Tremor physical examination

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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.

Physical Examination

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

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 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 tremor is usually normal.

HEENT

• HEENT examination of patients with tremor depends on the cause.
• Look for eye changes characteristic of hyperthyroidism.
• Eye movement should be assessed for cerebellar disorders and Parkinson's disease could have double vision due to convergence insufficiency.
• 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. possiblke cause could be a stroke.

Neck

• Neck examination of patients with tremor is usually normal.
• Hyperthyroidism may have neck swelling, thyromegaly / thyroid nodules.

Lungs

• Pulmonary examination of patients with tremor is usually normal.

Heart

• Cardiovascular examination of patients with tremor is usually normal.

Abdomen

• Abdominal examination of patients with tremor is usually normal.

Back

• Back examination of patients with [disease name] is usually normal.

OR

• Point tenderness over __ vertebrae (e.g. L3-L4)
• Sacral edema
• Costovertebral angle tenderness bilaterally/unilaterally
• Buffalo hump

Genitourinary

• Genitourinary examination of patients with tremor is usually normal.

Neuromuscular

• Patients are usually oriented to persons, place, and time. Detailed neuromuscular examination of patients with tremor should include:
• Muscle rigidity: Cogwheel rigidity
• Bradykinesia: Slow movement, occurs in Parkinsons disease.
• Abnormal gait: Rombergs test
• Unilateral/bilateral tremor:Frequency, amplitude, pattern, distribution.
• Finger-to-nose test / Dysmetria
• Dysdiadochokinesia (palm tapping test)

Extremities

• Assess for rigidity and bradykinesia by flexing and extending the patient's arms, seeking signs of cogwheel rigidity.
• Extremities examination of patients with is very important:

OR

• Clubbing
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities
• Muscle atrophy
• Fasciculations in the upper/lower extremity