Beep!πA new inpatient neuro consult for new onset "tremor." What's the first question that flies through my mind??
Is the patient on gabapentin? A #meded #medtwitter #neurotwitter #tweetorial
Is the patient on gabapentin? A #meded #medtwitter #neurotwitter #tweetorial
% of time inpatient consults for tremor are actually tremor....
Ok maybe it's 50% of the time- tremor is common! πBut what is it the rest of the time, you ask? Often, it's myoclonus!
Tremor is rhythmic and oscillatory. Think π₯ (rhythmic), think seesaw (oscillatory)
Myoclonus is jerky and quick. Positive myoclonus is due to a jerky contraction of a muscle. Negative myoclonus (asterixis) is due to a pathological relaxation of a muscle. Everyone has positive myoclonus sometimes! It's called the hiccups (diaphragmatic myoclonus).
Why do we test asterixis in the "stopping traffic" position? It requires constant activation of wrist extensors, so when they pathological relax you see the hands drop and recover. You can test it with any posture that requires constant muscle activation. (ok, but within reason)
There are a lot of things that can cause multifocal positive and negative myoclonus in an inpatient. Hyperammonemia, electrolyte derangements, uremia, hypercarbia....
And medications! What do I see EVERY SINGLE TIME I'm on service? New onset multifocal myoclonus due to gabapentin, often in the setting of AKI (gabapentin is cleared by the kidneys!π) πLooking at you too lyrica! You're not off the hook!
Of course the full ddx is enormous...but metabolic and meds is a great place to start.
Be a hero! Swoop in and fix the patient's disabling condition!
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