Unique and nicely organised clinical examination book … top of the list for anyone in their clinical years. Enjoy!” Some patients with tremor presenting to the office have tremors that are unusual or difficult to classify. Patients with ET may present in several ways that can confuse the inexperienced examiner. Patients may present with an isolated tremor of the voice, with no head tremor or action tremor of the hands. Patients with isolated vocal tremor are overwhelmingly women, usually over age 60, and almost always report improvement in their tremor if they drink alcohol. 14 Some patients with ET have very asymmetric presentation, with an action tremor affecting only one arm. More challenging, others present with an isolated tremor at rest that mimics a parkinsonian rest tremor but without bradykinesia or cogwheeling. These patients may be misdiagnosed with PD, although dopaminergic imaging studies are usually negative. Intention tremor, the increased amplitude of tremor as a target is neared, is not present at disease onset but is seen later in some patients with essential tremor; its emergence is associated with disease duration. 16 The prevalence of intention tremor in patients with essential tremor is around 44%. It may be associated with head and trunk tremor. 17 A clinical-epidemiologic study of 117 patients with essential tremor found that 40% had intention tremor in the arms. Approximately 27% (95% confidence interval 20% to 36%) of 128 patients with essential tremor enrolled in a clinical-epidemiologic study had intention tremor in one or both legs. 18 A case-control study reported kinetic leg tremor in 44% of 63 patients with essential tremor compared with 14% of controls (P<0.001); tremor was at least moderate in amplitude in about 14% of patients compared with 2% of controls (P=0.008). 19

Oculomotor, trochlear, and abducens nerves (Cranial nerve III, IV, and VI) are the nerves for extraocular muscle movement. Assessment involves drawing an invisible "H" in front of the patient and asking the patient to follow with their eyes. Abnormal findings present as disconjugate gaze or double vision. The involvement of the third cranial nerve by compression (aneurysm of the posterior communicating artery) leads to dilated pupil, ptosis, and eyes looking outward and downward. Lateral rectus palsy is due to the involvement of the sixth cranial nerve; it can be a false localizing sign in increased intracranial pressure (bilateral lateral rectus palsy). The involvement of the pathways in the brainstem (e.g., lacunar infarct, multiple sclerosis) can lead to internuclear ophthalmoplegia. This condition occurs when the medial longitudinal fasciculus (MLF), a heavily myelinated pathway that allows for coordinated horizontal gaze, is damaged. [13] Move – cont’d 11 Passive movement – “Tell me if this causes any discomfort”1! Flex both hip & knee to 90°, hold ankle & knee Pretty much THE essential text book for clinical examinations for all medical students. Good price and will take you from day one to qualifying as every colleague who has just graduated swears by this book for clinical OSCEs."information, methods, compounds or experiments described herein. Because of rapid advances in the medical 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.

The vestibulocochlear nerve (Cranial nerve VIII) supplies functions in hearing and equilibrium. Gross assessment of function can be done by whispering words behind the patient, rubbing fingers or hair together close to the ear, and asking if the patient can hear. If a hearing deficit is established, doing a Weber and Rinne test can differentiate sensorineural from conductive hearing loss. A normal Rinne exam will exhibit air conduction (AC) greater than bone conduction (BC). A conductive hearing loss will show BC greater than AC. In patients with sensorineural hearing loss, AC will be greater than BC, but for a shorter duration when compared to a normal subject. A normal Weber test shows hearing the sound/vibration equally in both ears. A conductive hearing loss will lateralize the sound to the abnormal ear while a sensorineural hearing loss will lateralize to the normal ear. [16] Now in full colour, the book retains the unique format and approach of the original which has proved so popular: Fekete R, Jankovic J. Revisiting the relationship between essential tremor and Parkinson’s disease. Mov Disord. 2011;26:391-398.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