Tremors

Published on 05/05/2015 by admin

Filed under Internal Medicine

Last modified 05/05/2015

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54 Tremors

Patient 1

Instruction

Look at this patient’s hands and demonstrate tremors.

Salient features

Examination

• Coarse resting tremor that is slow (4–6 per second)

• Adduction–abduction of the thumb with flexion–extension of fingers (pill-rolling movement)

• The tremor is halted by purposive movements of the hands. The upper limb tremor often increases as the patient walks

• Tell the examiner that you would like to do the following:

• Look for cog-wheel rigidity
• Comment on mask-like facies
• Check gait for festinant gait
• Ask the patient’s relatives whether sleep relieves the tremor and whether emotion makes it worse
• Examine the handwriting (Fig. 54.1).
image

Fig. 54.1 Handwriting and spiral drawing reflects tremor type. (A) Large scrawl in essential tremor. (B) Cramped, parkinsonian writing and spiral shows little tremor; writing is an action.

Diagnosis

This patient with resting tremor and mask-like facies (lesion) has Parkinson’s disease (aetiology) and is severely disabled by the tremor (functional status).

Patient 2

Instruction

Look at this patient’s hands and demonstrate tremors.

Salient features

Examination

• There is a 10-s physiological tremor that is brought on when the arms are outstretched. It can be amplified by laying a sheet of paper on the hands.

• Tell the examiner that you would like to do the following:

• Check for thyrotoxicosis
• Take a history for alcoholism
• Take a drug history (salbutamol, terbutaline, lithium)
• Take an occupational history to mercury (hatters’ shakes)
• Find out whether tremor runs in the family and is relieved by alcohol (benign essential tremor).

Diagnosis

This patient has fine tremor with an enlarged thyroid gland (lesion), which could be from hyperthyroidism (aetiology).

Patient 3

Instruction

Look at this patient’s hands and demonstrate tremors.

Salient features

Examination

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