Neuro Exam II

Question 1

What is a tremor?

Answer 1

an involuntary, rhythmic, oscillatory movement of a body part and is the most common movement disorder seen in Primary care practices.

Question 2

Resting Tremor

Answer 2

• Occurs in body part that is relaxed and completely supported against gravity
• Enhanced by mental stress or movement of another body part (walking)
• Diminished by voluntary movement of that body part

Question 3

Action Tremor -

1. Postural
2. Isometric
3. Kinetic

Answer 3

• Postural tremor – maintaining a position against gravity (i.e. arm elevation)
• Isometric tremor – muscle contraction against a rigid stationary object (i.e. making fist)
• Kinetic tremor associated with voluntary movement and includes intention tremor, which is produced with target-directed movement (i.e. reaching for a pen)

Question 4

Enhanced Physiologic

Answer 4

• Everybody has an asymptomatic physiologic tremor
• Low amplitude, high frequency at rest and during activity
• Enhanced by anxiety, stress, certain medications and metabolic conditions
• If patients have tremors that come and go with anxiety, med use, caffeine intake or fatigue, they don’t need further testing

Question 5

Essential Tremor

Answer 5

• Most common pathological tremor
• 95% of patients have primarily kinetic rather than postural
• Most common in hands and wrists, can also affect head, LEs and voice
• Usually bilateral, is present with different tasks and interferes with activities
• Can be inherited, tends to progress with age
• 25% of those affected retire early or modify career path, can cause social
embarrassment
• Caffeine and fatigue exacerbate these tremors, alcohol can lessen

Question 6

Parkinsonism Tremor

Answer 6

• Clinical syndrome characterized by:
• Various meds cause Parkinsonism by blocking or depleting dopamine
• Most common form is idiopathic Parkinson’s disease (PD), a chronic neurodegenerative disease with a prevalence of 1%
– 70% of patients with PD have a resting tremor as their presenting feature, can get better with action
– Classic tremor starts as a pill-rolling motion of the fingers
– Bradykinesia includes difficulty rising from a seated position, reduced arm swing while walking, micrographia

Question 7

Cerebellar Tremor

Answer 7

• CLASSIC: Low-frequency, slow-intension or postural tremor, and is typically caused by multile sclerosis with cerebellar plaques, stroke, or brainstem tumors.

Question 8

Psychogenic Tremor

Answer 8

• Can be difficult to differentiate from organic tremor
• Some features that are consistent include abrupt onset, spontaneous remission, changing tremor characteristics (including locaton and frequency), increase with attention and extinction with distraction.
• More frequently seen in patients employed in allied health professions, those involved in litigation

Question 9

Hx for tremor

Answer 9

• Family history of neurologic disease or tremor suggests genetic component, common in essential tremor.
• Tremor in older patients and gradual onset more likely to be PD or essential tremor.
• Sudden onset more likely to be psychogenic, related to medication use or toxin exposure or, in rare circumstances, a brain tumor.

Question 10

Hx/signs consistent with PD

Answer 10

• Tremor, Subtle decrease in dexterity
• Decreased arm swing on the first-
involved side
• Soft voice
• Sleep disturbances
• Decreased sense of smell
• Symptoms of autonomic dysfunction (eg, constipation, sweating abnormalities, sexual dysfunction, seborrheic dermatitis)
• Decreased facial expression
• A general feeling of weakness, malaise, or lassitude
• Depression or anhedonia • Slowness in thinking

Question 11

PD (a) vs. Essential Tremor (b)

1. Tremor
2. Frequency
3. Writing
4. FH
5. Other neuro signs

Answer 11

1. a. at rest, increases with walking; decreases with posture holding or action
   b. posture holding or action
2. a. 3-6 HZ
   b. 5-12 HZ
3. a. micrographia
   b. tremulous
4. a. less common (1%)
   b. often (30-50%)
5. a. bradykinesia, rigidity, loss of postural reflexes
   b. none