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Probability diagnosis

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Diabetic peripheral neuropathy

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Nutritional peripheral neuropathy esp. alcohol, B12, folate

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Hyperventilation with anxiety

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Nerve root pressure e.g. sciatica, cervical spondylosis

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Nerve entrapment esp. carpal tunnel syndrome

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Neurotoxic drugs

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Serious disorders not to be missed

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Vascular:

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  • CVA/TIA

  • Peripheral vascular disease

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Infection:

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  • AIDs

  • Lyme disease

  • Leprosy

  • Some viral infections

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Tumour/cancer:

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  • Disseminated malignancy

  • Cerebral/spinal cord tumours

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Other:

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  • CKF: uraemia

  • Guillain–Barré syndrome

  • Trauma to spinal cord

  • Marine fish toxins e.g. toadfish, Ciguatera

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Pitfalls (often missed)

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Migraine variant with focal signs

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Multiple sclerosis/transverse myelitis

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Hypocalcaemia

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Rarities:

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  • Chronic inflammatory polyneuropathy

  • Charcot–Marie–Tooth syndrome

  • Amyloidosis

  • Heavy metal toxicity e.g. lead

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Masquerades checklist

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Diabetes

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Drugs e.g. cytotoxic agents, interferon (see list)

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Anaemia: pernicious anaemia

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Thyroid/other endocrine: hypothyroid?

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Spinal dysfunction

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Is the patient trying to tell me something?

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Consider conversion reaction (hysteria), severe anxiety disorder. Some cases may be idiopathic.

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Key history

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Analyse symptoms: the nature, distribution, onset and associated neurological symptoms (motor, sensory), such as vertigo, seizures, vision. Check for other associated general symptoms such as fever, weight loss, pruritus, rash, weakness.

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History of diabetes, migraine, cancer, spinal problems, injury, possible bites, fever/sweating and other symptoms. Take a travel and diet history, incl. nutrition and alcohol. Gather a drug history, particularly cancer therapy, interferon, colchicine, thalidomide, statins, alcohol or any illicit drugs.

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Check the patient’s occupational history, e.g. exposure to lead, and psychiatric history, esp. anxiety states.

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Key examination

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  • General health and nutritional status.

  • Focused neurological especially sensory, motor function, reflexes.

  • Look for ‘glove and stocking’ distribution, muscle wasting e.g. thenar eminence.

  • Peripheral vasculature.

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Key investigations

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First line:

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  • urinalysis

  • blood sugar

  • FBE

  • ESR/CRP

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Consider:

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  • serum calcium

  • B12 and folate

  • LFTs (γGT)

  • U & E

  • TFTs

  • KFTs

  • nerve conduction studies

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According to clinical findings (refer):

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  • imaging e.g. spine, carotid vessels, CT or MRI, angiography

  • specific blood tests for infection

  • lumbar puncture (CSF protein, oligoclonol Ig G, etc)

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Diagnostic tips

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Take a detailed drug history including the above, alcohol and OTC medications. Intermittent perioral paraesthesia indicates hypocalcaemia associated with hyperventilation. In many cases of peripheral neuropathy or a sensory symptoms, the diagnosis is not only elusive but may not be identified.

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