How should I take a focused history and perform a targeted neurological exam in a 62‑year‑old primary‑care patient with a new right‑hand tremor of one‑year duration who is worried about Parkinson disease?

Focused History and Examination for Right Hand Tremor in Primary Care

Your primary goal is to clinically distinguish Parkinson's disease from essential tremor and other causes by systematically assessing for bradykinesia and rigidity alongside the tremor, as the diagnosis of PD is primarily clinical based on cardinal motor signs. 1, 2

Critical History Elements

Tremor Characteristics

• Determine when the tremor occurs: Ask specifically if the tremor is present at rest (sitting with hands in lap, walking with arms at sides) versus during action (holding a cup, writing, reaching for objects). Resting tremor strongly suggests PD, while action/postural tremor points toward essential tremor. 3, 2, 4
• Assess tremor progression: Document whether symptoms have spread to the other hand or other body parts, as PD typically begins asymmetrically and progresses gradually. 1, 4
• Identify exacerbating factors: Ask if stress worsens the tremor (common in both conditions) and critically whether alcohol improves it (suggests essential tremor, not PD). 5

Cardinal Motor Symptoms Beyond Tremor

• Screen for bradykinesia: Ask specifically about slowness in buttoning clothes, difficulty with handwriting (micrographia), reduced arm swing when walking, trouble getting out of chairs, and decreased facial expressions. 1, 2, 6
• Assess for rigidity symptoms: Ask about muscle stiffness, aching, or feeling "tight" in the limbs or neck. 2, 4
• Evaluate gait and balance: Ask about shuffling steps, freezing when starting to walk, difficulty turning, or falls (though postural instability appears later in PD). 1, 2

Prodromal and Nonmotor Features

• REM sleep behavior disorder: Ask if the patient or bed partner has noticed acting out dreams, punching, kicking, or talking during sleep—this can precede motor symptoms by years. 2, 6
• Olfactory dysfunction: Ask about loss of sense of smell, which is common in PD but not in essential tremor. 2, 6
• Autonomic symptoms: Screen for constipation (often severe and predating motor symptoms), urinary urgency, orthostatic lightheadedness, and excessive sweating. 2, 6
• Neuropsychiatric symptoms: Ask about depression, anxiety, apathy, or cognitive slowing, which frequently accompany PD. 2, 4, 6

Medication and Exposure History

• Drug-induced parkinsonism: Obtain detailed medication history focusing on antipsychotics (typical and atypical), antiemetics (metoclopramide, prochlorperazine), calcium channel blockers, and valproate. 1, 3
• Family history: Document any relatives with tremor or PD, as essential tremor has strong familial patterns. 5, 4

Targeted Neurological Examination

Tremor Assessment

• Observe tremor at rest: Have the patient sit quietly with hands resting in lap, fully supported. A 4-6 Hz "pill-rolling" tremor at rest that diminishes with purposeful movement suggests PD. 2, 4
• Test postural tremor: Have the patient extend arms forward with fingers spread. Tremor that emerges or worsens in this position suggests essential tremor. 5, 4
• Assess kinetic tremor: Have the patient perform finger-to-nose testing. Tremor during movement suggests essential tremor or cerebellar pathology, not typical PD. 5
• Check for asymmetry: Note which side is more affected, as PD characteristically begins unilaterally. 1, 4

Rigidity Examination (Critical for PD Diagnosis)

• Passive movement testing: Instruct the patient to completely relax while you passively move each limb (wrist, elbow, shoulder, ankle, knee) through full range of motion at varying speeds. 1, 3
• Compare both sides: Test upper and lower extremities bilaterally, noting any asymmetry (typical in PD). 1, 3
• Identify rigidity type: Feel for constant resistance throughout the movement (lead-pipe rigidity) or ratchet-like jerky resistance (cogwheel rigidity, which occurs when rigidity combines with tremor). 1, 3
• Use activation maneuvers: To detect subtle rigidity, have the patient open and close the opposite hand repeatedly or perform mental calculations while you test for rigidity—this often unmasks mild rigidity. 1, 3

Common pitfall: Patients may not fully relax during testing, creating voluntary resistance that mimics rigidity. Repeatedly instruct them to "let the arm go completely loose" and use distraction techniques. 1

Bradykinesia Assessment (Essential Diagnostic Feature)

• Finger tapping: Have the patient rapidly tap thumb to index finger with maximum amplitude for 10 seconds on each side. Look for progressive slowing, decreased amplitude, or hesitations—not just overall slowness. 1, 2
• Hand opening/closing: Ask the patient to rapidly open and close the fist with full extension and flexion. Note any decrement in speed or amplitude. 1, 2
• Rapid alternating movements: Have the patient rapidly pronate and supinate the forearm. Progressive slowing or irregular rhythm suggests bradykinesia. 1, 2
• Observe spontaneous movements: Note reduced blink rate, masked facies, decreased gesturing during conversation, and reduced arm swing when walking. 2, 4, 6

Gait and Postural Examination

• Observe natural gait: Watch the patient walk, noting reduced arm swing (especially asymmetric), shuffling steps, or en bloc turning. 2, 4
• Assess postural reflexes: Perform pull test (stand behind patient, warn them, then pull backward on shoulders). More than two steps backward or inability to recover suggests postural instability, though this typically appears later in PD. 1, 2

Red Flag Assessment for Atypical Parkinsonism

• Test vertical gaze: Have the patient look up and down without moving the head. Restricted downward gaze suggests Progressive Supranuclear Palsy, not idiopathic PD. 1, 3
• Check for cerebellar signs: Test for ataxia, dysmetria, or nystagmus. Their presence suggests Multiple System Atrophy. 1, 3
• Assess for pyramidal signs: Test for hyperreflexia, spasticity, or Babinski signs. Early pyramidal signs suggest atypical parkinsonism. 1, 3
• Screen for autonomic failure: Check orthostatic blood pressure (drop >20/10 mmHg within 3 minutes of standing). Early severe autonomic dysfunction suggests Multiple System Atrophy. 1, 3
• Look for alien limb phenomenon: Ask if one limb seems to "have a mind of its own." This with asymmetric rigidity suggests Corticobasal Syndrome. 1, 3

Clinical Decision Algorithm

If tremor is present at rest AND you detect bradykinesia (with or without rigidity): The diagnosis is likely Parkinson's disease. Refer to neurology or movement disorder specialist for diagnostic confirmation, as correctly diagnosing parkinsonian syndromes on clinical features alone is challenging. 1, 2, 4

If tremor is only postural/action-based AND no bradykinesia or rigidity is detected: The diagnosis is likely essential tremor, not PD. 3, 4

If clinical examination is equivocal or you cannot confidently detect rigidity/bradykinesia: Refer to neurology for specialist examination and consider I-123 ioflupane SPECT/CT (DaTscan), which definitively differentiates PD from essential tremor and drug-induced tremor. A normal DaTscan essentially excludes PD. 7, 1, 3

If any red flag features are present (vertical gaze palsy, cerebellar signs, early severe autonomic failure, pyramidal signs, alien limb): Urgent neurology referral is needed as these suggest atypical parkinsonian syndromes with different prognoses and treatment approaches. 1, 3

Imaging Considerations in Primary Care

• Do not order imaging initially if the clinical diagnosis is straightforward (clear resting tremor with bradykinesia and rigidity without red flags). The diagnosis of PD is clinical. 1, 2
• If you decide imaging is needed: Order brain MRI without contrast first to exclude structural causes (stroke, tumor, hydrocephalus, normal pressure hydrocephalus). MRI is often normal in early PD but essential to rule out alternative diagnoses. 7, 1
• Reserve DaTscan for uncertain cases: Only after neurology consultation, when clinical diagnosis remains unclear despite specialist examination. 7, 1, 3

Critical pitfall: Do not skip the rigidity examination or fail to use activation maneuvers, as subtle rigidity is often the key finding that distinguishes PD from essential tremor when tremor characteristics alone are ambiguous. 1, 3