Case 24 Neurology

Progressive Numbness and Paresthesias

Work it one clue at a time. The diagnosis stays hidden until you reveal it.

Clue 1

A 35 y/o woman presents with numbness in feet and legs, paresthesias, imbalance, and frequent falls, progressing over a period of months.

Your astute med student notices high arched feet and bent toes. What do these findings suggest?

Clue 2

The history along with the presence of pes cavus (high arch) and hammertoes (toes bent at middle joint) suggest peripheral neuropathy (eg, polyneuropathy). Let’s perform a hypothesis-driven exam. What would we expect the reflexes to be like in a patient with polyneuropathy?

Clue 3

Our pt has brisk upper extremity reflexes and absent lower extremity reflexes. Polyneuropathy is usually length-dependent, beginning in the legs before affecting the arms.

Next, we’ll test sensation, starting with pain and temperature (small fiber, anterolateral cord).

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