Tremor history and examination Flashcards
What kind of questions should you be asking for presenting complaint?
- site
- onset-gradually or suddenly
- timeframe-notice it becoming worse at any particular time of the day
- exacerbating/alleviating factors-
- worse on movement: intention tremor in cerebellar lesions; essential tremor
- worse at rest: parkinson’s
- does alcohol and caffeine make it worse?: looking for essential tremor
What kind of questions should you be asking if you suspect parkinson’s?
- tremor-do you notice ur hand shaking at rest
- rigidity-are you still able to eat and drink ok?
- gait-do you notice yourself walking more slowly
- neuropsychiatric- do you have trouble sleeping? changes in mood?
- postural hypotension-do you feel dizzy when you stnad up
- olfactory changes-do you have any changes in smell
What kind of questions should you be asking for parkinson’s plus syndrome?
- MSA- do you feel dizzy when standing up? urge to urinate? erectile dysfunction?
- PSP- do you have trouble reading? do you notice yourself falling more frequently? slurred speech?
- dementia with lewy bodies-do you have visual hallucinations
- drug-induced-do you noticed the tremor in both hands?
What other questions should you ask to screen for other causes of tremor?
- hyperthyroidism-notice yourself feeling hotter or losing weight? palpitations? how heavy is your menstruation?
- essential tremor-do you notice your head bobbing? (titubation)
- cerebellar-do you notice yourself having touble walking/falling down? do you notice yourself having problems with your eye (nystagmus) or problems with your speech (slurred speech)? raised intracranial pressure-headache, nausea, vomiting; specific neurological deficits-pins and needles; or muscle weakness
What questions should you ask for PMH/SH?
DH?
FH?
SH?
PMH/SH
DH
FH
- do you have any history of tremors in your family? (essential tremor)
SH
- is it affecting their occupation
- are you still able to eat/drink? wash/dress up?
- do you require any writing/walking aids?
- smoking/drug/alcohol history?
Background:
You are a junior doctor in the neurology clinic. The referral for this patient is as follows:
‘Mr Herron presents with a 6-month history of a tremor in his right hand and some difficulty walking. He is not taking any medication currently. He wonders if he may have Parkinson’s disease?’
Task:
Examine the patient and discuss your diagnosis with him.
What are the differentials for tremor? (location, timing-whether it is worse at rest/action, frequency-coarse or fine, symmetry)
What are the parkinson’s plus syndromes? (and the specific signs to look for):
- parkinson’s
- multiple system atrophy
- progressive supranuclear palsy (PSP)
- dementia with lewy bodies
- drug-induced parkinsonism
What would you expect to find in parkinsonian’s gait?
- slow movement-bradykinesia
- poor arm swinging
- shuffing gait
- having trouble turning
What should you do for focused neurological examination of tremor?
- inspection
- tone
Inspection
- hypomimia (poor facial expression in parkinson’s)
- use of walking or writing aids
- dyskinesia-due to levodopa side effect
- look for low volume monotomous speech
Tone:
- check for leadpipe or cogwheel rigidity (wrist)
- activation movements worsen this
- axial rigidity in neck
What should you do for focused neurological examination of tremor?
- Power
- Reflexes
- Power-should not be affected MRC grade 5/5
- Reflexes-should not be affected
What are the other things you can look out fore (PSP)?
- draw H
- check for vertical saccadic movement
- check for difficult vertical paresis
- check vestibulo-ocular reflex
- absent in severe PSP
- glabella tap
- tap the forehead continuously, blinking will continue in parkinson’s
What should you do for focused neurological examination of tremor?
- coordination
What other investigations should be done if you suspect parkinson’s?
For coordination:
- finger-to-nose test-intention tremor if there is a cerebellar lesion (cerebellar hemisphere)
- check for dysdiadochokinesia (cerebellar)
- ask them to write a sentence- handwriting will be small in parkinson’s
- look for bradykinesia-ask them to tap index and thumb finger together. Look for a progressive reduction in amplitude; ask them to play piano (difficulty in performing rapid alternating movement)
Investigations:
- cognitive assessment
- falls, mood and sleep history
