The connecting theme today was numbness, although one case was permanent and the other was temporary.
Hello and bonus program i just got home from my fifth day of my clinical apprenticeship i wore my paisley tie to clinic today shout out to my dog paisley you might notice i’m in my house and not in my car and that’s because i wanted to show you guys something on my a couple images on my ipad to better explain some of the things i’ll be talking about so the most
Interesting case uh that we had today was a six-year-old male who had over the last five months had developed some numbness and tingling in his bilateral toes and also just over the last month or so even some tingling and numbness in it like the tips of his fingers on both sides he had history of hypertension and hyperlipidemia which is high blood pressure high
Cholesterol but no known history of diabetes no family history of diabetes and the reason i point out diabetes is because a lot of times diabetics will develop neuropathies and that’s kind of where my head went as soon as he was saying the numbness the tingling and the distal extremities other forms of neuropathy can form from compression of nerves but with
This being bilateral and developing over time not necessarily positional i wouldn’t expect it to be compression of nerves in both legs and both hands that kind of thing another thing would be maybe an autoimmune autoimmune disorder kind of immune system attacking the nerves the blood vessels in the peripheral tissues there’s also toxic poly neuropathies which
It’s often caused by excessive alcohol use um also tobacco use can have a have an effect and he this this guy actually did attest to excessive alcohol use he said he was drinking three 24 packs of beer every week at one point this summer he’s also a 39 year smoker one pack per day so he’s got 39 pack years of smoking if he were two packs per day for 39 years
That’d be 39 times two quick math that’s so 78 pack years would be what his terminology was that’s kind of how that works among other things there’s also idiopathic polyneuropathies which basically just means that we don’t know what is the cause and it could be any number of things but we don’t have any specific idea of what it is so to get to what i was going to
Show you guys so this is a dermatome map and basically what it is it’s just showing the different parts of the body that are innervated by different spinal nerves here you can see you go from c1 there’s eight cervical nerves there’s 12 thoracic nerves there’s five lumbar nerves and then five sacral nerves so the parts that we focused on in our physical exam were
Where he was having the most numbness so you can see the l4 nerve innervates just the medial side of both feet the l5 is most of the digits most of the toes and then the s1 nerve gets the the pinky toe the fifth digit and also sometimes the fourth digit so those were the um dermatomes that we were checking with so we kind of just had him close his eyes there’s
We have a little poker stick we ask if he can feel when we’re poking and then so here’s just a little diagram i thought was useful for diabetic neuropathy so you can see in a normal nerve you got the blood vessels kind of running along the myelin sheath of the nerves normally obviously the vasculature can supply the nerves with enough nutrients to continue to
Work but in diseased blood vessels the nerves and the myelin sheath of the nerves begin to damage and that’s when you see a lot of the disappearance of the myelin sheath and then you’ll see a lot of the numbness because what the myelin sheath does is it protects the nerves and it also it also allows the nerves to conduct their electrical signals back up and
That’s that’s how you’re feeling all the sensations so with reduced blood flow in diabetes caused by the hyperglycemia that you’ll see a lot all the extra sugars can be damaging to the peripheral nerves which as i mentioned before are more susceptible to damage that’s why you typically see them in these in these areas first at the at the ends of toes and ends
Of fingers as they become damaged the nerves also become damaged and then they start to desensitize and what you’ll see if it’s unmanaged is the nerve dysfunction in the toes will start to creep up like slowly over months will creep up the foot into the leg and it’ll even creep up all the way throughout the legs if it’s not treated we weren’t for sure that it is
Neuropathy caused by diabetes but we also can’t be sure that it isn’t because he hasn’t he hasn’t been seen recently so his labs haven’t been checked so what my preceptor did was ordered some labs including the hemoglobin a1c which is a an average of your blood glucose levels over two to three months span he also ordered just a point of care glucose to get a good
Idea of where his blood glucose was at now even though it’s not a fasting level it still provides some information there certainly could be a diabetic factor but maybe the toxic neuropathy that i was talking about earlier is also playing a factor in that it’s kind of a combination of the two that is leading to this numbness as for long-term outlook unfortunately
Typically neuropathies like this aren’t necessarily reversible essentially what you’re doing now is just trying to stop further damage of vasculature and of the nerves in the feet and in the hands by lowering blood sugar in the case of a diabetic neuropathy or decreasing alcohol use or tobacco use in the case of toxic neuropathies thank you for watching i hope
This was educational a little bit that was probably the coolest case we had today i also got to inject some lidocaine some epidermal lidocaine for a skin biopsy we were just basically taking off some abnormal moles that have been causing some irritation sent them to the lab my preceptor didn’t think it would it was evidence of melanomas or cancer or anything
But better safe than sorry so hope you enjoyed that was my summary of my fifth clinic day i’m learning more every day so i hope you guys are too
Transcribed from video
Clinical Apprenticeship #5: Numbness – Neuropathy and Lidocaine By CVA AMP HP