benbadis, MD more... Share Print Feedback Close Facebook Twitter LinkedIn WhatsApp Email webmd.ads2.defineAd({id: 'ads-pos-421-sfp',pos: 421}); Sections Essential Tremor Sections Essential Tremor Overview Practice Essentials Background Etiology Epidemiology Prognosis Show All Presentation History Physical Examination Show All DDx Workup Approach Considerations Imaging Studies Other Tests Show All Treatment Approach Considerations Practical Management of Pharmacologic Therapy Additional Medications Thalamotomy (Radiofrequency Thalamotomy) Thalamic Deep Brain Stimulation Thalamotomy Versus Deep Brain Stimulation MRI-guided Focused Ultrasound Thalamotomy Nonpharmacological and Nonsurgical Treatment of Essential Tremor Follow-Up Show All Medication Medication Summary Beta-Blockers, Nonselective Anticonvulsants, Other Show All Questions & Answers References DDx Diagnostic Considerations Conditions to consider in the differential diagnosis of essential tremor include the following: e24fc04721