Polyneuropathy

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍symmetricalasymmetrical ‍numbnesstinglingburningweakness in ‍hands and feet

Onset was ‍gradualsudden

Pattern ‍progressiveintermittent

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍muscle weakness

‍muscle wasting

‍difficulty walking

‍loss of deep tendon reflexes

‍pain

‍cramps

‍autonomic symptoms (e.g., dry eyes, dry mouth, orthostatic hypotension, gastrointestinal disturbances)

‍skin changes

‍ulcers or sores that do not heal

‍changes in hair or nail growth

‍bowel or bladder dysfunction



Contributing factors:

‍chronic alcohol use

‍exposure to toxins

no history of: ‍diabetes, ‍HIV, ‍kidney disease, ‍vascular disease, ‍thyroid dysfunction, ‍vitamin B12 deficiency

no use of: ‍chemotherapy, ‍antiretrovirals, ‍anticonvulsants, ‍new medication

no family history of: ‍neuropathy





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Neurologic:

- Mental status: ‍alert, oriented to ‍3 spheres, speech ‍intact

- Cranial nerves: ‍all intact

- Strength: ‍intact 5/5 throughout except for ‍4/5 on ‍rightleft ‍, ‍pronator drift

- Sensation: ‍intact throughoutdecreasedabsent to ‍light touch on ‍

- Reflexes: ‍intact 2+ throughout except for ‍1+ on ‍rightleft ‍, ‍plantar downward

- Cerebellar function: ‍intact, ‍normalimpaired finger-nose, ‍normalimpaired rapid alternating movements, ‍normalimpaired heel-shin, Romberg ‍negative, Dix-Hallpike ‍negative

- Gait: ‍steadyunsteady, ‍intactimpaired tandem gait, ‍intactimpaired heel walk and toe walk





ASSESSMENT:

‍Peripheral polyneuropathy ‍likelysuspectedpossible

DDx: diabetic neuropathy, alcoholic neuropathy, Guillain-Barré syndrome, Charcot-Marie-Tooth disease, toxic neuropathies (e.g., heavy metal poisoning, medication-induced), vitamin B12 deficiency, HIV-associated neuropathy, amyloid neuropathy, chronic inflammatory demyelinating polyneuropathy (CIDP), hereditary neuropathies, vasculitis-associated neuropathy, hypothyroidism, Lyme disease, sarcoidosis, paraneoplastic syndromes, critical illness polyneuropathy, renal failure, liver disease, nutritional deficiencies, infectious diseases (e.g., leprosy), autoimmune diseases, paraproteinemia (e.g., multiple myeloma), chemotherapy-induced peripheral neuropathy, post-infectious neuropathy





PLAN:

Investigations:

- Blood work: ‍CBC, ‍creatinine, ‍electrolytes, ‍glucose, ‍TSH, ‍LFTs, ‍CRP, ‍ESR, ‍vitamin B12, ‍serum protein electrophoresis, ‍immunofixation electrophoresis, ‍HbA1c, ‍fasting lipid profile, ‍hepatitis C and B serologies, ‍HIV testing, ‍heavy metals, ‍ANA, ‍anti-SSA/Ro and anti-SSB/La antibodies, ‍anti-GM1 antibodies, ‍Lyme disease serology

- Nerve conduction study

- EMG

- MRI of the spine

- Lumbar puncture

Treatments:

- ‍NSAIDs

- ‍Neuropathic pain medications

- Physical therapy

- Occupational therapy

- Vitamin supplementation

- Optimize glycemic control if diabetic

- Smoking cessation

- Alcohol reduction

Further care:

- Referral to neurologist

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen, if new symptoms develop such as muscle weakness or autonomic dysfunction, or if symptoms do not improve with treatment