72 yo M with multiple ground level falls

Original case and content by Brandon Fainstad, MD.
Edits and graphics by Yilin Zhang, MD.




72 year old man presents to the ED after multiple ground level falls (GLFs) earlier in the day. Starting around 11 am his legs became weak and tremulous. He had about 8 GLFs in the 3 hours prior to presenting to the emergency room.  On review of systems, he reports dry mouth, palpitations and difficulty talking.  He denies fevers/chills, nausea/vomiting, chest pain, light-headedness, shortness of breath. He denies any illicit substance or alcohol use.  He has a history of bipolar disorder, hyperlipidemia, hypertension and a essential tremor that has been worsening over the past year.  He takes olanzapine, amitriptyline, venlafaxine, pregabalin, lisinopril, atorvastatin and zolpidem prn.

On exam, his vital signs are 35.9C , HR 100, BP 140/60, SaO2 95%. He appears mildly uncomfortable, he has dilated pupils that are responsive to light. His mucus membranes are dry. His cardiopulmonary exam is notable for irregularly irregular heart rate. He has facial twitching in the bilateral lower eyelids and a high amplitude tremor in his bilateral outstretched arms which resolves at rest. He has difficulty with finger to nose, slow rapid alternating movements but intact heel to shin bilaterally. He was unable to stand to test his gait.

How would you classify his tremor?

Chalk talk:
photo (4)

Cr 2 (baseline 1.4), WBC 15


L rib fractures

What is the most likely explanation for his presentation?

How do you want to treat it overnight?


Outcome and Take homes:

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