Makindo Medical Notes.com

History Taking

• Onset and Duration:
  • When did the tremor start?
  • Was it sudden or gradual in onset?
• Character of Tremor:
  • Is the tremor present at rest, during movement (intention tremor), or when holding a posture (postural tremor)?
  • Is it unilateral or bilateral?
  • Is it intermittent or continuous?
• Triggers:
  • What activities or situations trigger or exacerbate the tremor (e.g., stress, caffeine, fatigue, movement)?
  • Does alcohol improve or worsen the tremor?
• Associated Symptoms:
  • Inquire about other neurological symptoms such as bradykinesia, rigidity, postural instability (suggestive of Parkinson's disease), or ataxia (cerebellar disease).
  • Ask about history of seizures, weakness, or sensory deficits.
• Medication and Substance Use:
  • Review current medications (e.g., drugs like lithium, valproic acid, antipsychotics, which may cause tremors).
  • Inquire about alcohol use, caffeine intake, and drug use (illicit or prescription).
• Family History:
  • Ask about a family history of tremors or movement disorders (essential tremor, Parkinson’s disease, dystonia).

Physical Examination

• Observation:
  • Observe the patient at rest, during posture holding, and while performing specific tasks (e.g., finger-to-nose test).
  • Note the location (hands, head, legs) and amplitude of the tremor.
• Neurological Examination:
  • Assess for signs of Parkinsonism (bradykinesia, rigidity, resting tremor).
  • Look for cerebellar signs (ataxia, dysmetria, intention tremor).
  • Check for muscle strength, reflexes, and sensory abnormalities.
• Postural Tremor Testing:
  • Ask the patient to extend their arms in front of them and assess for tremors.
• Intention Tremor Testing:
  • Perform the finger-to-nose test or heel-to-shin test to assess for intention tremor.

Investigations

• Laboratory Tests:
  • Consider thyroid function tests to rule out hyperthyroidism (can cause tremor).
  • Assess serum electrolytes, calcium, and magnesium levels.
  • Perform liver function tests and renal function tests if metabolic disorders are suspected.
• Imaging:
  • Brain imaging (MRI) may be indicated to rule out structural causes (stroke, tumour, or cerebellar degeneration).
• Electrophysiological Studies:
  • Electromyography (EMG) can help characterize the tremor type and frequency.

Differentials

Management

• Treatment of Underlying Cause:
  • If the tremor is secondary to an underlying cause (e.g., hyperthyroidism, medication-induced), address the root cause.
• Medications:
  • For essential tremor: beta-blockers (e.g., propranolol) or primidone.
  • For Parkinsonian tremor: dopaminergic therapy (e.g., Levodopa).
  • For cerebellar tremor: Clonazepam or propranolol may be used for symptomatic relief.
• Non-Pharmacological Therapy:
  • Physical therapy to improve coordination and strength.
  • Occupational therapy to help with daily activities.
• Surgical Options:
  • Deep brain stimulation (DBS) may be considered for refractory cases of essential or Parkinsonian tremors.