Psychiatry

1. PRESENTOR - DR. GEETIKA RAO
(INTERN)
MODERATOR - DR. ABHISHRI
TREMORS AND
EXAMINATION

2. TREMORS
 Hyperkinetic Disorder.
 Most common movement disorder encountered in
clinical practice.
 Rhythmic oscillation of a body part due to intermittent
muscle contraction
 Repetitive movements of a regular frequency and
amplitude

3. TREMORS CAN BE
CLASSIFIED ACCORDING TO –
 DISTRIBUTION
 FREQUENCY
 ETIOLOGY
 RELATED NEUROLOGAL DYSFUNCTION

4. TYPES OF TREMORS
1. RESTING TREMORS
2. ACTION TREMORS
3. POSTURAL TREMORS
4. KINETIC TREMORS

5. TYPES OF TREMORS
1. RESTING TREMORS – Parkinsons Disease
2. ACTION TREMORS – Essential Tremors
3. POSTURAL TREMORS - Essential Tremors
4. KINETIC TREMORS – Cerebellar Disorders

6. PHYSIOLOGICAL TREMORS
 In normal individuals
 Mild, High frequency Postural or Action Tremors
 Mostly seen in Upper Limbs.

7. ENHANCED PHYSIOLOGICAL
TREMORS
Can affect 10% of population.
 Anxiety
 Fatigue
 Metabolic disturbances (Hyperthyroidism,
Dyselectrolytemia)
 Drugs ( Valproate, Lithium, Thyroxine, Nifedipine)
 Toxins (Caffeine, Alcohol)

8. PARKINSON’S DISEASE
TREMORS
 Resting Tremors
 Medium frequency
 Begin unilaterally first distally from digits and wrist
(Pill rolling)

9. PARKINSON’S DISEASE
TREMORS
 Spreads proximally ipsilateral and occasionally to
legs before crossing to the Contralateral side.
 Later stage - Involves Lips, Tongue, Jaw
 Spares – Head and Neck.

10. ESSENTIAL TREMORS
 Most common type (5% population)
 Can be present even in Childhood, but increase
drmatically after 70 years
 Postural or Action Tremors
 High frequency.
 Upper limbs
 Bilateral, Symmetrical involvement

11. ESSENTIAL TREMORS
 In severe cases, can interfere with functions like
Eating, Drinking.
 Head – 30% , Voice – 20% , Tongue – 20%
 Worsened by Stress, Improved by Alcohol
 Neurological examination is normal

12. .

14. EXAMINATION
 Consent is taken before examination
 Patient is asked to sit on a comfortable chair.
 Vitals are taken – Hyperthermia, Tachycardia,
Tachypnea can be present.
 General physical examination – Pallor, Icterus,
Clubbing, Cyanosis, Lymphadenopathy, Edema is
seen.

15. EXAMINATION
 Head to toe examination is done to note any
remarkable signs like – Posture, Resting tremors,
Facial masking, Eye changes, Neck swelling
(Hyperthyroidism).
 RESPIRATORY SYSTEM – Within normal limits
 CARDIOVASCULAR SYSTEM – Within normal
limits
 ABDOMEN – Within normal limits
 GENITOURINARY SYSTEM – Within normal
limits

16. EXAMINATION
 NEUROMUSCULAR SYSTEM –
Patients are usually oriented to Time, Place and
Person.
2. ESSENTIAL TREMORS –
Bilateral action tremor
Effecting Hands, Forearm
Absence of other neurological sign

17. EXAMINATION
2. PARKINSON’S DISEASE –
Cogwheel rigidity
Bradykinesia
Romberg’s Gait
Dysdiadochokinesia
Postural reflexes impaired

18. EXAMINATION
3. ALCOHOL INDUCED TREMOR-
Finger -to- nose test
4. CEREBELLAR TREMOR –
Wide –based gait
Truncal ataxia
Finger -to- nose test

19. EXAMINATION
 EXTREMITIES –
1. Ask the patient to pronate his both hands and
rest on his lap – see for resting tremors
2. Ask him to reposition his hand with little finger
down and thumb up – see for Parkinsonian
tremor
3. Ask the patient to Drink water from a glass
4. See for tremors when patient outstretches his
arms

20. REST TREMORS AND ACTION TREMORS

21. EXAMINATION
 SPIRAL TEST –
Ask the patient to draw a spiral on a blank paper.

22. REFERENCES
• Harrison’s Principles of Internal Medicine
• Hutchinson’s Clinical Methods