From the Guidelines
The workup for a patient with paresthesia of the hands with hypertension but no history of diabetes, hypothyroidism, or rheumatoid arthritis should begin with a thorough neurological examination focusing on sensory testing, motor strength, and deep tendon reflexes. Initial laboratory tests should include complete blood count, comprehensive metabolic panel, vitamin B12 level, folate level, and hemoglobin A1c to rule out undiagnosed diabetes 1. Thyroid function tests (TSH, free T4) should be ordered despite no prior history of thyroid disease, as hypothyroidism can cause neuropathy. Consider testing for inflammatory markers like ESR and CRP, and possibly ANA if autoimmune conditions are suspected. Nerve conduction studies and electromyography are important to differentiate between focal neuropathies like carpal tunnel syndrome and more generalized peripheral neuropathy. Imaging studies may include cervical spine MRI to evaluate for cervical radiculopathy or spinal cord compression. For this patient with hypertension, medication review is essential as some antihypertensives can cause paresthesia as a side effect. Additionally, evaluate for other potential causes including alcohol use, toxin exposure, and nutritional deficiencies. The paresthesia could be related to the patient's hypertension through small vessel disease affecting peripheral nerves, making blood pressure control an important aspect of management.
Some key points to consider in the workup include:
- A thorough neurological examination to identify any sensory or motor deficits
- Laboratory tests to rule out underlying conditions such as diabetes or hypothyroidism
- Imaging studies to evaluate for structural causes of paresthesia
- Medication review to identify any potential causes of paresthesia
- Evaluation for other potential causes such as alcohol use, toxin exposure, and nutritional deficiencies
It's also important to note that the patient's hypertension should be well-controlled, with a target blood pressure of <140/90 mmHg or <130/80 mmHg in patients with diabetes mellitus or chronic kidney disease 1. Lifestyle modification is recommended in all patients, individualized as to their specific circumstances. In patients with coarctation of the aorta who are at risk for hypertension and premature CAD, strict blood pressure control is of utmost importance. In all patients, obesity increases the risk.
The most recent and highest quality study 1 provides guidance on the management of hypertension in patients with congenital heart disease, which can be extrapolated to the general population. This study emphasizes the importance of monitoring and appropriate treatment of hypertension, as well as lifestyle modification, to reduce the risk of cardiovascular disease.
From the Research
Workup for Patient with Hands Paresthesia and No H/O Diabetes, Hypothyroid, RA
The patient presents with paresthesia (abnormal sensation) of the hands, no history of diabetes mellitus, hypothyroidism, or rheumatoid arthritis, and a history of hypertension. The workup for this patient should include:
- A comprehensive history to identify potential underlying causes of paresthesia, such as toxin exposure, nutritional deficiencies, or hereditary diseases 2
- A physical examination, including a comprehensive neurologic and musculoskeletal evaluation, to assess for sensory alterations, numbness, pain, or burning sensations in the hands 2
- Initial laboratory evaluation, including:
- Complete blood count
- Comprehensive metabolic profile
- Fasting blood glucose
- Vitamin B12 levels
- Thyroid-stimulating hormone levels
- Serum protein electrophoresis with immunofixation 2
- Electrodiagnostic studies, such as nerve conduction studies and electromyography, to help differentiate between axonal and demyelinating neuropathy 3, 2
- Consideration of referral to a neurologist for additional testing, such as specific antibody assays or nerve biopsy, if the initial evaluation is inconclusive 2
Potential Underlying Causes
Potential underlying causes of paresthesia in this patient include:
- Nutritional deficiencies, such as vitamin B12 deficiency 3, 2
- Toxin exposure, such as alcohol or certain medications 2
- Hereditary diseases, such as Charcot-Marie-Tooth disease 2
- Idiopathic peripheral neuropathy, which accounts for 25-46% of cases 2
Treatment
Treatment for paresthesia will depend on the underlying cause. If the cause is identified and treated, symptoms may improve. Additionally, medications such as gabapentinoids and antidepressants may be used to alleviate neuropathic pain 4, 2, 5.