Essential Examination, third edition: Step-by-step guides to clinical examination scenarios with practical tips and key facts for OSCEs

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Figure 1. Archimedes spiral performed by a patient with essential tremor. Note the axis of maximal amplitude of tremor at 60°. Tips for Examining a Patient With Tremor Witjas T, Carron R, Boutin E, et al. Essential tremor: update of therapeutic strategies (medical treatment and gamma knife thalamotomy). Rev Neurol(Paris). 2016;172:408-415. Steven J. Frucht, MD Many patients with essential tremor develop head tremor. Head tremor is typically a late clinical manifestation of the disease; the presence of isolated head tremor should raise suspicion for an alternate diagnosis (cervical dystonia). 24 25

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 Great revision buddy for finals"Would recommend to anyone as a good guide to finals Osce revision!" Optic nerve (Cranial nerve II) – Assessment of the optic nerve function includes a test for visual acuity and visual fields. Each eye is tested separately. Most problems with visual acuity are ophthalmologic in origin; however, damage to this nerve, like pseudobulbar neuritis or pressure from a pituitary tumor, can present with monocular blindness and visual field cuts. The extent of involvement will depend on what they can see during the examination as compared to the baseline. [11] Furthermore, the pupillary light reflex can be tested by shining a light directly into the eye. The afferent limb of this reflex is found on the optic nerve; the sensory input. Shining a light on one eye should show a constriction of the pupils on both eyes. The failure of the pupils to constrict could indicate either an optic nerve lesion, a lesion of the efferent limb (oculomotor nerve), or any lesion along the pathway. A dilated pupil that is unresponsive to light may indicate a lesion on the efferent limb of the pathway, while a constricted pupil can point to a lesion on the cervical sympathetic chain. A fundoscopic examination is also done to visualize the optic disk. Abnormalities like papilledema or retinal hemorrhages are red flags that can point to life-threatening conditions like increased intracranial pressure and subarachnoid hemorrhage. [12]Orthostatic tremor is an unusual tremor that affects the trunk and legs and is specifically triggered by standing. 13 Patients typically complain of difficulty standing or walking and may be unaware of their tremor. Touching the hand of the examiner or a wall stops the tremor, and tremor also usually abates when patients walk. Thenganatt MA, Jankovic J. Psychogenic tremor: a video guide to its distinguishing features. Tremor Other Hyperkinet. 2014;4:253.

The only book I used for OSCE revision! This book provides a succinct and accurate guide to final year medical OSCEs. Marsala SZ, Pistacchi M, Gioulis M, Ferracci F, Capus L. Clinical and imaging study of isolated and mixed rest and action tremor: essential tremor versus Parkinson’s disease. Ann Indian Acad Neurol. 2017;20:138-141.

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Although the majority of patients referred for the evaluation of tremor do not require extensive ancillary testing, 3 caveats apply. 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 Essential Examination is one of the bestselling medical textbooks on the market. It is particularly suitable for medical students preparing for OSCEs and those learning to examine patients.

Alqwaifly M. Treatment responsive Holmes tremor: case report and literature review. Int J Health Sci. 2016;10(4):558-562.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. Arthroscopy, arthroplasty, DHS1u Inflammation1u Inflammation, effusion1u OA, other hip pathology1u # NOF (acute or malunion)1u [a] Although alternative lead locations are under assessment, the approach for most surgeries in essential tremor is to target unilateral or bilateral lead placement in the thalamic ventral intermediate nucleus (ViM). 154 155 156 Improvement of tremor is thought to be due to the disruption of the synchronous firing in the ViM. Patients undergoing DBS in the ViM report improvement in severity of limb tremor and activities of daily living, as well as non-motor symptoms such as “tense feelings.” 157 158 A retrospective analysis of a patient cohort who had ViM DBS, including 28 patients with essential tremor, found sustained reduction in limb tremor 10 years after surgery, although some loss in efficacy was seen over time—66% improvement from baseline in year one and 48% improvement from baseline in year 10. 159 Head tremor often improves with both unilateral and bilateral ViM placement. Studies have shown inconsistent improvement in voice tremor. 160 161 162 Common side effects are listed in tabl