The Clinical Problem Solvers Episode 447: Neurology VMR – acute psychiatric disturbance and tremors
Feb 26, 2026
Zakariyya Ellemdin, a South African physician and case presenter, shares a puzzling young patient with psychiatric change, tremor, and liver findings. Sebastian Green, a UCLA neurology resident and educator, walks through neurologic reasoning, tremor phenomenology, and age-related liver-brain diagnoses. They compare tremor types, discuss Wilson disease testing, and outline practical neuro workup steps.
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Three Buckets For Acute Psychiatric Disturbance
- Approach acute psychiatric disturbance by time course and three broad buckets: medical, neurologic, and psychiatric.
- Most acute cases are medical (toxic metabolic, infection, medication/withdrawal); always consider can't-miss neurologic causes like stroke, seizure, or encephalitis.
Characterize Tremor By Phenomenology Not Localization
- When evaluating tremor, focus on phenomenology: amplitude, frequency, body parts, and state (rest, posture, action).
- Use exam features (rest vs postural vs intention) to narrow causes like Parkinsonism, essential tremor, cerebellar or rubral lesions.
Infection Type Predicts Movement Findings
- Infectious encephalitides have tropisms that predict movement findings: limbic HSV causes psychiatry/temporal lobe symptoms, arboviruses often involve basal ganglia producing parkinsonism or tremor.
- Think West Nile or other arboviruses when encephalitis includes tremor or parkinsonism with basal ganglia imaging changes.
