Tremor physical examination: Difference between revisions

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==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
[[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]].
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


==Physical Examination==
==Physical Examination==
Physical examination of patients with [disease name] is usually normal.
[[Physical examination]] of [[patients]] with tremor varies depending on the [[cause]] of tremor.


OR
*Important factors in [[physical examination]] are:
 
**Type of tremor
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
**[[Phenomenological]] features of tremor
 
**Associated [[neurological]] [[signs]]
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


===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]], [[posture]], [[facial]] expressions when the patient walks in.
*[[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.
*High-grade / low-grade fever
*[[Hyperthermia]] may be present in [[hyperthyroidism]].
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse may be found in [[hyperthyroidism]], [[stress]], [[anxiety]]
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Tachypnea]] may be found in [[stress]], [[anxiety]]
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Blood pressure]] with usually normal.
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
*Skin examination of patients with tremors is usually normal.
OR
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises
 
<gallery widths="150px">
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
*HEENT [[examination]] of [[patients]] with tremor depends on the cause.
OR
*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>
* Abnormalities of the head/hair may include ___
*[[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>
* Evidence of trauma
*[[Action tremor]] in [[patients]] under forty should be examined for [[Wilson's disease]] [[eye]] changes, [[Kayser–Fleischer]] ring in the [[cornea]].
* Icteric sclera
*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]].
* [[Nystagmus]]  
*Decreased blinking in [[Parkinson's disease]].
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
*[[Neck]] [[examination]] of patients with tremors is usually normal.
OR
*[[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>
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
*[[Pulmonary examination]] of [[patients]] with tremor is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
*[[Cardiovascular]] [[examination]] of [[patients]] with tremor is usually normal. [[Palpitation]] may occur in [[hyperthyroidism]], [[stress]], [[alcohol]] [[withdrawal]].
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope


===Abdomen===
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
*[[Abdominal examination]] of [[patients]] with tremor is usually normal.
OR
*[[Abdominal distension]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
*Back [[examination]] of [[patients]] with tremor is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
*[[Genitourinary]] [[examination]] of [[patients]] with tremor is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
{| class="wikitable"
OR
|+ 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>.
*Patient is usually oriented to persons, place, and time
| '''Position''' || '''Category''' || '''Causes'''
* Altered mental status
|-
* Glasgow coma scale is ___ / 15
| 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.
* Clonus may be present
|-
* Hyperreflexia / hyporeflexia / areflexia
| 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.
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
|-
* Muscle rigidity
| 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>.
* Proximal/distal muscle weakness unilaterally/bilaterally
|-
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
| 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.
*Unilateral/bilateral upper/lower extremity weakness
|}
*Unilateral/bilateral sensory loss in the upper/lower extremity
 
*Positive straight leg raise test
 
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*[[Patients]] are usually oriented to persons, place, and time. Detailed [[neuromuscular]] [[examination]] of [[patients]] with tremor should include:
*Positive/negative Trendelenburg sign
*[[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>
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
**[[Muscle]] rigidity: Cogwheel rigidity
*Normal finger-to-nose test / Dysmetria
**[[Bradykinesia]]: Slow movement, occurs in [[Parkinsons disease]].
*Absent/present dysdiadochokinesia (palm tapping test)
**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===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
 
OR
*[[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>
*[[Clubbing]]  
*[[Parkinson's disease]]: Shortening of stride length, [[appendicular]] [[bradykinesia]]
*[[Cyanosis]]  
*[[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.
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==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.
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