Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Characterize the current symptoms of neuropathy, including:
Location (e.g., feet, hands, legs, arms)
Severity (e.g., burning, numbness, tingling, pain)
Progression (worsening, stable, improving)
Impact on daily activities (e.g., difficulty walking, buttoning clothes)
Inquire about any recent changes in symptoms or new areas affected.
Ask about current medications and any side effects potentially related to neuropathy.
Objective:
Vital Signs: Include heart rate, blood pressure.
Physical Exam:
Neuromuscular:
Assess for muscle weakness in distal extremities.
Evaluate muscle tone and reflexes (ankle, knee).
Test for vibration and light touch sensation in feet and hands (using tuning fork and Semmes-Weinstein monofilaments).
Skin: Look for signs of trophic skin changes (dryness, thinning, discoloration).
Assessment:
Distal symmetric polyneuropathy based on clinical presentation.
Consider the chronicity of symptoms and possible etiologies based on history and physical exam:
Diabetic neuropathy: Explore history of diabetes mellitus and glycemic control.
Vitamin deficiency neuropathy: Investigate potential deficiencies (B12, thiamine).
Autoimmune neuropathy: Inquire about autoimmune conditions (Sjogren’s syndrome, lupus).
Toxic neuropathy: Ask about exposure to toxins (alcohol, medications).
Idiopathic neuropathy: No identified cause.
Severity of neuropathy based on symptoms and examination findings.
Plan:
Address potential underlying causes:
Diabetes: Optimize glycemic control.
Vitamin deficiencies: Supplementation with deficient vitamins.
Autoimmune conditions: Treatment of the underlying autoimmune disease.
Toxic exposures: Avoidance of the offending agent.
Symptomatic Management:
Medications: Consider pain relievers (e.g., gabapentin, duloxetine), topical pain medications (lidocaine patches).
Physical therapy: Improve balance, gait training, and manage muscle weakness.
Assistive devices: Canes, braces to improve mobility and prevent falls.
Diagnostic Testing: Depending on suspected etiology, consider investigations like:
Blood tests: Electrolytes, vitamin levels, autoimmune workup.
Nerve conduction studies and electromyography (EMG) to assess nerve function and muscle involvement.
Follow-up:
Schedule regular follow-up visits to monitor symptom progression and treatment response.
Discuss complication prevention (foot care education).
Consider referral to a neurologist for complex cases or if a specific cause is unclear.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant information regarding symptoms, physical findings, potential causes, and treatment plan.