Intended for healthcare professionals

Practice 10-Minute Consultation


BMJ 2013; 347 doi: (Published 12 December 2013) Cite this as: BMJ 2013;347:f7200
  1. Menelaos Pipis, foundation year 2 doctor1,
  2. Mohammad Dehabadi, foundation year 2 doctor2,
  3. Emma Matthews, specialist registrar in neurology3,
  4. Lawrence Gould, general practitioner4
  1. 1Accident and Emergency Department, Watford General Hospital, Watford WD18 0HB, UK
  2. 2Ophthalmology Department, Watford General Hospital
  3. 3Neurology Department, National Hospital for Neurology and Neurosurgery, London, UK
  4. 4The Stanmore Medical Centre, London, UK
  1. Correspondence to: M Pipis mpipis{at}
  • Accepted 12 September 2013

A middle aged man presents complaining of excessive shaking of his hand. Physical examination reveals bilateral hand tremor, right more so than the left, and worse when holding his arms outstretched. The remainder of the physical and neurological examinations are normal.

What you should cover

Tremor is the most common involuntary movement encountered in clinical practice. It is an unintentional, rhythmic muscle movement that usually affects the hands but can also affect the arms, head, legs, and rarely the trunk. Essential tremor is the commonest form, but tremor may sometimes be a symptom of an underlying neurological disorder or a manifestation of systemic disease, and patients are often worried about a diagnosis of Parkinson’s disease.


Medical history

  • Ask the patient for a description of the “tremor” and how it has progressed over time:

    • - You may find that the patient is describing a tic—a sudden, repetitive, non-rhythmic movement often involving a single muscle group.

    • - A tremor that appears first in one hand and subsequently the other, perhaps spreading to one or both legs, is suggestive of Parkinson’s disease.

    • - A tremor that appears in both hands symmetrically, perhaps also involving a head tremor or a tremulous voice, is suggestive of essential tremor.

  • Under which circumstances does it occur?

    • - A tremor that occurs at rest …

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