INSTRUCTION
Examine this patient's legs.
Carry out a neurological examination of this patient's legs.
SALIENT FEATURES
History
· Progressive and symmetrical numbness in the hands and feet which spreads proximally in a glove and stocking distribution.
· Distal weakness, which also ascends.
· History of diabetes, alcohol, connective tissue disorder, malignancy.
Examination
Bilateral symmetrical sensory loss for all modalities with or without motor weakness.
Proceed as follows:
· Look for evidence of the following:
-Diabetes mellitus (diabetic chart, insulin injection sites, insulin pump).
- Alcoholic liver disease (palmar erythema, spider naevi, tender liver).
- Drug history.
- Rheumatoid arthritis.
- Uraemia.
-Malignancy. (Mnemonic: DAD, RUM)
· Palpate for thickened nerves and look for Charcot's joints.
· Tell the examiner that you would like to do the following: -Look for anaemia and jaundice (vitamin Bi2 deficiency). -Check urine
for sugar.
-Take a history of alcohol consumption and a drug history.
DIAGNOSIS
This patient has symmetrical, bilateral sensory loss for touch and pain (lesion) due to diabetes mellitus (aetiology).
QUESTIONS
Mention a few causes of thickened nerves.
· Amyloidosis.
· Charcot-Marie-Tooth disease.
· Leprosy.
· Refsum's disease (retinitis pigmentosa, deafness and cerebellar damage).
· D5j5rine-Sottas disease (hypertrophic peripheral neuropathy).
What are the causes of motor neuropathy?
· Guillain-Barrd syndrome.
· Peroneal muscular atrophy.
· Lead toxicity.
· Porphyria.
· Dapsone toxicity.
· Organophosphorous poisoning.
What are the causes of mononeuritis multiplex?
Mononeuritis multiplex is a neuropathy affecting several nerves; causes include:
· Wegener's granulomatosis.
· Amyloidosis.
· Rheumatoid arthritis.
· Diabetes mellitus.
· SLE.
· Polyarteritis nodosa.
· Leprosy.
· Carcinomatosis, Churg-Strauss syndrome. (Mnemonic: WARDS, PLC).
Mention a few causes of predominantly sensory neuropathy.
· Diabetes mellitus.
· Alcoholism.
· Deficiency of vitamins Bi2 and Bi.
· Chronic renal failure.
· Leprosy.
What are the types of neuropathy described in diabetes mellitus?
· Symmetrical, mainly sensory, polyneuropathy.
· Asymmetrical, mainly motor, polyneuropathy (diabetic amyotrophy).
· Mononeuropathy.
· Autonomic neuropathy.
What drugs are used for painful peripheral neuropathy of diabetes?
Tricyclic antidepressants, phenytoin, carbamazepine and topical capsaicin.
ADVANCED-LEVEL QUESTIONS
What are the other effects of alcohol on the central nervous system?
· Wernicke's encephalopathy (ophthalmoplegia, nystagmus, confusion and neuropathy).
· Korsakoff's psychosis (recent memory loss and confabulation).
· Cerebellar degeneration.
· Marchiafava-Bignami disease (symmetrical demyelination of corpus callosum).
· Central pontine myelinolysis.
· Amblyopia.
· Epilepsy.
· Myopathy and rhabdomyolysis.
K. Wernicke (1848-1904) worked in Poland.
S.S. Korsakoff (1853-1900), a Russian neuropsychiatrist.
J. Churg (b. 1910) qualified in Poland and was Professor of Pathology in New York.
L. Strauss, a pathologist in New York.