“My hands shake when I reach for my cup or write — my dad had it too. Is it Parkinson’s?”

Distinguish ESSENTIAL TREMOR from PARKINSON’S — the core skill in a "shaking hands" presentation. Essential tremor is a postural/action/kinetic tremor that is WORSE ON ACTION and posture (reaching, holding, writing — spidery, eating) and BETTER at rest, typically BILATERAL and fairly SYMMETRICAL, often FAMILIAL, frequently IMPROVED by a small amount of alcohol, sometimes with head ("yes-yes"/"no-no") or voice tremor, and crucially WITHOUT bradykinesia, rigidity or gait disturbance. Parkinson’s tremor, by contrast, is a RESTING "pill-rolling" tremor, typically ASYMMETRIC (one side first), BETTER with action, and accompanied by the parkinsonian features — BRADYKINESIA (slowness, reduced arm swing, micrographia that decrements), RIGIDITY (cogwheel) and gait/postural changes (shuffling, stooped, festination) — so the rest-vs-action distinction and the presence/absence of the parkinsonian triad are the discriminators. Consider other tremors: enhanced PHYSIOLOGICAL (anxiety, caffeine, fatigue), HYPERTHYROIDISM (check TFTs), DRUGS (salbutamol, lithium, SSRIs, valproate — review), excess alcohol/withdrawal, cerebellar INTENTION tremor (worse approaching a target, with cerebellar signs) and dystonic tremor. Examine the tremor at rest, on posture (arms outstretched) and on action (finger-nose, cup, writing/spiral), and assess for bradykinesia, rigidity, gait and cerebellar signs, which underpins the diagnosis and reassurance. Manage essential tremor by reassuring when mild (directly addressing the Parkinson’s fear), and offering PROPRANOLOL (licensed for essential tremor; check for asthma, bradycardia/heart block and heart failure first) or primidone when functionally impairing or socially distressing (BNF; clinical practice rather than a guideline recommendation), while reducing caffeine, reviewing aggravating drugs and treating thyroid abnormality; refer to neurology for diagnostic uncertainty, atypical/asymmetric features, suspected parkinsonism (NICE NG71: quickly and untreated) or cerebellar signs, or refractory tremor. The hidden agenda is fear of Parkinson’s plus embarrassment/functional impact; make the action-vs-rest distinction, reassure appropriately while screening properly, address the impact and offer treatment, and refer if uncertain.