Location: Virgin Gorda, British Virgin Islands

Patient name: John Doe

Patient DOB: 01/01/1970

Date of Report: 04/05/2025

Requesting provider: Benjamin Smith, MD - BVI Medical Clinic (outpatient)

Physician to physician consultation - Consulting Provider Note

This is an inter-professional e-consult requested by Dr. Benjamin Smith. The patient was not evaluated in person, and no doctor-patient relationship has been established. Dr. Smith, the treating physician of record, requested neurology guidance due to limited specialist availability in his region. Recommendations are advisory only; final treatment decisions remain with Dr. Smith. 

Reason for Request: tremors

Dear Dr. Smith,

Thank you for your consultation request regarding your patient with tremors.  Based on the history provided, your patient has experienced progressively worsening tremors in the hands over the last 2 years that are interfering with his ability to write and bring food/drink to his mouth.  You have reported no resting tremor, no cogwheel rigidity of the limbs and no gait abnormalities.  The patient did note that his father and paternal grandmother had similar tremors.  The tremors do seem to improve with alcohol consumption and seem to be aggravated by stress.  You have noted that the patient seems to have a fine and fast tremor of the hands on sustention that seems to worsen in amplitude/frequency with intention.  You have diagnosed this patient with essential tremor, and I believe that is the correct diagnosis based on the information provided.  However, despite escalating doses of propranolol, he has not had any relief.  You are absolutely on the right track starting with a non-selective beta-blocker.  However, with propranolol being ineffective, I would suggest stopping it and trying primidone.  Primidone can be sedating, so a slow uptitration would be warranted.  If renal and hepatic function and normal, a starting dose of 25mg at bedtime is recommended.  

Primidone can be escalated every 5-7 days by an additional 25mg as tolerated.  Generally no more than 250mg nightly tends to produce satisfactory results.  If an afternoon wearing off phenomenon is observed and no daytime sedation is present, morning doses can be introduced in 25mg increments as tolerated.  Monitoring of CBC, CMP (including Cr/GFR and liver enzymes), folate level (if available) if recommended every 6 months.  I would stop primidone and get labs if the patient were to develop persistent side effects, such as sedation, dizziness, incoordination, anemia, rash, abdominal pain, depressed mood, respiratory depression, hepatic dysfunction or renal dysfunction.

I appreciate the opportunity to assist you with this case.  Please feel free to reach out with any questions or repeat consult for follow up issues.

Regards,

Jason Sebesto, DO, MSc

Diplomate of the American Board of Psychiatry and Neurology

Medical licensure in Florida