Tremor
Tremor is an involuntary, rhythmic, oscillatory movement of a body part produced by alternating or synchronous contractions of opposing muscle groups.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Essential tremor | Bilateral postural/kinetic tremor, often FHx+, improves with alcohol, NO rest tremor, NO bradykinesia [1] | 「你伸直手嗰陣震、定係放低手嗰陣震？屋企人有冇手震？飲酒會唔會好啲？」 |
| Enhanced physiological tremor (anxiety, caffeine, drugs, thyrotoxicosis) | Low-amplitude, symmetrical, postural; identifiable trigger [1][4] | 「最近有冇飲好多咖啡、壓力好大？有冇食新藥？有冇心跳快、出汗？」 | |
| Serious Not To Miss | Parkinson's disease | Unilateral resting tremor (pill-rolling 4-6 Hz), bradykinesia + rigidity, asymmetric [1][3] | 「隻手靜止嗰陣震唔震？做嘢慢咗未？」PE: cogwheel rigidity, masked facies |
| Cerebellar lesion (stroke, tumour, MS) | Intention tremor on finger-nose test, dysmetria, wide-based gait, nystagmus [2][8] | 「用手指掂下鼻再掂我手指」— intention tremor + past-pointing | |
| Wilson's disease (if < 40 y/o) | Tremor (rest or action) + liver disease + KF rings; young patient [7] | 「眼有冇黃？肚有冇唔舒服？」PE: KF rings on slit lamp | |
| Pitfalls | Drug-induced parkinsonism | Bilateral symmetrical parkinsonism, temporal relation to drug start (metoclopramide, antipsychotics, antihistamines) [3][6] | 「你食緊嘅藥幾時開始食？手震係咪之後先出現？」 |
| Functional (psychogenic) tremor | Variable frequency/amplitude, distractible, inconsistent, entrainment | 「數數字嗰陣手震有冇改變？」— frequency changes with distraction | |
| Masquerades | Hyperthyroidism | Fine postural tremor + weight loss, sweating, tachycardia, goitre [4][5] | 「有冇瘦咗、怕熱、心跳快？」PE: goitre, lid lag, sweaty palms |
| Drugs/toxins (lithium, valproate, β-agonists, caffeine, alcohol withdrawal) | Temporal association with drug/substance [1][6] | 「最近有冇食新藥或者停咗啲嘢？」 | |
| Hypoglycaemia | Adrenergic symptoms: tremor + sweating + palpitations + hunger; resolves with glucose [9] | 「有冇食糖尿藥？震嗰陣有冇出汗、心跳快、好肚餓？」 | |
| Trying to Tell Me Something? | Anxiety / stress / health anxiety / fear of Parkinson's | Tremor worse with stress, may have panic attacks, came because parent diagnosed with PD | 「你最擔心係咩？係咪有親人有柏金遜？最近壓力大唔大？」 |
GC Lecture High Yield [1]: Movement disorders are divided into hyperkinetic (tremor, chorea, tics, ballismus, myoclonus, dystonia) and hypokinetic (Parkinsonism, catatonia). Tremor types: rest, postural, kinetic (simple vs intention vs task-specific). Parkinsonism cardinal features = TRAP: resting Tremor, Rigidity, Akinesia/bradykinesia, Postural instability. [1][3]
GC Lecture High Yield [2]: Drug-induced parkinsonism (metoclopramide, antipsychotics, antihistamines) is reversible — must always ask drug history. Wilson's disease is another reversible cause in young patients. [3][6]
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好！我係今日嘅醫生，點稱呼你？今日嚟想我幫你睇下啲咩嘢？」 | Rapport, interpersonal marks. Patient-centred opening. |
| 0:30–1:30 | Chief complaint & HPI: tremor characterisation | 「你隻手震幾耐㗎？」「係靜止嗰陣震定係做嘢嗰陣震？」「單邊定係兩邊？」「有冇越嚟越差？」「有冇咩嘢會令到佢差啲或者好啲？」 | Core symptom analysis: onset, duration, type (rest vs action vs intention), laterality, progression, aggravating/relieving factors. |
| 1:30–2:30 | Associated symptoms & red flags | 「有冇行路唔穩、成日跌倒？」「有冇覺得郁嘢慢咗？」「有冇手腳僵硬？」「有冇心跳快、出汗多、瘦咗？」「有冇食咩新嘅藥？」「有冇頭痛、嘔吐、對嘢睇唔清楚？」 | Screens Parkinsonism (bradykinesia, rigidity, gait), hyperthyroidism, cerebellar lesion, drug cause, intracranial pathology. |
| 2:30–3:30 | PMH, drug Hx, FHx, social Hx | 「你有冇其他長期病？」「而家食緊咩藥？」「有冇飲酒、飲幾多？」「有冇食精神科藥？」「屋企人有冇手震？」「你做咩工作？手震影唔影響你做嘢？」 | Drug-induced Parkinsonism is a reversible cause — must ask. FHx for essential tremor and Wilson's. Functional impact = social. |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得手震可能係咩原因？」(Idea)「你最擔心啲咩？」(Concern)「你今日最希望我幫到你啲咩？」(Expectation) | Direct ICE marks. Hidden agenda often = fear of Parkinson's or brain tumour, or functional impact affecting work/daily life. |
| 4:30–5:15 | Focused physical exam sign (if allowed) / Summarise | 「等我幫你檢查下，伸直兩隻手出嚟…用你嘅食指掂下我手指再掂返你鼻…」 | Demonstrates clinical competence. Rest tremor vs postural/intention tremor is THE key discriminator. |
| 5:15–6:00 | Summarise, safety net, close | 「咁我總結返，你手震大概⋯⋯我哋接住想幫你安排⋯⋯如果手震突然差好多、或者行路跌倒、吞嘢困難，你就要盡快返嚟睇。你有冇嘢想問？」 | Summarising checks understanding, safety-net scores patient-safety marks, open closing scores interpersonal. |
How to uncover the hidden agenda: Ask 「你點解揀今日嚟睇？」or「係咪有啲嘢特別擔心？」— the patient may have come because a relative was diagnosed with Parkinson's, or tremor is now affecting their job or chopstick use. This is NOT the same as the symptom itself.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did the tremor start? Sudden or gradual? | 「手震幾時開始？係突然定係慢慢嚟？」 | Acute = drug/metabolic; gradual = ET/PD | Sudden: stroke, drugs. Gradual: PD, ET |
| Type of tremor | Does it shake at rest, when holding things, or when reaching? | 「靜止嗰陣震、定係攞嘢嗰陣震、定係伸手攞嘢嗰陣先震？」 | Rest tremor → Parkinsonism; postural tremor → essential tremor / enhanced physiological; intention tremor → cerebellar [1][2] | Rest: PD. Postural: ET, thyrotoxicosis. Intention: cerebellar |
| Laterality | One side or both sides? | 「單邊定兩邊？邊邊先開始？」 | Unilateral onset → PD; bilateral → ET, physiological, metabolic | Unilateral: PD. Bilateral: ET, thyrotoxicosis |
| Progression | Getting worse over time? | 「有冇越嚟越差？」 | Progressive → neurodegenerative | PD, Wilson's, cerebellar degeneration |
| Associated bradykinesia | Slower doing buttons, writing smaller? | 「你扣鈕、寫字有冇慢咗？字有冇越寫越細？」 | Bradykinesia is the essential criterion for Parkinsonism [1][3] | PD |
| Rigidity/stiffness | Limbs feel stiff? | 「手腳有冇覺得硬、唔靈活？」 | Rigidity is a cardinal feature of Parkinsonism | PD, drug-induced parkinsonism |
| Gait/falls | Walking unsteady? Falls? Shuffling? | 「行路有冇唔穩、跌過倒？行路係咪碎步？」 | Postural instability, shuffling gait → PD; wide-based gait → cerebellar [1][2] | PD, cerebellar lesion, NPH |
| Thyroid symptoms | Weight loss, sweating, palpitations, heat intolerance? | 「有冇瘦咗、出汗多、心跳快、怕熱？」 | Hyperthyroidism causes enhanced physiological tremor + fine hand tremor [4][5] | Thyrotoxicosis |
| Drug history | Any medications — especially psych, anti-nausea, lithium? | 「有冇食藥？特別係精神科藥、止嘔藥、鋰鹽？」 | Drug-induced parkinsonism (metoclopramide, antipsychotics) is reversible and must not be missed [3][6] | Drug-induced tremor/parkinsonism |
| Alcohol | How much alcohol? Does alcohol improve the tremor? | 「你飲唔飲酒？飲完酒手震會唔會好啲？」 | ET classically improves with alcohol; alcohol withdrawal causes tremor | ET (improves), withdrawal tremor |
| Family history | Anyone in family with tremor or neurological disease? | 「屋企人有冇手震或者柏金遜病？」 | ET is often familial (AD); Wilson's is AR | ET, Wilson's disease |
| Red flags | Headache, vomiting, weakness, vision change, dysphagia? | 「有冇頭痛、嘔、手腳冇力、睇嘢矇、吞嘢困難？」 | Intracranial lesion, brainstem/cerebellar pathology | Brain tumour, stroke, MS |
| Age | (Note patient's age) | — | Young patient + tremor → Wilson's; elderly → PD/ET | Wilson's ( < 40), PD (> 55) |
| Functional impact | Affecting eating, writing, work, daily life? | 「手震影唔影響你食飯、寫字、返工？」 | Determines severity & social problem for biopsychosocial | All diagnoses — scores social marks |
| Mood/anxiety | Feeling stressed, anxious, low mood? | 「最近壓力大唔大？心情點？有冇擔心好多嘢？」 | Anxiety → enhanced physiological tremor; depression comorbid with PD | Anxiety, depression, functional tremor |
| Liver disease clues | Jaundice, abdominal swelling? (if young) | 「有冇眼黃、肚脹？」 | Wilson's disease presents with liver + neuro in young patients [7] | Wilson's disease |
Case Report Form Answer Builder
Write: "Tremor of [duration], [body part], [type: rest/postural/intention]"
High-yield HPI points to capture:
- Onset, duration, progression
- Rest vs postural vs intention
- Unilateral vs bilateral; which side started first
- Aggravating factors (stress, rest, movement) & relieving factors (alcohol, purposeful action)
- Associated features: bradykinesia, rigidity, gait disturbance, thyroid symptoms
- Drug history (anti-psychotics, metoclopramide, lithium)
- Family history of tremor
- Functional impact on ADLs, work, eating, writing
Likely examples:
- "Tremor affecting daily activities (eating, writing, work)"
- "Worried about Parkinson's disease"
- "Tremor getting worse / new symptom"
- "Family member recently diagnosed with neurological disease"
How to phrase: State the SINGLE most important reason the patient came TODAY. It may be functional concern or fear rather than the tremor itself. Use the answer from 「你今日最主要想我幫你解決咩嘢？」
| Likely Content | Example Wording | |
|---|---|---|
| Idea | Patient thinks it might be Parkinson's disease / stress / ageing / thyroid | "Patient thinks tremor may be early Parkinson's disease" |
| Concern | Worried about progressive disability, unable to work, losing independence | "Patient is worried the tremor will worsen and affect ability to use chopsticks and continue working" |
| Expectation | Wants diagnosis, referral to neurologist, medication, reassurance | "Patient hopes for investigation and specialist referral to rule out serious cause" |
In a family medicine station, the most likely diagnosis depends on the stem:
- Elderly + unilateral rest tremor + bradykinesia + rigidity → Parkinson's disease
- Bilateral postural/kinetic tremor + FHx + no rigidity/bradykinesia → Essential tremor (most common cause of chronic tremor in FM)
- Fine tremor + weight loss + tachycardia → Thyrotoxicosis (enhanced physiological tremor)
- On anti-psychotic or metoclopramide → Drug-induced parkinsonism/tremor
Minimum supporting evidence for Essential Tremor (most likely FM station default):
- Bilateral postural/kinetic tremor, no rest tremor
- Positive family history
- No bradykinesia, rigidity, or postural instability
- ± improvement with alcohol
Minimum supporting evidence for Parkinson's Disease:
- Unilateral resting pill-rolling tremor
- Bradykinesia (essential criterion)
- Cogwheel rigidity
| DDx | One Key Discriminator |
|---|---|
| Essential tremor (if main Dx is PD) OR Parkinson's disease (if main Dx is ET) | Rest tremor + bradykinesia = PD; postural/kinetic tremor without bradykinesia = ET |
| Hyperthyroidism | Fine tremor + systemic features (weight loss, tachycardia, heat intolerance) + goitre |
| Drug-induced tremor/parkinsonism | Temporal association with offending drug (antipsychotic, metoclopramide, lithium) |
Other reasonable DDx: Cerebellar lesion (intention tremor + ataxia), Wilson's disease (young + liver disease + KF rings), anxiety/enhanced physiological tremor, alcohol withdrawal.
| Domain | Problem |
|---|---|
| Biological | Tremor causing difficulty with fine motor tasks (eating with chopsticks, writing, buttoning clothes) |
| Psychological | Anxiety / fear of progressive neurological disease (e.g., Parkinson's); embarrassment about visible tremor |
| Social | Functional impairment affecting work performance / risk of losing job; social withdrawal due to embarrassment; caregiver burden if elderly |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Essential tremor | Bilateral postural tremor without resting tremor | Ask patient to extend both arms horizontally with fingers spread, palms down. Observe for tremor. Then ask patient to touch nose — tremor is kinetic but NOT intention (no crescendo at target). Check for resting tremor by having hands relaxed on lap — absent. | ET is a postural/kinetic tremor; absence of rest tremor and bradykinesia excludes PD [1] |
| Parkinson's disease | Unilateral resting pill-rolling tremor with cogwheel rigidity | Observe hands resting on lap for asymmetric tremor (4-6 Hz). Test tone at wrist — cogwheel rigidity (tremor superimposed on rigidity) [8]. Ask patient to walk — shuffling gait, reduced arm swing [1][3] | Rest tremor + cogwheel rigidity + bradykinesia = Parkinsonism cardinal triad |
| Hyperthyroidism | Fine bilateral postural tremor + tachycardia + goitre | Place a sheet of paper on outstretched hands — fine tremor visible. Palpate thyroid for goitre. Check pulse rate. Look for lid lag/retraction. | Fine symmetrical tremor + goitre + tachycardia = thyrotoxicosis [4][5] |
| Cerebellar lesion | Intention tremor on finger-nose test with dysmetria | Ask patient to alternately touch your finger and their nose with arm fully outstretched. Observe for crescendo tremor near target and past-pointing [2][8] | Intention tremor = cerebellar pathology; distinguishes from ET and PD |
| Drug-induced parkinsonism | Bilateral symmetrical parkinsonism (rigidity + bradykinesia), ± tardive dyskinesia | Test tone bilaterally — symmetrical rigidity. Look for orofacial dyskinesia (lip-smacking, tongue protrusion). | Bilateral and symmetrical onset (cf PD which is asymmetric) + temporal drug association [3][6] |
| Wilson's disease | Kayser-Fleischer rings on slit-lamp examination | Requires slit-lamp (not available in FM station). In station: mention "I would arrange slit-lamp examination for KF rings." | KF rings are pathognomonic of Wilson's with neurological involvement [7] |
Top Traps That Lose Marks
- Forgetting to ask drug history — Drug-induced parkinsonism (metoclopramide, haloperidol, risperidone) is a reversible cause and a classic exam trap. ALWAYS ask what medications the patient takes.
- Confusing rest tremor with postural tremor — Rest tremor = PD; postural/kinetic = ET. This single distinction drives your diagnosis.
- Labelling all tremor as Parkinson's — Essential tremor is MORE common than PD. Don't default to PD without bradykinesia.
- Missing thyrotoxicosis — Fine tremor can be the presenting complaint; must screen for thyroid symptoms.
- Not asking about alcohol — Both a cause (withdrawal tremor) and a diagnostic clue (ET improves with alcohol).
- Forgetting ICE — Many patients come because they're terrified of Parkinson's, not because of the tremor per se.
- Not asking about functional impact — This is your social problem for biopsychosocial and it scores marks.
- In young patients ( < 40), forgetting Wilson's disease — treatable, fatal if missed.
Must-Not-Miss Red Flags → Urgent Referral:
- Acute onset tremor with focal neurology (weakness, speech, visual) → stroke → A&E
- Rapidly progressive tremor + ataxia + cognitive decline → structural lesion/prion disease → urgent neuro referral
- Young patient + tremor + liver disease → Wilson's disease → urgent referral for ceruloplasmin, slit-lamp, copper studies
- Tremor + severe headache + papilloedema → raised ICP → urgent imaging
Shortest safe management/safety-net line: 「如果手震突然嚴重好多、出現手腳冇力、行路跌倒、講嘢困難、吞嘢困難、或者視力有變化，你要即刻去急症室。」
High Yield Summary
What to ASK: Rest vs postural vs intention; unilateral vs bilateral; bradykinesia; drug history; thyroid symptoms; alcohol; family history; functional impact; ICE (especially fear of Parkinson's).
What to WRITE: Specify tremor type and laterality in chief complaint. Main RFC is often "fear of Parkinson's" or "functional impairment." Most likely diagnosis in FM is usually essential tremor (bilateral postural, FHx+, no bradykinesia) or Parkinson's disease (unilateral rest, bradykinesia+). DDx must include drug-induced, thyrotoxicosis, and cerebellar cause. Biopsychosocial: biological = tremor type; psychological = anxiety/fear of PD; social = work/ADL impact.
What NOT to miss: Drug history (reversible cause!), Wilson's in young patients, thyrotoxicosis, red-flag focal neurology.
Active Recall - Family Medicine Clinical Test
[1] GC 091. Unsteady gait cerebellar lesions; movement disorders; Parkinsonism.pdf [2] CFB_Neuro clinical skills demonstration_01.08.22_file to students.pdf (coordination examination) [3] Neurology - Two cases of movement disorders.pdf; learning_points_output.txt (Movement Disorders learning points) [4] GC 063. I am losing weight and sweating all the time.pdf [5] Block A - I am losing weight and sweating all the time_ causes of severe, weight loss; thyrotoxicosis; hypothyroidism.pdf (signs of hyperthyroidism) [6] Ryan Ho Neurology.pdf (5.2 Parkinsonism and Parkinson's Disease; 5.1.1 Approach to Abnormal Movements) [7] MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (Wilson's disease — neurologic manifestation) [8] MBBS Final MB (Medicine) (Felix PY Lai).pdf (cerebellum clinical manifestation; Parkinson's diagnostic criteria) [9] Block A - Polyuria and polydipsia_ glucose metabolism; diabetes mellitus; diabetic ketoacidosis.pdf (hypoglycaemia symptoms)
Toe Pain
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Urinary Incontinence
Involuntary loss of urine due to impaired bladder storage or sphincter function, classified as stress, urge, overflow, or functional incontinence.