Marie A Savard MD

Solve the Medical Riddle: Her Hands Have Started Trembling, and Her Voice Is Shaky, First Week

Editor’s note: Welcome to our thirdAGE feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the PCP will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Patty is worried because her hands have started trembling and her voice is shaky.

As always in thirdAGE Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Patty told the PCP:

“After I turned 50 a year ago, my left hand started shaking a little every now and then. It’s my dominant hand. I was having trouble steadying it to sign checks. I also began having some trouble holding my coffee cup. I even spilled it once. My husband noticed the shaking about the same time I did. However, it was so subtle that we weren’t worried. But in the past few months, I’ve noticed a tremor in my right hand as well. Not only that, but my daughter mentioned that my voice sounded a little shaky when we were doing FaceTime with her and my grandchildren. I didn’t hear the voice tremor myself although my husband agreed with my daughter. Now I’m terrified that something is really wrong. I can’t get my eye makeup on straight any longer! I can still drive, thank goodness, but I’m afraid this might progress. When I was in grade school, I had a teacher with shaky hands and voice. Also, her head kept turning from side to side. A lot of the kids thought she was funny, but she freaked me out. I never learned what was wrong with her. I always had in the back of my mind that I would end up like that. Now my fear seems to be coming true! I hope you’ll tell me this is nothing serious and help me find a cure.”


Patty had no history of thyroid disease (high or low), and no history of autoimmune disease. She was taking no new medications except hydrochlorothiazide (HCTZ) for mild high blood pressure. She was not under more stress than usual other than her worry about how the tremor might affect her job as legal secretary, and embarrassment at the thought of people noticing the tremor.

Family History: Her father had mild hand shake she believes when he drank coffee but she doesn’t recall whether his head or voice were affected. He died of a heart attack fairly young in his 60’s.


The doctor did a complete neurological exam and general exam. The results showed a mild head tremor in “yes-yes” direction, no tongue tremor, mild tremor of left hand greater than right hand when asked to hold a pen and a cup, but minimal if any tremor with hands resting in her lap. The tremor was not worse when she reached out her hand.

She had no cerebellar abnormalities. Her gait, muscle tone, strength, and reflexes were all normal. The doctor had her drink from a glass of water and she shook more.

A thyroid exam revealed no nodules or enlargement. Blood pressure was borderline high at 140/90. Patty’s pulse was about 80, a little high because she was nervous, but not high enough to indicate an overactive thyroid. Her resting pulse was in the 90s to 100’s.

The doctor ordered laboratory tests for complete blood count, chemistry panel, and thyroid functions. She asked Patty to schedule a second visit after the results of the tests were available . . .

To be continued . . .

Come back to next Thursday to learn the results of Patty’s tests . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit


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