Shaking or Tremor of the Hands

Fine tremor of hands

Elicited by asking patient to hold arms out straight in front and placing sheet of paper to rest on them (to amplify fine tremor).

Some differential diagnoses and typical outline evidence

Thyrotoxicosis	Suggested by: fine tremor, anxiety, tachycardia, sweating, weight loss, goitre, increased reflexes.
	Confirmed by: ↑ FT4 or FT3 and ↓↓ TSH.
	Management:
Anxiety state	Suggested by: fine tremor, anxiety, tachycardia, sweating, weight loss, goitre, increased reflexes.
	Confirmed by: normal thyroid function tests. Improvement with sedation, psychotherapy etc.
Alcohol withdrawal	Suggested by: fine or coarse tremor, history of high alcohol intake and recent withdrawal, anxiety.
	Confirmed by: improvement with sedation, etc.
	Management:
Sympathomimetic drugs	Suggested by: fine tremor, drug history.
	Confirmed by: improvement with withdrawal of drug.
Benign essential tremor	Suggested by: usually coarse tremor, long history, no other symptoms or signs.
	Confirmed by: normal thyroid test results. Improvement with beta blocker.

Coarse tremor of hands

Elicited by asking patient to hold arms out straight in front and extending wrists (for asterixis or flap), then asking the patient to touch their own nose and then the examiner's, finger with arm extended, repetitively (for intention tremor).

Some differential diagnoses and typical outline evidence

Hepatic failure	Suggested by: flapping tremor (asterixis) aggravated when wrists extended. Spider naevi. Jaundice.
	Confirmed by: abnormal liver function tests and prolonged prothrombin time.
	Management:
Carbon dioxide retention	Suggested by: flapping tremor (asterixis), aggravated when wrists extended. Muscle twitching, bounding pulse, warm peripheries.
	Confirmed by: blood gases show ↑ pCO2.
	Management:
Cerebellar disease	Suggested by: intention tremor (past pointing) when patient attempts to touch examiner's finger.
	Confirmed by: MRI scan.
Parkinsonism due to Parkinson's disease, drug-induced (chlorpromazine, haloperidol, metoclopramide, prochlorperazine); multisystem atrophy, Alzheimer's disease; postencephalitis, normal-pressure hydrocephalus	Suggested by: resting coarse tremor, (‘pill-rolling’); ‘lead-pipe rigidity’; expressionless face, paucity of movement, small hand writing, rapid shuffling (‘festinant’) gait with small steps.
	Confirmed by: clinical findings e.g. persistent blinking when forehead tapped (e.g. ‘glabellar tap’). Clinical improvement with appropriate treatment.
	Management:
Benign essential tremor	Suggested by: usually coarse tremor, long history, no other symptoms or signs.
	Confirmed by: normal thyroid test results. Improvement with beta blocker.