Tremor physical examination: Difference between revisions

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==Overview==
==Overview==
[[Physical examination]] of [[patients]] with tremor varies depending on the [[cause]] of tremor.
[[Physical examination]] of [[patients]] with tremor varies depending on the [[cause]] of tremor. The basis of [[physical examination]] is to determine the type of tremor, [[phenomenological]] features of tremor, associated [[neurological]] [[signs]].


==Physical Examination==
==Physical Examination==
[[Physical examination]] of [[patients]] with tremor varies depending on the [[cause]] of tremor.
[[Physical examination]] of [[patients]] with tremor varies depending on the [[cause]] of tremor.
*Important factors in [[physical examination]] are:
**Type of tremor
**[[Phenomenological]] features of tremor
**Associated [[neurological]] [[signs]]


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with tremor may present with variable appearance depending on the cause of tremor. It is important to observe for [[gait]], [[apathy]], [[resting tremor]], tremor with voluntary movement, [[posture]], [[facial]] masking, [[sweating]] when the patient walks in and during [[history taking]].
*[[Patients]] with tremor may present with variable appearance depending on the cause of tremor. It is important to observe for [[gait]], [[apathy]], [[resting tremor]], tremor with voluntary movement, [[posture]], [[facial]] masking, [[sweating]] when the patient walks in and during [[history taking]].


===Vital Signs===
===Vital Signs===
*[[Temperature]] is usually normal in common causes of tremor.
*[[Temperature]] is usually normal in common causes of tremor.
*[[Hyperthermia]] may be present in [[hyperthyroidism]].
*[[Hyperthermia]] may be present in [[hyperthyroidism]].
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===Skin===
===Skin===
* Skin examination of patients with tremor is usually normal.
*Skin examination of patients with tremors is usually normal.


===HEENT===
===HEENT===
* HEENT [[examination]] of [[patients]] with tremor depends on the cause.
*HEENT [[examination]] of [[patients]] with tremor depends on the cause.
*Look for [[eye]] changes characteristic of [[hyperthyroidism]]<ref name="pmid27994349">{{cite journal| author=Sharma S, Pandey S| title=Approach to a tremor patient. | journal=Ann Indian Acad Neurol | year= 2016 | volume= 19 | issue= 4 | pages= 433-443 | pmid=27994349 | doi=10.4103/0972-2327.194409 | pmc=5144461 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27994349  }} </ref>.
*Look for [[eye]] changes characteristic of [[hyperthyroidism]]. <ref name="pmid27994349">{{cite journal| author=Sharma S, Pandey S| title=Approach to a tremor patient. | journal=Ann Indian Acad Neurol | year= 2016 | volume= 19 | issue= 4 | pages= 433-443 | pmid=27994349 | doi=10.4103/0972-2327.194409 | pmc=5144461 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27994349  }} </ref>
*[[Eye]] movement should be assessed for [[cerebellar]] [[disorders]] and [[Parkinson's disease]] could have double vision due to convergence insufficiency<ref name="pmid14596441">{{cite journal| author=Smaga S| title=Tremor. | journal=Am Fam Physician | year= 2003 | volume= 68 | issue= 8 | pages= 1545-52 | pmid=14596441 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14596441  }} </ref>.
*[[Eye]] movement should be assessed for [[cerebellar]] [[disorders]] and [[Parkinson's disease]] could have double vision due to convergence insufficiency. <ref name="pmid14596441">{{cite journal| author=Smaga S| title=Tremor. | journal=Am Fam Physician | year= 2003 | volume= 68 | issue= 8 | pages= 1545-52 | pmid=14596441 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14596441  }} </ref>
*[[Action tremor]] in [[patients]] under forty should be examined for [[Wilson's disease]] [[eye]] changes, [[Kayser–Fleischer]] ring in the [[cornea]].
*[[Action tremor]] in [[patients]] under forty should be examined for [[Wilson's disease]] [[eye]] changes, [[Kayser–Fleischer]] ring in the [[cornea]].
*Assess for [[nystagmus]] if cause of tremor is sudden in onset, associated with new onset [[headache]], [[vertigo]], [[gait]] changes. possible cause could be a [[stroke]].
*Assess for [[nystagmus]] if cause of tremor is sudden in onset, associated with new onset [[headache]], [[vertigo]], [[gait]] changes. possible cause could be a [[stroke]].
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===Neck===
===Neck===
* [[Neck]] [[examination]] of patients with tremor is usually normal.  
*[[Neck]] [[examination]] of patients with tremors is usually normal.
*[[Hyperthyroidism]] may have [[neck]] [[swelling]], [[thyromegaly]] / [[thyroid]] [[nodules]]<ref name="pmid14596441">{{cite journal| author=Smaga S| title=Tremor. | journal=Am Fam Physician | year= 2003 | volume= 68 | issue= 8 | pages= 1545-52 | pmid=14596441 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14596441  }} </ref>.
*[[Hyperthyroidism]] may have [[neck]] [[swelling]], [[thyromegaly]] / [[thyroid]] [[nodules]]. <ref name="pmid14596441">{{cite journal| author=Smaga S| title=Tremor. | journal=Am Fam Physician | year= 2003 | volume= 68 | issue= 8 | pages= 1545-52 | pmid=14596441 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14596441  }} </ref>


===Lungs===
===Lungs===
* [[Pulmonary examination]] of [[patients]] with tremor is usually normal.
*[[Pulmonary examination]] of [[patients]] with tremor is usually normal.


===Heart===
===Heart===
* [[Cardiovascular]] [[examination]] of [[patients]] with tremor is usually normal.
*[[Cardiovascular]] [[examination]] of [[patients]] with tremor is usually normal. [[Palpitation]] may occur in [[hyperthyroidism]], [[stress]], [[alcohol]] [[withdrawal]].


===Abdomen===
===Abdomen===
* [[Abdominal examination]] of [[patients]] with tremor is usually normal.
*[[Abdominal examination]] of [[patients]] with tremor is usually normal.


===Back===
===Back===
* Back [[examination]] of [[patients]] with tremor is usually normal.
*Back [[examination]] of [[patients]] with tremor is usually normal.


===Genitourinary===
===Genitourinary===
* [[Genitourinary]] [[examination]] of [[patients]] with tremor is usually normal.
*[[Genitourinary]] [[examination]] of [[patients]] with tremor is usually normal.


===Neuromuscular===
===Neuromuscular===
{| class="wikitable"
|+ Assessment of tremor<ref name="pmid7001967">{{cite journal| author=Jankovic J, Fahn S| title=Physiologic and pathologic tremors. Diagnosis, mechanism, and management. | journal=Ann Intern Med | year= 1980 | volume= 93 | issue= 3 | pages= 460-5 | pmid=7001967 | doi=10.7326/0003-4819-93-3-460 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7001967  }} </ref>.
| '''Position''' || '''Category''' || '''Causes'''
|-
| At rest || Resting tremors || Tremors that are worse at rest include Parkinsonian syndromes and essential tremor if severe. This includes drug-induced tremors from blockers of [[dopamine receptors]] such as [[haloperidol]] and other [[antipsychotic]] drugs.
|-
| During contraction (eg a tight fist while the arm is resting and supported) || Contraction tremors || Tremors that are worse during supported contraction include essential tremor and also cerebellar and exaggerated physiologic tremors such as a hyperadrenergic state or hyperthyroidism<ref name="pmid7001967">.</ref>. Drugs such as [[adrenergic]]s, [[anti-cholinergic]]s, and [[xanthine]]s can exaggerate physiologic tremor.
|-
| During posture (eg with the arms elevated against gravity such as in a 'bird-wing' position) || Posture tremors || Tremors that are worse with posture against gravity include [[essential tremor]] and exaggerated physiologic tremors<ref name="pmid7001967">.</ref>.
|-
| During intention (eg finger to nose test) || Intention tremors|| [[Intention tremor]]s are tremors that are worse at during intention and the patient's finger approaches a target include cerebellar disorders.
|}
*[[Patients]] are usually oriented to persons, place, and time. Detailed [[neuromuscular]] [[examination]] of [[patients]] with tremor should include:
*[[Patients]] are usually oriented to persons, place, and time. Detailed [[neuromuscular]] [[examination]] of [[patients]] with tremor should include:
*[[Parkinson's disease]]<ref name="pmid28638597">{{cite journal| author=Chen W, Hopfner F, Becktepe JS, Deuschl G| title=Rest tremor revisited: Parkinson's disease and other disorders. | journal=Transl Neurodegener | year= 2017 | volume= 6 | issue=  | pages= 16 | pmid=28638597 | doi=10.1186/s40035-017-0086-4 | pmc=5472969 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28638597  }} </ref>:
*[[Parkinson's disease]] <ref name="pmid28638597">{{cite journal| author=Chen W, Hopfner F, Becktepe JS, Deuschl G| title=Rest tremor revisited: Parkinson's disease and other disorders. | journal=Transl Neurodegener | year= 2017 | volume= 6 | issue=  | pages= 16 | pmid=28638597 | doi=10.1186/s40035-017-0086-4 | pmc=5472969 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28638597  }} </ref>
**[[Muscle]] rigidity: Cogwheel rigidity  
**[[Muscle]] rigidity: Cogwheel rigidity
**[[Bradykinesia]]: Slow movement, occurs in [[Parkinsons disease]].
**[[Bradykinesia]]: Slow movement, occurs in [[Parkinsons disease]].
**Abnormal gait: Rombergs test
**Abnormal gait: Romberg's test
**Unilateral/bilateral tremor:[[Frequency]], [[amplitude]], [[pattern]], [[distribution]].
**Unilateral/bilateral tremor:[[Frequency]], [[amplitude]], [[pattern]], [[distribution]].
**[[Dysdiadochokinesia]] (palm tapping test)
**[[Dysdiadochokinesia]] (palm tapping test)
**Postural [[reflexes]] impaired.
**Postural [[reflexes]] impaired.
*[[Essential Tremor]]:
*[[Essential Tremor]]:
**Bilateral action tremor  
**Bilateral action tremor
**Effecting [[hands]],[[forearms]]  
**Effecting [[hands]],[[forearms]]
**Absence of other [[neurological]] [[signs]]
**Absence of other [[neurological]] [[signs]]
*[[Cerebellar]] Tremor:
*[[Cerebellar]] Tremor:
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===Extremities===
===Extremities===
*[[Hands]] should be [[pronated]] and resting on the lap to induce resting tremor, it is important to be patient as tremors may take up to thirty seconds to appear. Repositioning hand with little finger down and thumb up can induce [[Parkinsonian]] tremor and [[Holmes tremor]]<ref name="pmid27833521">{{cite journal| author=Alqwaifly M| title=Treatment responsive Holmes tremor: case report and literature review. | journal=Int J Health Sci (Qassim) | year= 2016 | volume= 10 | issue= 4 | pages= 558-562 | pmid=27833521 | doi= | pmc=5085351 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27833521  }} </ref>.
 
*[[Hands]] should be [[pronated]] and resting on the lap to induce resting tremor, it is important to be patient as tremors may take up to thirty seconds to appear. Repositioning hand with little finger down and thumb up can induce [[Parkinsonian]] tremor and [[Holmes tremor]]. <ref name="pmid27833521">{{cite journal| author=Alqwaifly M| title=Treatment responsive Holmes tremor: case report and literature review. | journal=Int J Health Sci (Qassim) | year= 2016 | volume= 10 | issue= 4 | pages= 558-562 | pmid=27833521 | doi= | pmc=5085351 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27833521  }} </ref>
*[[Parkinson's disease]]: Shortening of stride length, [[appendicular]] [[bradykinesia]]
*[[Parkinson's disease]]: Shortening of stride length, [[appendicular]] [[bradykinesia]]
*[[Essential Tremor]]: Bilateral action tremor effecting [[hands]] and [[forearms]]. Other [[neurological]] [[signs]] are absent.
*[[Essential Tremors]]: Bilateral action tremor affecting [[hands]] and [[forearms]]. Other [[neurological]] [[signs]] are absent. Following quick test should be done to evaluate tremor, drink from a glass, outstretch arms, and draw a spiral.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
 
[[Category:Neurology]]
{{WH}}
[[Category:Primary care]]
{{WS}}
[[Category:Signs and symptoms]]
[[Category: (name of the system)]]
[[Category:Medicine]]

Latest revision as of 16:05, 26 May 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

Overview

Physical examination of patients with tremor varies depending on the cause of tremor. The basis of physical examination is to determine the type of tremor, phenomenological features of tremor, associated neurological signs.

Physical Examination

Physical examination of patients with tremor varies depending on the cause of tremor.

Appearance of the Patient

Vital Signs

Skin

  • Skin examination of patients with tremors is usually normal.

HEENT

Neck

Lungs

Heart

Abdomen

Back

Genitourinary

Neuromuscular

Assessment of tremor[3].
Position Category Causes
At rest Resting tremors Tremors that are worse at rest include Parkinsonian syndromes and essential tremor if severe. This includes drug-induced tremors from blockers of dopamine receptors such as haloperidol and other antipsychotic drugs.
During contraction (eg a tight fist while the arm is resting and supported) Contraction tremors Tremors that are worse during supported contraction include essential tremor and also cerebellar and exaggerated physiologic tremors such as a hyperadrenergic state or hyperthyroidism[3]. Drugs such as adrenergics, anti-cholinergics, and xanthines can exaggerate physiologic tremor.
During posture (eg with the arms elevated against gravity such as in a 'bird-wing' position) Posture tremors Tremors that are worse with posture against gravity include essential tremor and exaggerated physiologic tremors[3].
During intention (eg finger to nose test) Intention tremors Intention tremors are tremors that are worse at during intention and the patient's finger approaches a target include cerebellar disorders.


Extremities

References

  1. Sharma S, Pandey S (2016). "Approach to a tremor patient". Ann Indian Acad Neurol. 19 (4): 433–443. doi:10.4103/0972-2327.194409. PMC 5144461. PMID 27994349.
  2. 2.0 2.1 Smaga S (2003). "Tremor". Am Fam Physician. 68 (8): 1545–52. PMID 14596441.
  3. 3.0 3.1 3.2 Jankovic J, Fahn S (1980). "Physiologic and pathologic tremors. Diagnosis, mechanism, and management". Ann Intern Med. 93 (3): 460–5. doi:10.7326/0003-4819-93-3-460. PMID 7001967.
  4. Chen W, Hopfner F, Becktepe JS, Deuschl G (2017). "Rest tremor revisited: Parkinson's disease and other disorders". Transl Neurodegener. 6: 16. doi:10.1186/s40035-017-0086-4. PMC 5472969. PMID 28638597.
  5. Alqwaifly M (2016). "Treatment responsive Holmes tremor: case report and literature review". Int J Health Sci (Qassim). 10 (4): 558–562. PMC 5085351. PMID 27833521.