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Special tests (again) 11 Trendelenburg test [a Fig. 2, Fig. 3]1! Sit on a chair in front of pt1! Place your hands on their iliac crests with your thumbs over ASISs1! “Put your hands on my shoulders or hold my arms & support yourself”1! Ask pt to stand on one leg at a time – the ‘good leg’ first1! Normal: pelvis tilts upwards on unsupported side1! Positive test: pelvis tilts downwards on unsupported side & trunk leans Laryngoscopy of essential tremor patients with vocal tremor shows an entrained, oscillatory motion of several anatomic structures during sustained phonation. Many patients have oscillatory movements during quiet respiration. Tremor can involve muscles of the palate, pharynx, tongue, and other articulatory muscles in addition to the larynx. This involvement does not distinguish vocal tremor of essential tremor from spasmodic dysphonia. A cross sectional study of 19 ear, nose, and throat patients with either essential tremor or dystonic tremor found that dystonic patients were more likely to have reduction of tremor in the palate (P=0.02), pharynx (P=0.038), and larynx (P=0.002) when using a higher “falsetto” pitch. 36
The ring bound format of the essential examination book makes it easy to use and access information. Each section of the book provides helpful tips of what to say to a patient and provides a step to step guide for each system and how to examine. I found the space for notetaking particularly helpful and enabled me to highlight parts I wanted to explore further. Strengths & weaknesses: Benito-Leon J, Domingo-Santos A. Orthostatic tremor: an update on a rare entity. Tremor Other Hyperkinet Mov. 2016;6:411.
Summary
This book is intended primarily to be used by medical students in their ‘clinical’ years who, having attained a sound grasp of clinical science and disease processes are beginning to hone examination techniques. It is of particular use to those who are preparing for final assessments and practising techniques during revision.
Propranolol should be used with caution in patients with diabetes mellitus, as the adrenergic signs and symptoms of hypoglycemia can be masked. In the absence of contraindications, patients with stable heart failure due to left ventricular systolic dysfunction may take propranolol. 120 Some patients fall into an overlap syndrome between PD and ET; these patients typically present with a history of ET for many years, and then develop a rest tremor with mild parkinsonian signs. 5,6 The presence of postural and kinetic tremor out of proportion to that expected in PD should raise the suspicion of a PD/ET syndrome.
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The IMDA and the 2005 AAN practice parameters recommend botulinum toxin injections in medically refractory cases of essential tremor. In 1996 the first randomized, double blind, placebo controlled trial (n=25, 13 in treatment arm) reported modest outcomes in patients with essential tremor treated with onabotulinum toxin. 143 Patients in the treatment arm received 50 units of toxin (15 units flexor carpi radialis, 15 units flexor carpi ulnaris, 10 units extensor carpi radialis, 10 units extensor carpi ulnaris). Another set of injections was administered four weeks later in doubled doses in the case of no clinical response and no weakness. Patients reported modest improvements, but no significant improvement in function was seen. Musculoskeletal GALS screen Hip Knee Foot and ankle Shoulder Elbow Spine Hands – general / musculoskeletal
Some patients with tremor presenting to the office have tremors that are unusual or difficult to classify. Patients with ET may present in several ways that can confuse the inexperienced examiner. Patients may present with an isolated tremor of the voice, with no head tremor or action tremor of the hands. Patients with isolated vocal tremor are overwhelmingly women, usually over age 60, and almost always report improvement in their tremor if they drink alcohol. 14 Some patients with ET have very asymmetric presentation, with an action tremor affecting only one arm. More challenging, others present with an isolated tremor at rest that mimics a parkinsonian rest tremor but without bradykinesia or cogwheeling. These patients may be misdiagnosed with PD, although dopaminergic imaging studies are usually negative.
Contents
Fekete R, Jankovic J. Revisiting the relationship between essential tremor and Parkinson’s disease. Mov Disord. 2011;26:391-398. A basic neurologic examination can be performed rapidly with practice. The presence of an abnormal result usually warrants further investigation and referrals to specific specialties. It helps to recognize and therefore manage diseases earlier in their course.A complete neurologic examination should contain an assessment of sensorium, cognition, cranial nerves, motor, sensory, cerebellar, gait, reflexes, meningeal irritation, and long tract signs. Specific scales are useful to improve interobserver variability. Introduction 11 Wash/gel hands11 Introduce yourself, confirm pt, explain examination & gain consent11 Expose & position pt (down to pants or shorts, supine with 1 pillow)11 “Which hip is sore? Where is it sore?”11 “I would like to compare the affected hip with the unaffected one” Before the 1990s, the main surgical intervention for essential tremor was thalamic lesioning. However, this approach fell out of favor with the development of deep brain stimulation (DBS). DBS can be done with or without general anesthesia. A frontal burr hole is drilled and then electrodes are implanted. Microelectrode and macroelectrode recordings can be used to assist in location of leads. The intracranial electrodes are ultimately connected to an implanted pulse generator. Thenganatt MA, Jankovic J. Psychogenic tremor: a video guide to its distinguishing features. Tremor Other Hyperkinet. 2014;4:253.
The layout of the book and its ring bound format makes it an easy to use book that could be used daily in clinical practice. It is slim in appearance but contains all the information necessary and also uses pictures as aids for undertaking examination which is extremely useful. The examinations are separated into what to examine for and the potential findings the examination may find. The book, however, does rely on the reader having a good understanding of the physiology and pathophysiology of the systems discussed so may not be useful to novices. Who should read it? In a separate column is a collection of key information: potential findings, differential diagnoses of clinical signs and practical tips. Small studies indicate that long acting propranolol is as effective as the short acting formulation; patients with exposures to both prefer the ease of the long acting formulation. 110 116 One year follow-up of patients taking propranolol showed a continued but sometimes reduced response to treatment; some patients needed dose increases. 117 118 including photocopying, recording, or any information storage and retrieval system, without permission in writing from Undisplaced intracapsular #1! Inevitable interruption of intramedullary vessels, possible disruption to cervical arteries1! Moderate risk of AVN1! Usually pinned in the hope that AVN will not develop (~30% risk)persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any
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