Thursday, May 13, 2010

Post 11: Tremor

Examine this patient's tremor.

Came out in one of our short cases.

Inspect the tremor at rest. Nature? Speed per sec?

Then ask the patient to stretch out the hand straight in front, and spread his fingers and keep it there. (Spread the fingers for fun...dunno got difference or not)

Tremor types:

1. Resting tremor. 3-4 cycles a second at best. Coarse. Pill rolling. Abolish on active movement like when the patient move his hand to stretch out for the second instruction. Should be asymmetry. Parkinson.

2. Intentional tremor. irregular. large amplitude and worst at the end of a purposeful act. Cerebellar lesion, MS or cerebellar stroke.

3. Postural Tremor. Absent at rest. Present at maintained position, like when hands out straight. divided into benign essential or acquired.

Benign essential - asymmetry, slower and persist throughout action and keeping posture. Idiopathic.

Acquired - symmetry, faster, purely postural. Abolish on active movement. Causes: Thyrotoxicosis, salbutamol, anxiety.

Treatment for both, beta blockers, and for acquired, rx underlying cause.

4. Last type is the flapping tremor in liver failure and respiratory failure.


I think it would be a parkinson's patient. So likely to ask you to inspect and tell findings.

Lack of facial expression and got unku (flex neck) a bit.

Core features of parkinsons - TRAP.

T - Tremor as described.

R - Rigidity - check tone, looking for rigidity cog wheeling, which is spastic + tremor.

A - Akinesia or bradykinesia. chcek the finger pinching and piano playing speed.

P - Posture which is very observational - Stoop posture, ask the patient to walk across and turn, slow initiation, hard to get up from the chair, minimal hand swing, hand over hernia postion, festinant steps ie getting faster and faster, very slow in turning, shuffling gait.

Treatment - LDopa with peripheral dopa decarboxylase inhibitors for side effects. Dopamine agonist, Anticholinergics, COMT inhibitors...cannot remember liau. And surgery is the new thing. Deep brain stimulation i think. HAHAH. dun care.

Causes of parkinson - Idiopathic, vascular - stroke, trauma - muhd ali, drug - antipsychotics, lithium, metoclopramide, metabolic - copper ie wilson's disease, parkinson plus - MSA, Shy Dragger cant remember liau la...

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