Having trouble remembering all the important questions to ask during your patient encounter? Then try this Tremor Mnemonic for USMLE Step 2 CS.
PHYSICAL EXAMINATION Tremor mnemonic
NOTE: Make sure to wash your hands or wear gloves before you start physical examination. Make sure to ask for permission before you start each physical exam. Make sure to use proper draping (don’t forget to tie back patient’s gown). Make sure to explain each physical examination in layman’s term to your patient. Do NOT repeat painful maneuvers.
- Neurologic exam: Mini-Mental Status Exam, Cranial nerves (2-12), Muscle strength exam, Sensory exam, DTRs, Cerebellar, Gait.
- CV exam: Auscultation
- Pulmonary exam: Auscultation
DIFFERENTIAL DIAGNOSIS Tremor Mnemonic
- Parkinson’s disease (resting tremor): This is the most common cause of resting tremor (ie, a tremor that is evident with the affected body part supported and completely at rest but improves or subsides with voluntary activity), although some patients with PD also have a postural/action tremor that is indistinguishable from essential tremor (ET, see below)
- Essential tremor (postural tremor, action tremor): This is the most common neurologic cause of postural tremor (ie, tremor that is apparent when the arms are held outstretched) or action tremor (ie, tremor that increases at the end of goal directed activity such as finger-to-nose testing). Tremor is often asymmetrically involves the distal upper extremity. The head, voice, chin, trunk, and legs can also be involved. Essential tremor is not associated with other neurologic signs and improves following the ingestion of small amounts of alcohol.
- Physiologic tremor (postural tremor, action tremor): The tremor is often not visible, but when enhanced by medications or other medical conditions. Conditions that can enhance it include anxiety, excitement, sleep deprivation/fatigue, hypoglycemia, caffeine intake, alcohol withdrawal, thyrotoxicosis, fever, and pheochromocytoma.
- Hyperthyroidism: Conditions such as Grave’s disease can cause this. It is associated with (fine tremor) along with a variety of other classic signs and symptoms.
- Drug induced tremor: Many medications can enhance physiologic tremor, notably β-agonists (eg, albuterol), nicotine, theophylline, TCAs, lithium, valproic acid, and corticosteroids. Mercury and arsenic exposure may also contribute to tremor.
- Wilson’s disease (resting tremor): Wilson’s disease is a rare inherited disorder that causes copper to accumulate in your liver, brain and other vital organs.
- Midbrain lesion (resting tremor): Seen in midbrain injury due to stroke, trauma, or demyelinating disease such as Multiple sclerosis.
DIAGNOSTIC WORK-UP Tremor mnemonic
- TSH and Free T4
- Heavy metal screens (e.g. arsenic and mercury)
- Brain MRI
- Slit lamp for Kayser-Fleischer ring, Serum Ceruloplasmin, AST/ALT, Liver biopsy (Wilson’s disease work up)
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