A man in his 30s presents to the emergency department after experiencing paresthesia in his hands and feet for the last week. The patient describes his symptoms as a tingling sensation rather than numbness. He states that when he washes his hands, they feel extra cold. In the past 4 days, he has developed progressive weakness in both his arms and his legs, but the weakness is more pronounced in his legs. He says it is becoming harder each day to walk up the stairs in his house. He denies any pain, fever, injury, recent illness, trouble controlling bowel or bladder function, or other complaints.

Vital Signs and Physical Examination 

All of the patient’s vital signs are within normal range, and the results of a physical examination are unremarkable except for his neurologic assessment. He has normal speech and no focal weakness. However, the clinician is unable to elicit any deep tendon reflexes (DTRs). Although his muscle is functioning normally (5/5 grade against resistance), the patient is having difficulty performing serial lunges. He is only able to do 4 or 5 90 degree lunges before failing. Pinprick and position sense tests are both normal.

Can you diagnose this condition? What is the best next step in testing and treatment?

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