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==Overview==
==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==
During a physical exam a doctor can determine whether the tremor occurs primarily during action or at rest. The doctor will also check for tremor symmetry, any sensory loss, weakness or muscle atrophy, or decreased reflexes.
[[Physical examination]] of [[patients]] with tremor varies depending on the [[cause]] of tremor.


The degree of tremor should be assessed in four positions. The tremor can then be classified by which position most accentuates the tremor: <ref name="pmid7001967">Jankovic J, Fahn S. Physiologic and pathologic tremors. Diagnosis, mechanism, and management. Ann Intern Med. 1980;93:460-5. PMID 7001967</ref>
*Important factors in [[physical examination]] are:
**Type of tremor
**[[Phenomenological]] features of tremor
**Associated [[neurological]] [[signs]]


===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]].
===Vital Signs===
*[[Temperature]] is usually normal in common causes of tremor.
*[[Hyperthermia]] may be present in [[hyperthyroidism]].
*[[Tachycardia]] with regular pulse may be found in [[hyperthyroidism]], [[stress]], [[anxiety]]
*[[Tachypnea]] may be found in [[stress]], [[anxiety]]
*[[Blood pressure]] with usually normal.
===Skin===
*Skin examination of patients with tremors is usually normal.
===HEENT===
*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>
*[[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]].
*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]].
*Decreased blinking in [[Parkinson's disease]].
===Neck===
*[[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>
===Lungs===
*[[Pulmonary examination]] of [[patients]] with tremor is usually normal.
===Heart===
*[[Cardiovascular]] [[examination]] of [[patients]] with tremor is usually normal. [[Palpitation]] may occur in [[hyperthyroidism]], [[stress]], [[alcohol]] [[withdrawal]].
===Abdomen===
*[[Abdominal examination]] of [[patients]] with tremor is usually normal.
===Back===
*Back [[examination]] of [[patients]] with tremor is usually normal.
===Genitourinary===
*[[Genitourinary]] [[examination]] of [[patients]] with tremor is usually normal.
===Neuromuscular===
{| class="wikitable"
{| class="wikitable"
| '''Position''' || '''Name''' || '''Description'''
|+ 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.
  | 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 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 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 during intention, e.g. as the patient's finger approaches a target, including cerebellar disorders.
  | 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.
|}
|}
===Neurological Examination==
 
[[Neurological exam]] to assess nerve function and motor and sensory skills. The tests are designed to determine any functional limitations, such as difficulty with handwriting or the ability to hold a utensil or cup. The patient may be asked to place a finger on the tip of her or his nose, draw a spiral, or perform other tasks or exercises.
 
*[[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>
**[[Muscle]] rigidity: Cogwheel rigidity
**[[Bradykinesia]]: Slow movement, occurs in [[Parkinsons disease]].
**Abnormal gait: Romberg's test
**Unilateral/bilateral tremor:[[Frequency]], [[amplitude]], [[pattern]], [[distribution]].
**[[Dysdiadochokinesia]] (palm tapping test)
**Postural [[reflexes]] impaired.
*[[Essential Tremor]]:
**Bilateral action tremor
**Effecting [[hands]],[[forearms]]
**Absence of other [[neurological]] [[signs]]
*[[Cerebellar]] Tremor:
**Finger-to-nose test / [[Dysmetria]]
**Truncal [[ataxia]]
**Wide-based [[gait]].
*[[Alcohol]] induced tremor:
**Finger-to-nose test / [[Dysmetria]]
 
===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>
*[[Parkinson's disease]]: Shortening of stride length, [[appendicular]] [[bradykinesia]]
*[[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:Needs content]]
[[Category:Neurology]]
[[Category:Primary care]]
[[Category:Signs and symptoms]]
[[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.