This document discusses different types of tremors, their clinical manifestations, and examples of diseases they may be associated with. It describes resting tremor, which is abolished with movement and seen in Parkinson's disease. Intentional tremor has consistent amplitude throughout movement with no dysmetria, as seen in essential tremor. Action tremor is present with maintained posture and seen in essential tremor, anxiety, thyrotoxicosis, and medication side effects. Postural tremor develops after a 10 second delay and is seen in Parkinson's disease. Re-emergent tremor is also discussed. The document provides guidance on examining patients for tremor.

1. Clinical
Manifestation
of Disease
Prepared by:
malek ahmad
University of Malaya

2. Tremor
•Abolished on movement
•Eg: parkinsonismResting tremor
•Increase amplitude as reach target (dysmetria)
•Eg: cerebellar damage (MS, stroke)
Intentional
tremor
•Amplitude remains the same throughout movement (no
dysmetria)
•Eg: essential tremor
Action tremor
•Present on maintained posture
•Eg: benign essential tremor (AD, improve with alcohol), anxiety,
thyrotoxicosis, B-agonist
Postural tremor
•Postural tremor developing after a delay of ~10sec
•Eg: parkinson
Re-emergent
tremor
Rhythmic, oscillatory movement of body part (hands and legs)

3. Approach of patient
with tremor
Sit up with arm supported
by pillow (accentuated by
count 100 backward)
Stretch out the arms with
fingers seperated
Finger-nose test
Rest
tremor
Postural
tremor
Intentional
trempr
Action
tremorIn exam always think of
Parkinson’s disease

4. Cerebellar signs
• Slurred/ataxic/staccatoSpeech
• NystagmusEye movement
• ReduceTone and power
• Finger-nose test/dysdiadochokinesiaCoordination
• Failed Romberg’s testyGaits
• Intentional tremorTremor
DANISH

5. Assessment of
coordination
• Finger-nose test
• Dysdiadochokinesia
• Pronator drift
UL
• Heel-shin test
LL

7. Dupuytren contracture
Nodular thickening of CT over 4th and 5th finger
Local hypoxia, ischemia, increase XO xtvt, reduce O2, free
radical, fibroblast proliferation, type III collagen, fibrosis
Alcohol Smoking
Heavy
manual
labour
Trauma
DM HIV
Epilepsy-
phenytoin
CLD

9. Palmar erythema
Liver
dysfunction –
portal HPT
Pregnancy
Polycythemia Thyrotoxicosis
Dermatoses-
exzema/psoriasis
RA

11. Finger clubbing
CVS
• Cyanotic heart disease
• IE
• Infected graft
• Aneurysm
• Atrial myxoma
RESPI
• Bronchiectasis
• CF
• Cancer
• Empyema
• Fibrosing alveolitis
• TB
• Mesothelioma
GIT
• GI lymphoma
• IBD
• Malabsorption;coeliac
• Cirrhosis
Unilateral
• UL artery aneurysm
• Bronchial AV malformation

12. Grade
•Softening of nail bed
Grade I
•Obliteration of the angle of the nail bed
Grade II
•Overlying skin to become tense, shiny and wet and
increasing the curvature of the nail, resulting in
parrot beak or drumstick appearanceGrade III
•Swelling of the fingers in all dimensions associated
pain and swelling of the wrist and radiographic
evidence of subperiosteal new bone formationGrade IV

15. Occur due to
interruption of
Face sympathetic supply
• At brainstem: demyelination, vascular disease
• At cord: syringomyelia
• At thoracic outlet: pancoast’s tumor
Sympathetic’s trip on internal carotid
artery
• Into the skull: carotid aneurysm
• Thence the orbit

16. Horner’s syndrome
• PtosisP
• AnhydrosisA
• MyosisM
• EnopthalmosE
• Loss of ciliaspinal reflexLa

17. Pancoast’s syndrome
• Ipsilateral horner’s syndrome
Invade sympathetic plexus
• Arm pain
Brachial plexus
• Hoarse voice, bovine cough, due to vocal
cord palsy
Recurrent laryngeal nerve

18. RA: 0-8
mmHg
LA: 1-10
mmHg
RV: 15-30 /
0-8 mmHg
LV: 100-140 /
5-12 mmHg
PA: 15-30 /
3-12 mmHg
AO: 100-140 /
60-80 mmHg
O2 saturation:
LH (95%)
RH (75%)