Family medicine
Numbness / Tingling (paraesthesia)
Paraesthesia is an abnormal sensory perception of numbness, tingling, or "pins and needles" resulting from dysfunction or irritation of peripheral or central sensory neural pathways.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Carpal tunnel syndrome | Median nerve distribution (thumb, index, middle, radial half of ring); nocturnal waking; positive Tinel/Phalen [1] | 「夜晚有冇痺醒？甩吓手會唔會好啲？」 (Wake at night? Shaking hand relieves it?) |
| Diabetic peripheral neuropathy | Chronic, bilateral, glove-and-stocking, ↓ankle jerks, DM Hx [3][4] | 「兩隻腳由腳趾開始痺？有冇糖尿？」 | |
| Cervical spondylotic radiculopathy | Dermatomal UL numbness, neck pain, Spurling test + | 「郁頸嗰陣會唔會差啲？」(Worse on neck movement?) | |
| Serious Not To Miss | Stroke / TIA | Sudden onset, unilateral, ± weakness, speech/facial droop | 「係唔係突然間一邊面或者手腳痺？」 |
| Spinal cord compression | Bilateral LL numbness ascending, weakness, sphincter disturbance, sensory level [2] | 「兩隻腳痺有冇愈嚟愈上？有冇去唔到廁所？」 | |
| Cauda equina syndrome | Saddle anaesthesia, urinary retention, bilateral sciatica | 「屎忽附近有冇痺？小便有冇去唔到？」 | |
| Malignancy (cord/nerve compression) | Weight loss, known cancer Hx, progressive | 「有冇瘦咗？有冇癌症病史？」 | |
| GBS | Ascending symmetrical weakness + areflexia + paraesthesia, days-weeks [6] | 「係唔係由腳開始痺同冇力再上到手？」 | |
| Pitfalls | Cubital tunnel syndrome | Ring + little finger numbness, elbow Tinel + [1] | 「尾指同無名指痺？踭位有冇唔舒服？」 |
| Thoracic outlet syndrome | UL numbness + vascular symptoms on arm elevation | 「舉高手會唔會差啲？」 | |
| Multiple sclerosis | Young adult, relapsing-remitting, optic neuritis, Lhermitte sign [7] | 「之前有冇試過隻眼突然矇咗？低頭有冇觸電感？」 | |
| Vitamin B12 deficiency | Macrocytic anaemia, subacute combined degeneration | 「有冇食素？手腳痺加行路唔穩？」 | |
| Masquerades | Depression / anxiety | Hyperventilation → respiratory alkalosis → perioral/bilateral hand paraesthesia | 「最近有冇壓力大或者心情唔好？有冇覺得抖唔到氣？」 |
| Diabetes (again) | Screen all paraesthesia for DM [4] | 「有冇驗過血糖？」 | |
| Drugs | Isoniazid, ethambutol, chemotherapy, statins [5] | 「食緊咩藥？」 | |
| Hypothyroidism | Fatigue, weight gain, constipation, CTS | 「有冇怕凍、便秘、肥咗？」 | |
| Hypocalcaemia | Perioral + digital paraesthesia, post-thyroidectomy, Chvostek/Trousseau [8] | 「口周圍同手指痺？最近有冇做過頸部手術？」 | |
| Trying to Tell Me Something? | Health anxiety / fear of stroke | Relative had stroke; fear of paralysis | 「有冇屋企人試過中風？你係唔係擔心中風？」 |
| Work stress / disability fear | Worried about losing job due to hand numbness | 「會唔會擔心影響到份工？」 |
Numbness / Tingling (Paraesthesia) — Family Medicine Clinical Test Page
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, consent | 「你好，我係X醫生。今日想同你傾吓你嚟嘅原因，我會問你幾個問題，可以嗎？」 (Hello, I'm Dr X. I'd like to chat about why you're here, I'll ask a few questions, is that OK?) | Interpersonal marks: greeting + permission |
| 0:30–2:00 | HPI: symptom analysis — site, onset, character, radiation, duration, pattern, aggravating/relieving, severity, progression | 「痺嘅位置喺邊度？幾時開始？係成日都痺定時時痺？有冇愈嚟愈差？」(Where is the numbness? When did it start? Constant or intermittent? Getting worse?) 「隻手痺定隻腳痺？兩邊都有定淨係一邊？」 | Core HPI marks; establishes distribution & laterality — key to localisation |
| 2:00–3:00 | Red flags + targeted systems review — weakness, bowel/bladder, falls, neck/back pain, visual symptoms, weight loss | 「有冇覺得隻手／腳冇力？有冇大小便控制唔到？有冇跌過？」 | Must-not-miss: cord compression, stroke, malignancy |
| 3:00–3:45 | PMHx, Drug Hx, FHx, SHx — DM, thyroid, B12, alcohol, medications, occupation (repetitive hand use) | 「你有冇糖尿病？食緊咩藥？做咩工作？飲唔飲酒？」 | Masquerade check (DM, drugs, alcohol) |
| 3:45–4:30 | ICE — Ideas, Concerns, Expectations | 「你自己覺得呢個痺可能係咩問題？（Ideas）最擔心嘅係咩？（Concerns）你今日嚟最想我幫到你啲咩？（Expectations）」 | High marks for ICE; uncovers hidden agenda |
| 4:30–5:15 | Functional impact + psychosocial | 「呢個痺有冇影響到你返工或者做日常嘢？有冇因為呢個問題覺得好煩或者瞓得唔好？」 | Biopsychosocial marks |
| 5:15–5:45 | Summarise back to patient | 「等我總結吓：你隻右手最近兩個月夜晚痺醒，尤其係拇指同食指……啱唔啱？」 | Checks understanding, earns interpersonal marks |
| 5:45–6:00 | Close: safety net + plan | 「如果突然間隻手腳冇力，或者大小便失禁，要即刻去急症室。我建議你做吓檢查……」 | Safe closure, demonstrates competence |
Hidden agenda tip: Ask 「點解你今日先嚟睇醫生？」 — the patient may have come because a relative had a stroke, or they fear they are losing hand function at work. This is often the real RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site & distribution | Which part is numb? One side or both? Hands, feet, or both? | 「邊度痺？一邊定兩邊？手定腳？」 | Localises lesion: glove-stocking = polyneuropathy; dermatomal = radiculopathy; unilateral = stroke/cord | Polyneuropathy vs radiculopathy vs central |
| Onset & duration | When did it start? Sudden or gradual? | 「幾時開始？突然間定慢慢嚟？」 | Sudden = vascular (stroke/TIA); gradual = neuropathy, entrapment | Stroke/TIA if sudden; CTS/DM neuropathy if gradual |
| Pattern | Constant or intermittent? Worse at night? | 「成日都痺定時時先痺？夜晚有冇痺醒？」 | Nocturnal waking = carpal tunnel syndrome (CTS) [1] | CTS |
| Aggravating factors | Worse with specific posture, neck movement, wrist use? | 「有冇郁頸或者屈手腕會差啲？」 | Neck movement → cervical radiculopathy/myelopathy; wrist flexion → CTS | Cervical spondylosis, CTS |
| Motor weakness | Any weakness, dropping things, difficulty walking? | 「有冇覺得手腳冇力？有冇跌嘢？行路有冇唔穩？」 | Weakness = more serious (cord compression, stroke, motor neuron) | Myelopathy, GBS, stroke |
| Bowel/bladder | Any incontinence or difficulty urinating? | 「有冇大小便失禁或者去唔到廁所？」 | RED FLAG: sphincter involvement → cord compression [2] | Cauda equina, myelopathy |
| Back/neck pain | Any neck or back pain? | 「有冇頸痛或者腰痛？」 | Spinal pathology | Disc prolapse, cervical myelopathy, cord compression |
| DM history | Do you have diabetes? How long? HbA1c? | 「你有冇糖尿病？幾耐？控制得好唔好？」 | Diabetic peripheral neuropathy is the most common cause of chronic glove-stocking paraesthesia [3][4] | Diabetic polyneuropathy |
| Thyroid | Any thyroid problems? | 「有冇甲狀腺問題？」 | Hypothyroidism → CTS; also direct neuropathy | CTS, polyneuropathy |
| Drug history | Any medications? (metformin, isoniazid, chemotherapy) | 「食緊咩藥？有冇食TB藥或者化療藥？」 | Drug-induced neuropathy (isoniazid, ethambutol, cisplatin, metformin → B12↓) [5] | Drug-induced neuropathy |
| Alcohol | How much alcohol do you drink? | 「你飲唔飲酒？飲幾多？」 | Alcoholic neuropathy | Alcoholic polyneuropathy |
| B12/diet | Are you vegetarian? Any dietary restriction? | 「你食唔食素？」 | B12 deficiency | Subacute combined degeneration |
| Occupation | What is your job? Repetitive hand use? | 「你做咩工作？要唔要成日用手或者打字？」 | Occupational entrapment neuropathy | CTS, cubital tunnel syndrome |
| Family history | Anyone in family with similar problems or DM? | 「屋企人有冇類似問題或者糖尿？」 | Hereditary neuropathy (CMT) | Charcot-Marie-Tooth |
| Visual symptoms | Any blurred vision, double vision? | 「有冇眼矇或者睇嘢有重影？」 | MS, diabetic mononeuropathy | MS, CN III/VI palsy |
| ICE | What do you think is causing this? What worries you? What do you hope I can do? | 「你自己覺得點解會痺？最驚係咩？想我幫你做啲咩？」 | Direct exam marks | — |
| Functional impact | Does it affect sleep, work, daily activities? | 「痺有冇影響瞓覺、返工、做家務？」 | Biopsychosocial | — |
Case Report Form Answer Builder
- CC: "Numbness/tingling of [location] for [duration]"
- HPI high-yield points: Site and distribution (dermatomal vs glove-stocking vs median nerve territory); onset (sudden vs gradual); character (pins-and-needles vs numbness vs burning); temporal pattern (constant/intermittent/nocturnal); aggravating/relieving factors; associated weakness, back/neck pain, bowel/bladder; PMHx (DM, thyroid); medications; functional impact
- Examples: "Progressive hand numbness affecting daily function" / "Worried about stroke after relative's diagnosis" / "Numbness waking from sleep, wants diagnosis"
- How to phrase: Combine the symptom with the trigger for attendance → e.g. "Increasing bilateral foot numbness over 6 months causing difficulty walking; worried about diabetic complication"
| Likely Content | Exact Wording Example | |
|---|---|---|
| Ideas | "I think it might be poor blood circulation" / "I read it could be a nerve problem" | "Patient thinks the numbness is due to poor blood circulation" |
| Concerns | "I'm worried it could be a stroke" / "afraid I'll lose the use of my hand" | "Patient is worried about having a stroke" |
| Expectations | "I want a blood test" / "I want a referral to a specialist" / "I want to know what's causing it" | "Patient expects a diagnosis and referral if needed" |
Choose based on the stem:
- If middle-aged woman + nocturnal hand numbness in first 3.5 digits → Carpal Tunnel Syndrome [1]
- Minimum evidence: median nerve distribution, nocturnal waking, positive Phalen/Tinel
- If chronic DM + bilateral foot/hand numbness in glove-stocking pattern → Diabetic Peripheral Neuropathy [3][4]
- Minimum evidence: known DM, symmetrical distal distribution, ↓ankle reflexes, monofilament ↓
- If sudden unilateral numbness ± weakness → Stroke/TIA
| DDx | Key Discriminator |
|---|---|
| Cervical spondylotic radiculopathy/myelopathy | Dermatomal distribution, neck pain, Spurling +, UMN signs below if myelopathy [9] |
| Peripheral polyneuropathy (B12 deficiency / alcoholic / drug-induced) | Bilateral glove-stocking, macrocytosis, dietary/alcohol/drug history |
| Stroke / TIA | Sudden onset, unilateral, ± motor/speech deficit, vascular risk factors |
| Domain | Problem Example |
|---|---|
| Biological | Uncontrolled diabetes leading to progressive neuropathy / Median nerve compression |
| Psychological | Anxiety about serious diagnosis (e.g. stroke, cancer); sleep disturbance due to nocturnal paraesthesia |
| Social/Functional | Impaired hand function affecting work (e.g. typing, cooking); safety risk (inability to feel sharp/hot objects → burns/injuries) |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Carpal tunnel syndrome | Positive Tinel's sign over carpal tunnel | Tap over the flexor retinaculum at the wrist → reproduces tingling in median nerve distribution | Confirms median nerve irritation at the carpal tunnel [1] |
| Diabetic peripheral neuropathy | Reduced sensation to 10g monofilament in glove-stocking distribution | Apply monofilament to plantar surface of great toe and metatarsal heads; also ↓ankle jerks [3][4] | Symmetric distal sensory loss classic for diabetic polyneuropathy |
| Cervical myelopathy | Hyperreflexia + upgoing plantar (Babinski +) in lower limbs | Test deep tendon reflexes and plantar response | UMN signs below the level of cord compression [9] |
| Stroke/TIA | Unilateral facial droop or pronator drift | Ask patient to hold both arms outstretched with eyes closed; check facial symmetry | Lateralising UMN sign consistent with cerebral lesion |
| Hypocalcaemia | Positive Trousseau's sign | Inflate BP cuff above systolic BP for 3 min → carpopedal spasm [8] | Demonstrates neuromuscular hyperexcitability from low calcium |
| B12 deficiency | Reduced vibration sense at ankles + positive Romberg | Test vibration with 128 Hz tuning fork at medial malleolus | Posterior column involvement (subacute combined degeneration) |
Must-Not-Miss Red Flags — Refer Urgently
- Sudden onset unilateral numbness ± weakness → Stroke/TIA → A&E immediately
- Bilateral ascending numbness + weakness + areflexia → GBS → A&E
- Saddle anaesthesia + urinary retention → Cauda equina syndrome → emergency MRI + surgical referral
- Progressive cord signs (UMN in legs, sensory level) → Spinal cord compression → urgent MRI [2][9]
- Numbness + unexplained weight loss → Malignancy compressing nerve/cord
Top traps that lose marks:
- Not asking about distribution — you cannot localise without knowing exactly which fingers/areas are affected. Median nerve ≠ ulnar nerve ≠ dermatomal ≠ glove-stocking.
- Forgetting DM screening — diabetic neuropathy is the most common cause of chronic paraesthesia in HK primary care [3][4]. Ask every patient.
- Missing CTS clues — nocturnal waking, shaking hand to relieve, worse with wrist flexion. Many students jump to cervical causes.
- Not checking ICE — the patient's real worry (stroke? cancer?) is often the main reason for consultation.
- Forgetting drugs — isoniazid, ethambutol, chemotherapy agents, and metformin (→ B12 depletion) all cause neuropathy [5].
- Not asking bowel/bladder — missing cauda equina/cord compression is an exam fail point.
- Confusing radiculopathy with myelopathy — radiculopathy = LMN at one level; myelopathy = UMN below the level [9]. Exam loves this distinction.
GC 227 Cervical Spine Pathology: "Clinical features of cervical myelopathy — Numbness or sensory disturbance (fingers, upper limb), Loss of hand dexterity, Poor proprioception + spastic gait, Motor weakness and sphincteric dysfunction appear in the late stage, Pain is not a predominant feature, UMN signs below level of compression, LMN signs at the level of compression" [9]
Shortest safe management/safety-net line: 「如果突然間一邊手腳冇力、講嘢唔清楚、或者大小便失禁，要即刻打999去急症室。」 (If you suddenly have one-sided weakness, slurred speech, or lose control of your bladder/bowels, call 999 and go to A&E immediately.)
High Yield Summary
What to ASK: Distribution (which digits/area), onset (sudden vs gradual), pattern (nocturnal vs constant), motor weakness, bowel/bladder, DM, thyroid, drugs, alcohol, diet, occupation, ICE, functional impact.
What to WRITE:
- CC: "Numbness/tingling of [site] for [duration]"
- RFC: Combine symptom + trigger (e.g. "worsening numbness → worried about stroke")
- ICE: Patient's own theory, biggest fear, and what they want done
- Most likely Dx: CTS (nocturnal, median distribution) OR Diabetic neuropathy (glove-stocking, DM) — pick based on stem
- DDx: Cervical radiculopathy/myelopathy, B12 deficiency/polyneuropathy, Stroke/TIA
- Biopsychosocial: nerve damage (bio), anxiety about serious disease (psych), work/ADL impairment (social)
- Physical sign: Tinel/Phalen (CTS), monofilament + ankle jerk (DM neuropathy), Babinski (myelopathy)
What NOT to MISS: Sudden onset → stroke; ascending weakness → GBS; saddle anaesthesia → cauda equina; UMN signs → cord compression; every patient → screen for DM.
Active Recall - Family Medicine Clinical Test
[1] Maksim Surgery Notes (Carpal tunnel syndrome section, p.245) [2] GC 110. Paraplegia Spinal cord compression Transverse myelitis Spinal dysraphism Neuroimaging III Spinal Cord.pdf (p.10) [3] Ryan Ho Endocrine (Diabetic neuropathy section, p.97-98) [4] 2025 Fourth Summative MCQ (Question 29, p.12) [5] Gen Clerk Anaes + Microbiology Summary (p.41 — isoniazid, ethambutol neuropathy) [6] MBBS Final MB (Pediatrics) (Felix PY Lai) (GBS section, p.547) [7] MBBS Final MB (Medicine) (Felix PY Lai) (MS sensory symptoms, p.1275) [8] Ryan Ho Endocrine (Hypocalcaemia section, p.45); Block A - Confused and dehydrated: hypercalcaemia; hypocalcaemia [9] GC 227. Cervical Spine Pathology.pdf (p.17 — cervical myelopathy clinical features)
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