What is the format for taking a history and performing a physical examination in a patient with peripheral neuropathy?

Comprehensive Format for History Taking and Examination in Peripheral Neuropathy

A systematic approach to history taking and physical examination is essential for accurate diagnosis and management of peripheral neuropathy, focusing on identifying the pattern, etiology, and severity to guide appropriate treatment.

History Taking Components

1. Symptom Assessment

• Onset and progression: Acute (<4 weeks), subacute (4-8 weeks), or chronic (>8 weeks) 1
• Distribution pattern: Distal symmetric (stocking-glove), asymmetric, multifocal, or focal 2
• Sensory symptoms:
  • Positive symptoms: Pain (burning, shooting, electric-shock like), tingling, prickling
  • Negative symptoms: Numbness, deadness, tightness 3
  • Progression pattern (distal to proximal is typical for length-dependent neuropathies) 4

2. Motor Symptoms

• Weakness (distal/proximal)
• Muscle cramps
• Fasciculations
• Difficulty with fine motor tasks 2

3. Autonomic Symptoms

• Orthostatic hypotension
• Gastrointestinal issues (early satiety, constipation, diarrhea)
• Urinary dysfunction
• Sexual dysfunction
• Abnormal sweating 5, 4

4. Risk Factor Assessment

• Medical conditions: Diabetes, renal disease, thyroid disorders, autoimmune diseases 5
• Family history: Hereditary neuropathies, diabetes 6
• Medication history: Neurotoxic medications (chemotherapy, antibiotics, antiretrovirals) 4
• Toxin exposure: Heavy metals, industrial chemicals, solvents 5
• Alcohol consumption: Pattern and quantity 2
• Nutritional status: Vitamin deficiencies (B12, folate), malabsorption 2
• Occupational history: Repetitive movements, prolonged standing/sitting 4

5. Impact Assessment

• Functional limitations
• Effect on activities of daily living
• Falls or injuries due to sensory loss 5

Physical Examination Components

1. General Examination

• Vital signs (including orthostatic blood pressure)
• Body habitus (weight loss/gain)
• Skin changes (trophic changes, ulcerations, dryness) 5

2. Neurological Examination

a. Sensory Examination

• Small fiber function:
  • Pain perception (pinprick)
  • Temperature sensation
  • Light touch 4
• Large fiber function:
  • Vibration sensation using 128-Hz tuning fork
  • Joint position sense
  • 10-g monofilament testing (particularly important for diabetic neuropathy) 5, 4
• Distribution mapping: Document areas of sensory loss in stocking-glove pattern or other distributions 3

b. Motor Examination

• Muscle bulk assessment (atrophy)
• Muscle tone evaluation
• Muscle strength testing (MRC scale 0-5)
  • Distal muscles: Foot dorsiflexion, plantar flexion, finger abduction
  • Proximal muscles: Hip and shoulder girdle 1
• Fasciculations or involuntary movements 2

c. Reflex Testing

• Deep tendon reflexes (ankle, knee, biceps, triceps)
• Plantar responses 3

d. Coordination Testing

• Finger-to-nose test
• Heel-to-shin test
• Rapid alternating movements
• Romberg test
• Gait assessment (including tandem gait) 1, 3

3. Vascular Examination

• Palpation of peripheral pulses (dorsalis pedis, posterior tibial)
• Capillary refill time
• Temperature and color of extremities
• Presence of edema 5

4. Foot Examination (Particularly Important in Diabetic Neuropathy)

• Inspection for ulcers, calluses, deformities
• Assessment for Charcot arthropathy
• Footwear evaluation 5

Special Examination Techniques

1. Pattern Recognition

• Length-dependent pattern: Distal symmetric polyneuropathy (most common in diabetes)
• Non-length dependent pattern: Asymmetric, multifocal (suggests vasculitis, immune-mediated)
• Mononeuropathy: Single nerve involvement (entrapment, trauma)
• Mononeuropathy multiplex: Multiple individual nerves (vasculitis, diabetes) 1, 3

2. Autonomic Testing

• Heart rate variability with deep breathing
• Blood pressure response to standing
• Sudomotor function (sweat testing) 5

Documentation and Classification

1. Document Neuropathy Pattern

• Symmetric vs. asymmetric
• Axonal vs. demyelinating (based on clinical features)
• Sensory, motor, or mixed
• Small fiber, large fiber, or mixed 1

2. Severity Assessment

• Mild: Sensory symptoms without significant functional impairment
• Moderate: Sensory symptoms with mild to moderate functional impairment
• Severe: Significant sensory and motor deficits with marked functional impairment 2

3. Risk Classification (For Diabetic Neuropathy)

• Category 0: No loss of protective sensation
• Category 1: Loss of protective sensation
• Category 2: Loss of protective sensation with deformity
• Category 3: History of ulceration or amputation 5, 4

Diagnostic Planning

Based on the history and examination findings, plan appropriate investigations:

• Laboratory tests (glucose, HbA1c, vitamin B12, thyroid function, etc.)
• Electrodiagnostic studies (nerve conduction studies, electromyography)
• Specialized testing (skin biopsy for small fiber neuropathy, genetic testing)
• Imaging studies if focal or compressive neuropathy is suspected 2, 3

Following this systematic approach ensures comprehensive evaluation of patients with peripheral neuropathy, facilitating accurate diagnosis and appropriate management planning.