“My feet have gone numb and tingly — it’s creeping up, and now my fingers too”

SYMMETRICAL, distal, length-dependent sensory loss and tingling that starts in the FEET and ascends, later involving the hands ("GLOVE-AND-STOCKING"), with reduced sensation (including unnoticed injury) and diminished ankle reflexes, is the classic pattern of a peripheral (typically sensory) POLYNEUROPATHY — and the core skill is to SEARCH SYSTEMATICALLY FOR THE CAUSE rather than simply apply the label. The major causes are DIABETES (the commonest — check HbA1c), ALCOHOL excess, vitamin B12/folate DEFICIENCY, HYPOTHYROIDISM, chronic kidney/liver disease, and DRUGS/TOXINS, with less common inflammatory/immune (CIDP), paraproteinaemia/myeloma, vasculitic and hereditary causes; the history (alcohol intake, diabetes risk, drugs, diet, family history) directs the work-up. Use recorded findings (monofilament, vibration, foot pulses and skin) and what video shows (gait, balance), and arrange a face-to-face examination of reflexes, any weakness/wasting and proprioception, plus signs of an underlying cause, distinguishing a length-dependent neuropathy from mononeuropathy/radiculopathy and central causes. Order targeted tests — HbA1c/glucose, B12/folate, U&E, LFTs/GGT, TFTs, FBC, ESR, with serum protein electrophoresis/paraprotein and HIV considered (thiamine is given on NICE CG100 criteria rather than measured) — and use nerve conduction studies/neurology referral where the cause is unclear, the pattern atypical, or features severe. Recognise RED FLAGS needing urgent assessment: rapidly progressive or ASCENDING weakness (Guillain-Barré syndrome — a neurological emergency, monitor breathing/bulbar function), prominent motor involvement, marked asymmetry, autonomic features or acute onset. Manage the MODIFIABLE causes (alcohol reduction — AUDIT, and no sudden stop if dependent, NICE CG115 — with thiamine on NICE CG100 criteria, glycaemic control, B12/folate/thyroid replacement), give FOOT-CARE/safety advice given the injury/burn/ulcer risk, treat neuropathic pain if present (NICE CG173), and address alcohol/glycaemia honestly but non-judgementally.