Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Evaluation of symptoms suggestive of diabetic neuropathy (pain, numbness, burning, tingling, weakness)
Follow-up visit to monitor neuropathy and manage symptoms
Medication adjustment or other treatment plan modification
II. History of Present Illness:
Duration of diabetes mellitus (type 1 or type 2)
Location, character, and severity of neuropathy symptoms (pain, numbness, burning, tingling)
Onset and progression of symptoms
Impact of symptoms on daily activities (sleep, work, etc.)
History of falls (increased risk with neuropathy)
III. Past Medical History:
Other diabetes complications (retinopathy, nephropathy)
History of injuries or foot problems
IV. Family History:
Diabetes or neuropathy in first-degree relatives
V. Social History:
Smoking history (worsens neuropathy)
Alcohol use (can contribute to neuropathy)
Occupational hazards (exposure to toxins)
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
Neurological exam:
Sensory testing (vibration, light touch, temperature) – assess for loss of sensation
Muscle strength testing – assess for weakness
Reflexes (ankle, knee) – may be diminished or absent
Foot exam (assess for diabetic foot complications)
VII. Laboratory Studies (consider as appropriate):
Serum vitamin B12 and folate levels: Deficiencies can mimic neuropathy symptoms.
Autoimmune blood tests (e.g., ANA): May be considered to rule out other causes of neuropathy.
VIII. Assessment:
Type of diabetic neuropathy (distal sensory neuropathy, autonomic neuropathy, motor neuropathy) based on symptom presentation and exam findings.
Severity of neuropathy
Impact on quality of life and risk of complications (foot ulcers, falls)
IX. Plan:
Management plan may include:
Blood sugar control optimization: Good glycemic control can help prevent further nerve damage.
Pain management: Medications (gabapentin, pregabalin, duloxetine) and non-pharmacological approaches (acupuncture, topical pain relievers).
Neuropathic pain specialty consult: For patients with complex or refractory pain.
Foot care education: Self-care measures to prevent foot ulcers (daily inspection, proper footwear).
Lifestyle modifications: Smoking cessation, weight management, and regular exercise (may improve symptoms).
Management of autonomic symptoms: Medications or lifestyle changes to address issues like constipation, urinary problems, or sexual dysfunction.
X. Prognosis:
Discuss the prognosis based on the type and severity of neuropathy, response to treatment, and glycemic control.
Early diagnosis and good diabetes management can help prevent worsening of neuropathy.
XI. Notes:
Address the patient’s concerns and answer questions about diabetic neuropathy.
Provide emotional support and validate the challenges of living with neuropathy.
Offer resources for support groups or pain management education.
XII. Resources:
Consider providing patient education materials on diabetic neuropathy from reputable sources (e.g., American Diabetes Association (ADA), American Academy of Neurology (AAN)).