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Pearls and Oy-sters: Evaluation of peripheral neuropathies

Peripheral neuropathy is common, with an estimated prevalence of 2% in the general population and prevalence as high as 8% in those over the age of 55 years. 1 Residents and fellows will undoubtedly evaluate many patients with various types of peripheral neuropathies during their careers. The evaluation for the etiology of a patient’s peripheral neuropathy can be challenging given the vast number of potential etiologies 2,3 and the fact that despite an appropriate evaluation, a high percentage of cases will remain idiopathic. 4,5 In this article, we provide a simple, easy-toremember algorithm that can simplify the evaluation of peripheral neuropathy. PERIPHERAL NEUROPATHY ALGORITHM The evaluation of peripheral neuropathy should begin with the gathering of clinical data including the history of present illness, past medical history, family history, and physical examination. The determination of what of that clinical data is relevant requires knowledge of various diseases and the risk factors for those diseases. The information then needs to be synthesized in order to characterize the complaints and findings and determine an appropriate workup. The appropriate characterization of the complaints and findings is essential in order to perform an efficient, cost-effective, and successful evaluation. We recommend characterizing the neuropathy by answering four basic questions about the neuropathy: What? Where? When? What setting? (figure). 6 This simple algorithm should facilitate the early step in clinical reasoning of creating a mental abstraction—that is, a problem representation or one-sentence summary of the defining and discriminating characteristics of the case. 7 The creation of an accurate problem representation will allow the evaluating physician to focus on a small list of potential etiologies. This critical step in diagnostic reasoning will usually guide the physician down the correct diagnostic path, but it must be kept in mind that our algorithm is not absolute and there will always be cases that prove to be exceptions. The creation and utilization of problem representations will also serve as anchor points in memory that should allow the physician to more efficiently evaluate future cases and particularly to identify subtle but meaningful variations in similar cases. 7