Jane, a 68 year old women presents to you with both her feet feeling numb. This has been slowly worsening over 2 years. She reports some burning on the soles of her feet but otherwise no pain or weakness. She is overweight and slowly putting on more weight. She denies weight loss, recurrent infections or bruising. Her last pap smear was 1 year ago and mammogram 1 year ago, both normal. She drinks regularly but has never smoked. She takes panadol OTC for her feet but no other medications. She is allergic to morphines. She has been with her husband for 46 years. On examination her BP is 160/95 and BMI 38. Her feet reveal present but reduced sensation on the plantar surfaces of her feet.
What are the most likely differential diagnosis? List 6
- Type 2 diabetic neuropathy
- B12 deficiency
- B1 deficiency
- Alcoholic neuropathy
- Peripheral vascular disease
- Hypothyroidism
- Chronic Liver disease
- Chronic Renal disease
NB – there are a very wide range of conditions that can cause peripheral neuropathy. Less likely causes given the stem include bilateral sciatic neuropathy, malignancy (breast, lung and myeloma), HIV infection, heavy metal toxicity etc that would gain no marks as this stem makes them less likely and the question asked for most likely
What initial blood test investigations do you want to perform? List 4
- Fasting glucose
- B12
- LFTs
- UEC
- TSH
What medication options are available for idiopathic peripheral neuropathy? List 4
- Endep 10mg nocte
- Pregabalin 75mg bd
- Gabapentin 300mg daily
- Duloxetine 60mg daily
What are other management considerations for Jane? List 4
- Reduce alcohol
- Weight loss
- Nutrient dense diet
- Regular exercise
- Foot care/podiatry review
