IGNACIO, RICHELLE ANGELIKA E. Dr.

Roy Torcuator
2017-0116 Neuroscience II

[November 20, 2019 1:00-3:30 PM Disc. Rm. 6]

IDENTIFYING DATA
Patient. A.C is a 72 year-old married male, right-handed, Roman Catholic, who lives in Rizal and previously worked as
a contractor.
Referral. Self-referred.
Source & Reliability. The information was taken from the patient and his guardian, both were unreliable and
inconsistent.

CHIEF COMPLAINT
“Tusok tusok sa kamay”

HISTORY OF PRESENT ILLNESS

Five years prior to consult, following his diagnosis of Non-Small Cell Lung Cancer stage III, A.C. undergone
chemotherapy (Afatinib) where he noted generalized weakness and fatigability. However, he stopped treatment due to
difficulty in acquiring his medicines.

Three years prior to consult, chemotherapy was resumed and he complained of a pins-and-needles sensation in his
hands and feet with associated weakness in his legs. It was described to be a diffuse symmetrical weakness and lasts
for 5 minutes. Alaxan provides temporary relief while exercise aggravates it. No dizziness, numbness, and sensory
deficit was reported. In the interim, no further treatment was done.

Six months prior to consult, patient sought his first consult at St. Luke’s for his chemotherapy but it was discovered that
his cancer progressed to Stage IV. Upon MRI, it revealed a mass in the left parietal region of the brain. 2D Echo was
also done but results were unrecalled. He reported that the pins-and-needles sensation is still present but is intermittent
by nature.

Two months prior to consult, patient had to undergo whole brain radiation therapy for 10 sessions with adjunct steroid
treatment for 2 weeks. His chemotherapy was also put on hold. No relief of pins-and-needles sensation was noted.

PAST MEDICAL HISTORY

Childhood illnesses. Unrecalled.
Adult illnesses. Hypertension; prescribed with Losartan 100 mg, 1x/day; usual blood pressure is 130/80 mmHg. No
diabetes and asthma but uses nebulizer for relief.
Medical treatment and hospitalization.
Surgical. None.
Psychiatric. No history of anxiety, depression, or mental disorders. No history of psychiatric consult.
Health maintenance.
Immunization. Unrecalled if immunization completed. No recent immunizations.
Screening tests. MRI (May 2019) revealed a left mass in the left parietal region.
Medications.
Dexamethasone 4 mg/tab
- Nov 21-22 take 1 tab 2x/ d
- Nov 23-24 take 1 tab in AM ½ tab in PM
- Nov 25-26 Take ½ in AM ½ tab in PM
- Nov 27-28 Take ½ tab OD then discontinue.
Mupirocin (Bactroban) for skin infection
- Apply on affected area 3x/day
Allergies. N/A.

FAMILY HISTORY
Family history of hypertension and cancer (lung and breast) were noted. No diabetes, asthma, liver and kidney
diseases. No history of brain cancer.

PERSONAL AND SOCIAL HISTORY

A.C. is a college graduate who worked as a contractor for 30 years and currently runs a sari-sari store. He does
not smoke and drinks alcohol occasionally (once a month).
 REVIEW OF SYSTEMS
General. Difficulty in ambulation. No fever, weight loss, or fatigue.
Skin. No rashes, lumps, sores, itching, and dryness. No changes in color or changes in hair or nails.
HEENT. No pain, redness, lacrimation. No nosebleeds. No hearing aid, tinnitus, difficulty in hearing, earache, ear
discharge. Cerumen seen in the ear canal. Does not wear eyeglasses. No bleeding gums, dentures, sore throat.
Neck. Numbness from the nape down to the shoulder. No goiter, lumps, pain, or stiffness in the neck.
Breasts. No lumps, pain, or discomfort, and nipple discharge. Patient does not do self-examination.
Respiratory. No dyspnea, wheezing, and pleuritic pain.
Cardiovascular. Orthopnea; uses 2 pillows to sleep. No chest pains and palpitations. No history of rheumatic fever. No
heart murmurs and paroxysmal nocturnal dyspnea.
Gastrointestinal. No trouble swallowing, heartburn, and nausea. Normal bowel movements. No pain with defecation,
rectal bleeding or black or tarry stools. No hemorrhoids, constipation, diarrhea. No abdominal pain, food intolerance,
liver, or gallbladder trouble. No jaundice and hepatitis.
Urinary. Frequent urinary output; yellow in color. Dysuria noted. No hematuria, and urinary infections. No kidney or
flank pain, kidney stones, ureteral colic, suprapubic pain and incontinence.
Musculoskeletal. Tremors were reported. No joint pains, arthritis, gout, stiffness of muscles, and backache.
Psychiatric. No nervousness, tension, depression, memory change, suicidal ideation, and suicide plans or attempts.
No history of counseling, psychotherapy, or psychiatric admissions.
Neurologic. No changes in mood, attention, or speech; No changes in orientation, memory, insight, or judgment. No
episodes of fainting, blackouts, and seizures. No tinnitus.
Hematologic. Easy bruising or bleeding was not reported.
Endocrine. No heat or cold intolerance. No excessive sweating, excessive thirst or hunger, polyuria, or change in glove
or shoe size.

PHYSICAL EXAMINATION
General Survey. The patient has a large physique and has a stooped posture and is well-dressed. He is alert, awake
and cooperative. Supported ambulation with a cane noted.
Vital Signs. Blood pressure (right arm) 120/70 mmHg. Pulse rate 117 bpm. Respiratory rate 26 bpm. Body temperature
(temporal) 37.1 C. Weight and height not obtained.
Skin. Skin color good; intact skin turgor and warm to touch. A lesion was noted at the intravenous site on his left hand.
No lesions, redness, scalings, and swelling.
Head. Normocephalic. Sparse black hair due to chemotherapy. Scalp without lesions. No redness, deformities. No
lumps, depression, tenderness on the skull. Symmetrical bilateral facial muscle contraction.
Eyes. Normal symmetry and alignment of eyes and eyebrows. Pink palpebral conjunctiva, anicteric sclera. Ears. No
deformities. Non-hyperemic ear canals. Sparse cerumen on both ears. Tympanic membrane intact. No discharge, pain,
redness, and swelling.
Nose & Sinuses. No discharge, pain, redness, and swelling. No septal deviation.
Mouth, & pharynx. Lips unremarkable. Pink oral mucosa. Tongue with white patches. Pharynx with exudates. Gums
were unremarkable.
Neck. No redness. Trachea midline. Lymph nodes not palpable. No thyroid gland enlargement.
Thorax & Lungs. Patient is not in respiratory distress. No use of accessory respiratory muscles. Thorax is asymmetric
with expansion greater at the right than left. Breathing sounds were heard more on the right than the left.
Cardiovascular. Fast heart beats but regular. No murmurs.
Abdomen. Not examined.
Musculoskeletal.
Upper Extremities. Shoulders asymmetric with the left side more elevated. No swelling or redness in the TMJ.
Neck range of motion intact without pain.
Lower Extremities. Difficulty in sitting down, standing up. Walks with a cane. No evidence of edema,
discoloration and ulcers. No deformities, swelling or effusion of joints. Patient able to extend and flex at the knee
but with assistance. Intact range of motion.
Neurologic.
Mental Status Examination. Alert, relaxed, and cooperative. Oriented to 3 spheres. Follows commands. No
R-L confusion, acalculia, apraxia, or aphrasia. GCS 15/15. Total MMSE score: 23/30. Clock-drawing test 1/3.

MSE
Max Patient Questions
5 5 Orientation to day and place
 5 5 Orientation to place
3 3 Naming and asking to repeat 3 unrelated objects
5 3 Counting/spelling backwards (KARNE)
3 1 Recall 3 things: Mangga, Bola, Pera
2 2 Patient naming objects herself
1 1 Repeat phrase
3 1 3-step command
1 1 Following written instructions
1 1 Make up a sentence
1 0 Copy picture
30 (Total) 23 Mild cognitive impairment

Motor System. Action tremor on upper limbs; resting tremor on the left arm. Motor strength 5/5 on upper
extremities; 4/5 on lower extremities. No twitches, tics, chorea, or fasciculations.
Sensory System. Pain and vibration intact in both left and right extremities. Fine touch intact in the left
extremities with a slight deficit in the right extremities. Proprioception intact except in the lower right extremities
where there is decreased to none elicited. Agraphia on both hands. No astereognosia.
Temperature and two-point discrimination not tested.
Cerebellar. Romberg’s test positive with patient leaning towards the left. Finger-to-nose test negative but slow
and unsteady. Heel-to-shin test on both extremities smooth and steady. Tandem walk unsteady.
Reflexes. All reflexes intact. No Babinski and Clonus.

2+ 2+

2+ 2+
2+ 2+

2+ 2+

Cranial nerves.
CN I No odor perception. Cannot smell coffee on both nostrils.
CN II Visual tracking intact. Visual fields intact. Pupillary reflex slow. As per fundoscopy, disc margins
sharp, no hemorrhage, and no arterial narrowing.
CN II, III No peripheral visual field cuts. Pupils are 4mm constricting to 2mm. Equally round and briskly
reactive to light
CN III, IV, VI Equal and complete opening of eyes with normal convergence. EOMs intact. No ptosis, diplopia,
and nystagmus.
CN V Sensory. can feel pain and light touch equally on both sides
Motor. Temporal and masseter strength intact L: 5/5; R: 5/5
CN VII Facial symmetric; able to smile, frown, and raise eyebrows. Taste not tested.
CN VIII Bilateral hearing loss; undetermined because patient cannot follow instructions.
CN IX, X No difficulty in swallowing. Gag reflex intact. Uvula midline. Equal elevation of palate.
CN XI Elevate shoulders equally against resistance; can turn head from side to side against resistance.
Strength 5/5.
CN XII Tongue midline. No protrusion or fasciculations; can stick tongue out and move from side to side.

SALIENT FEATURES

SUBJECTIVE POSITIVE SUBJECTIVE NEGATIVE OBJECTIVE POSITIVE OBJECTIVE NEGATIVE

o 72 y/o M o No numbness in o Tongue with white o No R-L confusion,
o Right handed extremities patches finger agnosia, apraxia,
o Stage IV lung cancer o No sensory deficit in o Pins and needles or aphasia
o with chemotherapy of 5 his extremities sensation on the o Intact sensory and
years duration o Non smoker upper extremities motor strength on
upper extremity
o Weakness and o Slow coordinated o No Babinski
fatigability movements o No Clonus
o Pins and needles o Difficulty in standing
sensation in the hands with assisted
and feet for 5 minutes, ambulation
and aggravated by o MMSE 23/30
exercise and movement o Clock Drawing Test
of the arm 1/3
o Dizziness and diffuse o No odor perception
weakness in the legs (CN I)
o Whole brain radiation o Face is asymmetric
with steroids with right nasolabial
o Family history of lung fold less prominent
cancer o Action tremor on
o Hypertensive upper limbs
o Difficulty in ambulation o Resting tremor on
left arm
o (+) Romberg’s test -
patient leaning on
the left
o Decreased to none
proprioception on
LR extremities
o Agraphia on both
hands

DIFFERENTIAL DIAGNOSES

Vascular Cerebellar stroke may be considered given that the patient presents with the classic
manifestations of stroke such as weakness of extremities with accompanying cerebellar
symptoms like Postive Rombergs and unsteady F-N test. In addition, he has a history of
hypertension. However, his hypertension is controlled and the patient did not report of any
episodes of stroke. Hence, this is not likely the diagnosis.
Infectious Patient has no history of any infectious diseases, hence, this is not likely the cause.
Traumatic Patient has no history of any accidents or traumatic events, hence, this is not likely the cause.
Autoimmune Chronic inflammatory demyelinating polyneuropathy (CIDP) is the inflammation of
nerve roots and peripheral nerves and destruction of the fatty protective covering (myelin sheath)
over the nerves. It presents with weakness, paralysis and/or impairment in motor function,
especially of the arms and legs (limbs). Sensory disturbance may also be present. It usually
presents symmetrically. This condition may be considered in the patient because of the duration
of the disease which is slow progressing and the weakness manifesting symmetrically. However,
the patient does not present with motor symptoms like in this condition, which is the main
manifestation. Upon PE, the sensory deficit does not appear symmetrical considering that only
the LR extremity is affected significantly.
Metabolic Patient does not present with any metabolic deficiencies, especially the most common ones such
as diabetes mellitus, thyroid disorders, or kidney failure. Hence, this is least likely the cause.
Iatrogenic Chemotherapy Induced Peripheral Neuropathy (CIPN) is highly likely to be the condition since
the patient has a long-standing history of cancer therapy, his symptoms may be explained by the
iatrogenic effects of chemotherapeutic drugs. Symptoms typically has a symmetric, distal,
"stocking and glove" distribution, which was reported by the patient as his initial symptoms. CIPN
predominantly consists of sensory rather than motor symptoms, and motor nerve function usually
remains unchanged during treatment. Persistent sensory and motor neuropathy is a significant
clinical problem in cancer survivors that can result in chronic pain, limited mobility, and disruption
of fine motor sensations, proprioception, and balance, and can contribute to functional limitations
which are all evident in this patient based on his sensory, motor, and cerebellar neurologic
examinations. Hence, it is ruled in with high suspicion.
Neoplastic Paraneoplastic Syndrome (PNS)
Since the patient has Stage IV cancer, paraneoplastic neurologic syndrome is considered to be
a possible cause of his “pins and needles” sensation. PNS is a heterogeneous group of
neurologic disorders associated with systemic cancer and caused by mechanisms other than
metastases, metabolic and nutritional deficits, infections, coagulopathy, or side effects of cancer
treatment. Patients frequently complain of the sensation of "pins and needles" or "electric
shocks”, as in his chief complaint. The symptoms may initially affect one extremity and progress
to involve other extremities, the face, and axial areas, parallel to the progression seen in this
 case. The symptoms typically predate the discovery of a tumor, however in this case it was
noticed after his cancer treatment. By the time the patient is first examined, there is usually
moderate to severe involvement of all sensory modalities, which may be apparent by his
generalized and diffuse peripheral neuropathy. These sensory deficits frequently lead to
prominent ataxia, which is exacerbated by eye closure and associated with pseudoathetoid
movements of the fingers and extremities, as evidenced by his sensory and cerebellar neuro
exam wherein positive Romberg, slow movements, tremors, decreased proprioception, agraphia,
and ⅘ sensory sensation were observed.
Congenital Patient has no history of any congenital disease. Hence, this is unlikely to be the cause.
Degenerative Due to his old age, several physiologic functions of the body start to degenerate. Hence, Vit B6
deficiency is also considered because given that the patient presents with a sensory neuropathy
described to be a “pins-and-needles” sensation which started at the feet and hands and
weakness of the lower extremities, vitamin B6 deficiency is highly considered. Neuropathies
caused by Vit B6 deficiency are described to be ascending from the legs towards the hands and
characterized as numbness with mild distal weakness. Moreover, vitamin B6 deficiency is
common among the elderly, hence our patient is likely predisposed to this condition. However,
he does not present with other symptoms associated with Vit B6 deficiency such as dermatitis,
glossitis, and cheilosis. Hence, this diagnosis is unlikely. There was also no mention of taking
any supplements by the patient so further tests are needed to confirm the diagnosis.
Endocrine Patient has no history of endocrine diseases. He does not manifest with endocrine abnormalities.
Hence, this is unlikely.

WORKING IMPRESSION
Chemotherapy-induced peripheral neuropathy with mild cognitive impairment

CLINICAL ASSESSMENT

The patient was diagnosed with Stage IV lung cancer bilateral. It could be possible that the patient developed brain
metastases since 20-40% of adults with non-small cell lung cancer go on to develop brain metastases. This was seen
observed in the patient wherein a brain mass was seen in the parietal area upon MRI. Most often, patients who have
brain metastasis in general, may present with a decrease in memory, attention, and reasoning, weakness, unsteadiness,
difficulty in speaking, numbness, tingling sensation. These symptoms were seen in the patient during consult, thus his
brain metastasis may be considered as one of the reasons for his presentation. Brain metastases are a common
complication in a wide range of cancers, but they are particularly common among patients with lung cancer.
Approximately 10% of patients with advanced non-small cell lung cancer (NSCLC) have brain metastases, which is
apparent in this patient having been diagnosed with Stage III brain cancer which progressed to Stage IV. Metastases
are the most common intracranial tumors in adults. However, the patient did not present with typical upper motor neuron
signs such as Babinski and clonus, which makes this unlikely.

Given his history of cancer therapy, his symptoms may be explained by the iatrogenic effects of chemotherapeutic drugs.
Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse effect of cancer therapy, which typically
presents as dose-dependent and cumulative, that can have a profound impact on quality of life and survivorship.
Persistent sensory and motor neuropathy is a significant clinical problem in cancer survivors that can result in chronic
pain, limited mobility, and disruption of fine motor sensations, proprioception, and balance, and can contribute to
functional limitations which are all evident in this patient based on his sensory, motor, and cerebellar neurologic
examinations. In particular, the deleterious impact on proprioceptive input can significantly alter postural stability,
balance, and gait, increasing the risk of falls, which may be the cause of his positive Romberg sign having noted a
decreased proprioception on his lower extremities. It is also important to note that the patient had difficulty standing from
a sitting position which means that proximal muscles are affected. Given the patient’s chronic use of steroids as adjunct
to his chemotherapy treatment, steroid myopathy may also be present. Steroid myopathy is usually an insidious disease
process that causes weakness mainly to the proximal muscles of the upper and lower limbs and to the neck flexors. Its
pathophysiologic mechanism is due to the excess of either endogenous or exogenous corticosteroids. It is also important
to note that the patient is of the elderly population, hence, some physiologic functions may be impaired, including his
metabolism. In line with this, patient had white patches in his tongue, which could also be an effect of prolonged steroid
use in addition to his immunocompromised state after undergoing several chemo- and radiotherapies. This phenomenon,
called “oral thrush,” happens when the immune system is weakened and the normal host flora is disrupted, resulting to
overgrowth of yeast in the oral mucosa, which causes the accumulation of epithelial cells, bacteria, and necrotic tissue,
forming the white patches called pseudomembrane observed in the patient. Vitamin B6 deficiency cannot be ruled out
because it can coexist with the patient’s present condition. Although it may not be the main cause of the patient’s existing
neuropathy, this can be a contributory factor given that this condition is very common among his age. Like our patient
who is elderly, they are predisposed to developing Vitamin B6 deficiency due to decreased absorption along with dietary
changes and decreased food intake that comes with aging. Vitamin B6 plays a significant role in nerve repair, specifically
in nerve tissue regeneration and recovery of nerve function. Hence, a deficiency would present as a peripheral
neuropathy.
Among all his symptoms, his MMSE findings are significant, showing that his score is 23/30 which would indicate a mild
cognitive impairment. It should be noted that the patient is already 72 years old and his mild cognitive impairment may
be associated to his age. With increasing age, the brain atrophies and there is loss of neurons and synapses causing
large reduction in extensiveness of nerve cell connections. It is highly likely that the presentation of mild cognitive
impairment may be part of the normal changes of the aging brain. However, it should also be noted that the patient had
undergone whole brain radiation therapy, which is a common cause of cognitive dysfunction among patients undergoing
radiotherapy. Other symptoms may be explained by different mechanisms. His observed action tremor can be due to
various factors but cerebellar and essential tremors were primarily considered in this case. Cerebellar tremor typically
has a component of intention tremor, in that the tremor increases in severity, either gradually or abruptly, as the hand
moves closer to its target, as observed in this patient during his physical examination. The frequent association with
ataxia, dysmetria, titubation, and other cerebellar signs serves to identify the cerebellar origin of intention tremor, hence
it is considered given the findings on the patient’s cerebellar neurologic examination. However, the most common
causes are multiple sclerosis, midbrain trauma, and stroke which were not elicited in this case and should warrant further
evaluation. On the other hand, Essential tremor (ET) is the most common cause of action tremor in adults. The
pathogenesis of ET is largely unexplained but it seems to have a strong genetic component. It is often bilateral and
asymmetric and classically involves the hands and is brought out by arm movement and sustained against gravity
postures, affecting common daily activities such as writing, drinking from a glass, handling eating utensils, and even
finger-to-nose testing as observed in this patient. It is slowly progressive and can involve the head, voice, and rarely the
legs, in addition to the upper limbs. The neuropathologic basis of ET remains poorly defined and controversial, but the
cerebellum and brainstem (locus ceruleus) have been most commonly implicated, which may also explain his abnormal
cerebellar findings.

DIAGNOSTICS AND ANCILLARY TESTS

Given that the patient is a known case of lung cancer with a brain mass, CT scan of the lungs and MRI of the brain
may be warranted to evaluate the progression of his condition. Neurophysiological assessment, which consist of
nerve motor and sensory conduction testing, electromyography, evoked potentials and autonomic testing,
provides the most practical and convenient methods available to confirm a clinical diagnosis of CIPN. It evaluates
severity of signs/symptoms and determines the scope and progression of CIPN. It can also determine if the disorder is
due to a primary nerve (neuropathy) or muscle disorder (myopathy). Also, it rules out causes for neuropathy other than
those induced by chemotherapy agents. EMG/NCS, specifically, can reveal whether it is axonal or demyelinating in
character. Direct assay of blood and urine is also ordered to rule out metabolic deficiencies such as Vitamin B
deficiency, since it is highly considered in the patient. If results are equivocal, muscle biopsy may provide the accurate
diagnosis of myopathy. In patients with primary neurogenic disease, muscle biopsy may show fiber-type grouping or
grouped atrophy.

TREATMENT AND MANAGEMENT

Currently, no established agents that can be recommended for the prevention of chemotherapy-induced peripheral
neuropathy (CIPN) in patients with cancer undergoing treatment with neurotoxic agents. The treatment for CIPN is
mostly symptomatic and includes neuropathic pain management (opioids, tricyclic antidepressants, anticonvulsants,
serotonin-norepinephrine reuptake inhibitors, nonsteroid anti-inflammatory agents) and nutritional supplements. Among
pain-killers, pregabaline, an antiepileptic drug is recommended as a first choice drug in neuropathic pain treatment.
However, in severe cases, the peripheral neuropathy may be so pronounced and resistant to treatment, that the
chemotherapy must be withdrawn.

In addition, history of patient’s medication intake (what drugs, doses, and duration) should be evaluated which would
need to be lessened or would need an adjunct to counter his symptoms since chemotherapy is the most likely considered
cause of his complaint. Vitamin B complex supplementation should be initiated to help his nerves maintain its function.

REFERENCES

• Iżycki, D., Niezgoda, A., Kaźmierczak, M., Piorunek, T., Iżycka, N., Karaszewska, B., & Nowak-Markwitz, E.
(2016). Chemotherapy-induced peripheral neuropathy — diagnosis, evolution and treatment. Retrieved from
https://journals.viamedica.pl/ginekologia_polska/article/view/GP.2016.0036/35523
• Geller, M., Oliveira, L., Nigri, R., Mezitis, S., Ribeiro, M., Fonesca, A., … Wajnsztajn, F. (2017, June 28). B
Vitamins for Neuropathy and Neuropathic Pain. Retrieved from https://www.omicsonline.org/open-access/b-
vitamins-for-neuropathy-and-neuropathic-pain-2376-1318-1000161.php?aid=90896
• Cheng, H., Chen, H., Lv, Y., Chen, Z., & Li, C. R. (2018). Prospective memory impairment following whole brain
radiotherapy in patients with metastatic brain cancer. Cancer medicine, 7(10), 5315–5321. doi:10.1002/cam4.1784
• Hammond, N., Wang, Y., Dimachkie, M., & Barohn, R. (2013, May). Nutritional Neuropathies. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4199287/
• Spindler, MA. and Tarsy, D. (2019). Overview of tremor. Uptodate. Retrieved from
uptodate.com/contents/overview-of-
 tremor?search=action%20tremor&source=search_result&selectedTitle=1~20&usage_type=default&display_rank=1
#H1715311942 on Nov 30, 2019.
• Liang, TW. and Tarsy, D. (2019). Essential tremor: Clinical features and diagnosis. Uptodate. Retrieved from
uptodate.com/contents/essential-tremor-clinical-features-and-
diagnosis?search=action%20tremor&source=search_result&selectedTitle=3~20&usage_type=default&display_ran
k=3#H3607744139 on Nov. 30, 2019.
• West, H. and Shaw, AT. (2019). Brain metastases in non-small cell lung cancer. Uptodate. Retrieved from
https://www.uptodate.com/contents/brain-metastases-in-non-small-cell-lung-
cancer?search=brain%20mets%20steroids&source=search_result&selectedTitle=3~150&usage_type=default&disp
lay_rank=3#H1371264986 on Nov. 30, 2019.
• Dalmau, J. and Rosenfeld, MR. (2017). Paraneoplastic syndromes affecting the spinal cord and dorsal root
ganglia. Uptodate. Retrieved from https://www.uptodate.com/contents/paraneoplastic-syndromes-affecting-the-
spinal-cord-and-dorsal-root-
ganglia?search=pins%20and%20needles&source=search_result&selectedTitle=2~150&usage_type=default&displ
ay_rank=2#H8 on Nov. 30, 2019.
• How Radiation Therapy Can Affect Different Parts of the Body. (n.d.) American Cancer Society. Retrieved from
https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/effects-on-different-parts-
of-body.html on Nov. 30, 2019.
• Rutkove, SB. (2019). Overview of polyneuropathy. Uptodate. Retrieved from uptodate.com/contents/overview-of-
polyneuropathy?search=peripheral%20neuropathy&source=search_result&selectedTitle=1~150&usage_type=defa
ult&display_rank=1#H9 on Nov. 30, 2019.
• Loprinzi, CL. (2019). Prevention and treatment of chemotherapy-induced peripheral neuropathy. Uptodate.
Retrieved from https://www.uptodate.com/contents/prevention-and-treatment-of-chemotherapy-induced-peripheral-
neuropathy?sectionName=Chronic%20neurotoxicity&search=peripheral%20neuropathy&topicRef=5284&anchor=
H2008174582&source=see_link#H2008174582 on Nov. 30, 2019.