Diagnose this skin lesion with newest Stanford 25 video and topic. What is the exam of calciphylaxis? Rick Hodes. Happy Halloween! What is it? An interesting illustration of the physical exam If you put your stethoscope over this, what will you hear? A patient presents with foot pain and these chronic findings? This patient presents with chest pain.

Website Reaches Half a Million Visitors! A patient asks you… what is this? Verghese Welcome New Stanford Interns!!!! Teaching the teachers… Our methods. Do you know Marcus Gunn? Abdominal Wall Pain Do you know what this is??? Measuring Central Venous Pressure with the Arm. Involuntary Movements and Tremor Diagnosis Involuntary movements compose a group of uncontrolled movements that may manifest as a tremor, tic, myoclonic jerk, chorea, athetosis, dystonia or hemiballism.

Types of Involuntary Movements. General Definitions Tremor: Rhythmic oscillations caused by intermittent muscle contractions. Tics: Paroxysmal, stereotyped muscle contractions, commonly suppressible, might be simple single muscle group or complex. Temporarily suppressible.

Myoclonus: Shock-like, arrhythmic twitches. Not suppressible. Chorea: Dance-like, unpatterned movements, often approximate a purpose e. Often rapid and may involve proximal or distal muscle groups. Athetosis: Writhing movements, mostly of arms and hands. Often slow. Dystonia: Sustained or repetitious muscular contractions, often produces abnormal posture. Hemiballismus: wild, large-amplitude, flinging movements on one side of the body, commonly affecting proximal limb muscles but can also affect the trunk.

Approach to the Exam of Tremor. Mainly a postural tremor but if worsened, will occur at rest Commonly bilateral and symmetric. Classically, tremor decreases with EtOH, worsens with stress. Neurological exam is otherwise normal. Differentiate from Parkinson by noting absence of resting tremor, rigidity, bradykinesia, etc.

Intention Tremor Cerebellar Tremor Slow action tremor that most commonly occurs with purposeful movement such as in doing finger to nose test Usually associated with other cerebellar findings Seen in any process that causes damage to the cerebrellum stroke, tumor, multiple sclerosis, chronic alcohol abuse, certain medications Unlike the cerebrum, cerebellar disease causes problems on the SAME SIDE of the body as the the cerebellar lesion Titubation refers to tremor of the head and sometimes trunk due to cerebellar disease Parkinsonian Tremor Most common cause of a resting tremor that usually involves the distal muscles e.

Tremor when skeltal muscle holding in on position against gravity. Tremor when in process of voluntary contraction of muscle. Physical Exam Test Observe at rest. Observe while asking patient to do mental work may increase. Ask patient to extend arms and hold in mid air. Finger to nose, rapid alternating movements or heel to shin. Examples Parkinson's disease, Parkinsonian tremor e. Note: There can be overlap between these categories. For example, certain forms of Parkinson's disease will exhibit postural tremor.

Conversely, severe essential tremor will be present at rest. It is important to look for other signs of the suspected diagnosis to make sure you don't miss the correct one! Show video transcript. Please visit us at med. Physiologic myoclonus is often normal in people, for example myoclonic jerks during sleep transitions. Epileptic myoclonus referred to myoclonus in the setting of epilepsy. Essential myoclonus is a familial condition typified by multifocal jerks, usually benign.

Symptomatic secondary myoclonus refers to myoclonus that occurs secondary to neurodegenerative diseases such as alzheimer's disease, Huntington disease, Lewy body dementia and Creutzfeldt-Jacob disease. Negative myoclonus is the term sometimes used to contrast myoclonus.

It represents short periods of loss of muscle tone most commonly seen in liver disease patients with hepatic encephalopathy. Is can also be seen in severe uremia and certain toxins sometimes referred to as reversible myoclonus. Huntington's Disease Huntington's chorea is arrhythmic, nonrepetitive, semi-purposeful and involves the limbs, trunk, and face.

It is most common among female patients, years old. TOURETTE syndrome TS is a developmental neuropsychiatric disorder that appears in childhood or adolescence and is characterized by motor and phonic tics with a waxing and waning course during the individual's life.

While myoclonic and dystonic tics are not unusual among patients with TS, 5 , 6 to our knowledge, tremoric movements rhythmic and sustained movements have not been described previously as possible tic equivalents in TS. Tourette syndrome and psychogenic movement disorders share many characteristics, such as the presence of associated psychopathologic disorders, bizarre movements that increase with anxiety and improve with distraction, and periods of spontaneous remission.

Therefore, in patients with mild symptomatic TS and associated psychopathologic disorders, the onset of unusual movement disorders, such as tremoric movements incongruous with the common organic tremors during adulthood, could be misdiagnosed as psychogenic. We describe 4 such patients with previously unrecognized mild TS, exacerbated during adulthood by the onset of tremor, who were all referred for the evaluation of psychogenic tremor.

The demographic and clinical characteristics of the 4 patients with TS are summarized in Table 1 and Table 2. All patients gave informed consent to be recorded on videotape.

On evaluating videotape recordings, 2 raters J. A year-old, right-handed woman with diagnoses of major depression and generalized anxiety disorder was referred by her psychiatrist for the evaluation of possible psychogenic tremor. She complained of a chronic tremor of her arms that had worsened in the 6 months before referral. Family history was notable for phonic tics affecting 1 brother.

Her personal history showed that at age 11 years she had developed nail biting, throat clearing, and humming. At age 16 years she developed repetitive, stereotyped, bilateral stretching of the hands and fingers. The movements were preceded by uncomfortable, occasionally painful sensations in the upper limbs, and were associated with groans and guttural sounds.

At age 20 years, the stereotyped movements had been replaced by bursts of bilateral, regular, clonic movements of the arms, lasting several seconds and occurring many times a day. As she did not consider these symptoms to be socially disabling, she did not seek medical help.

At age 30 years, she was diagnosed as having recurrent major depression and generalized anxiety with agoraphobia and panic attacks, which were successfully treated with electroconvulsive therapy.

Between 54 and 67 years of age, she intermittently received diazepam, alprazolam, amitriptyline hydrochloride, and nortriptyline hydrochloride but not neuroleptics. She reported that, since their appearance in childhood, phonic tics and arm movements had had a fluctuating course, with remission periods lasting several months.

At age 68 years, when the recurrence of anxiety was accompanied by exacerbation of her tics, she was diagnosed as having psychogenic tremor by a local neurologist. Results of neurologic and mental status examination were normal apart from occasional low-volume moans and abnormal shaking of the upper limbs left more than right. Tremoric movements consisted of asymmetric bursts of stereotypic high-amplitude, 4- to 6-Hz rhythmic contractions of her shoulders, arms, and hands lasting more than 10 seconds each.

They markedly diminished when she performed voluntary movements and increased with tasks that required concentration, such as mental counting. She was able to voluntarily suppress the abnormal movements for at least 3 minutes, during which she reported increased feelings of inner tension. Periods of voluntary control of the movements were followed by rebound exacerbation of motor tics and repetitive groans and sniffles. She also reported feelings of discomfort in her hands, which she attempted to alleviate by forcefully compressing her fingers.

On the Tourette Syndrome Global Scale 7 her total tic score was 10 mild tic symptoms. Electroencephalogram, cranial computed tomographic scan, and blood screen results were normal. In the 3 years of follow-up, tremor bursts waxed and waned in severity. During periods of improvement, upper limb tics had a more irregular, myoclonic appearance. A year-old, right-handed, single, unemployed woman was referred to us by her family physician, who advised her to have the degree of disability caused by tremor evaluated so that she could apply for government social assistance.

She complained of bilateral, mainly right, bursts of postural tremor of her arms that had begun gradually 1 year earlier but worsened to the point of impairing daily activities, such as drinking, buttoning, and sewing. According to the patient, the tremor caused her to be dismissed from her former job. When previously referred by her family physician to another neurologist, she received the diagnosis of "psychogenic tremor, conversion disorder.

Her birth and early childhood had been unremarkable. She attended normal school until age 11 years, when she was withdrawn because she had severe attention problems and learning disability.

Thereafter, she helped her mother in domestic tasks until she obtained her first job as a domestic worker at age 19 years. She reported no familial or personal history of tremor or tic disorder. She had never received stimulants, neuroleptics, or other dopamine receptor antagonists.

During the first interview, when she was asked about her obvious phonic tics, she alleged that she had always made the same "normal" sounds. In a second evaluation when she was accompanied by her mother and her adolescent brother, it was noted that these relatives also exhibited a variety of motor and phonic tics grunting, snorting, humming, and hissing. The patient's mother nevertheless denied having tics when they were pointed out and became upset at the neurologist's persistent questioning.

Although she was aware of her daughter's tremor, she minimized the presence of phonic tics in her daughter and interpreted the motor tics tics of the face, head, neck, and limbs as the natural "nervousness" of her family. On neurologic examination, the patient exhibited grunting, throat clearing and abnormal word accentuation, impaired fine motor coordination and alternating hand movements, and intermittent bursts of a coarse postural and kinetic tremor of the upper limbs, right more than left, lasting between 10 and 30 seconds.

There was a marked increase in the tremor when her attention was drawn to her upper limbs. Fairly frequently, if distraction was accomplished by drawing her attention to another body part, the trembling limb became still for a while, but she became fidgety and exhibited camouflaged tics such as head shaking, along with twisting tonic movements of the neck and shoulders. When indicated, she could either voluntarily suppress or prolong tremor bursts. The patient explained that bursts of tremor were preceded by an unpleasant sensation—"like putting my arms in alcohol"—that was temporarily alleviated by the tremor.

On the Tourette Syndrome Global Scale, 7 her total tic score was 10 mild tic symptoms. Accelerometric and electromyographic recordings Figure 1 showed prolonged bursts of a predominantly 6-Hz tremor with some fluctuation in tremor amplitude, many changes in tremor frequency to 4 and 5 Hz during the period of recording, lack of discharges of the antagonistic muscles, and a reduction of tremor with distractibility. Complete blood cell count and levels of acanthocytes, serum copper, ceruloplasmin, and uric acid as well as an electroencephalogram were all within normal limits.

Patient 2. Recordings of the accelerometric top trace , agonistic middle trace , and antagonistic bottom trace electromyographic activity of the outstretched right hand extended in front of the chest.

Haloperidol 1. Although they did not completely subside, tremor bursts had a waxing and waning course in the 2 years of follow-up. A year-old, right-handed man who worked as a bricklayer was referred for evaluation of cephalic tremor and right-hand posturing and resting tremor of possible psychogenic origin. He had a long history of insomnia, obsessions of contamination, checking and arranging compulsions, and short temper.

In addition, he had abused alcohol between 23 and 28 years of age. He reported that since the age of 25 years he had suffered discomfort in the shoulders and neck. At the age of 46 years, he was examined by a family physician and a neurologist because of a 2-year history of pain, paresthesia, and action and postural tremor of the upper limbs.

A cervical root compression was suspected, but ancillary studies ruled out this possibility. The patient was given an early retirement and had a presumed diagnosis of "generalized osteoarthrosis and tremor. On examination, his family physician noticed intermittent cephalic and right-hand tremor and referred the patient to a neurologist, who diagnosed idiopathic Parkinson disease. He then received levodopa and a variable combination of anticholinergics, bromocriptine mesylate, pergolide mesylate, and selegiline hydrochloride during the next 7 years.

Symptoms of essential tremor can remain mild or moderate for many years, but in a significant percentage of people the tremor becomes more intense over time. There are other conditions that can cause tremor. Some people experience shaking and trembling as a side effect of certain medications, such as seizure and asthma medications. Tremors usually occur in the hands, but they can also affect the arms, legs, trunk, head, face, and voice.

Tremors are usually exacerbated by certain postures and activities, such as eating, drinking, and writing. Physical and emotional stress can also exacerbate tremors. Dystonia causes unintentional muscle contractions, which lead to slow, repetitive, and sometimes painful movements or unusual postures. There are several forms of dystonia. Some affect only one muscle, others affect groups of muscles, and some affect muscles in multiple body parts.

Symptoms vary depending on the form of the condition. They may include an involuntary turning of the neck, rapid and uncontrollable blinking in both eyes, or spasms that cause the eyes to close completely. Dystonia may also cause one foot to cramp, turn, or drag sporadically after running or walking.