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.