What should a History and Physical (H&P) for neuropathy include?

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Comprehensive H&P Documentation for Neuropathy

A thorough H&P for neuropathy should include specific assessments of small and large fiber function, with particular attention to sensory, motor, and autonomic symptoms in a systematic pattern to identify the type, distribution, and potential causes of neuropathy. 1

History Components

Symptom Assessment

  • Sensory symptoms:
    • Pain characteristics (burning, shooting, electric-like, stabbing)
    • Paresthesias (tingling, pins and needles sensation)
    • Dysesthesias (unpleasant abnormal sensations)
    • Numbness and distribution pattern (stocking-glove distribution vs. other patterns)
    • Timing of symptoms (continuous vs. intermittent)
    • Allodynia (pain from non-painful stimuli)

Functional Impact

  • Effect on daily activities
  • Presence of foot ulcers or injuries
  • Falls or balance issues
  • Sleep disturbances related to neuropathic symptoms

Risk Factors and Associated Conditions

  • Diabetes history:
    • Duration of diabetes
    • Glycemic control (recent A1C values)
    • Other diabetic complications (retinopathy, nephropathy)
  • Other potential causes:
    • Alcohol consumption
    • Medication history (chemotherapy, antibiotics)
    • Toxic exposures
    • Family history of neuropathy
    • Nutritional deficiencies
    • Autoimmune disorders

Autonomic Symptoms

  • Orthostatic dizziness or syncope
  • Gastrointestinal symptoms (early satiety, nausea, constipation)
  • Genitourinary symptoms (erectile dysfunction, urinary incontinence)
  • Abnormal sweating patterns
  • Cardiac symptoms (resting tachycardia)

Physical Examination

Sensory Examination

  • Small-fiber function assessment: 1

    • Pinprick sensation
    • Temperature sensation
    • Pain perception

  • Large-fiber function assessment: 1

    • Vibration sensation using 128-Hz tuning fork
    • Proprioception
    • Lower extremity reflexes (ankle, knee)

  • Protective sensation: 1

    • 10-g monofilament testing (critical for identifying risk of foot ulceration)

Motor Examination

  • Muscle strength assessment (distal > proximal)
  • Muscle bulk/atrophy evaluation
  • Assessment for fasciculations

Autonomic Assessment

  • Orthostatic blood pressure measurements
  • Heart rate variability
  • Skin assessment (dry, cracked skin, especially in extremities)

Foot Examination (Critical for Diabetic Neuropathy)

  • Comprehensive foot inspection: 1

    • Skin integrity
    • Callus formation
    • Ulcerations
    • Deformities (hammer toes, Charcot foot)
    • Nail abnormalities

  • Vascular assessment: 1

    • Pedal pulses
    • Capillary refill
    • Skin temperature
    • Signs of arterial insufficiency

Documentation of Findings

Pattern Recognition

  • Distribution pattern (length-dependent, multifocal, asymmetric)
  • Predominant fiber type involved (sensory, motor, autonomic, mixed)
  • Temporal progression (acute, subacute, chronic)

Severity Assessment

  • Use standardized scales when appropriate
  • Document functional limitations
  • Note risk classification for complications (especially for diabetic neuropathy)

Differential Diagnosis

  • Document consideration of non-diabetic causes of neuropathy 1
  • Note findings that suggest alternative diagnoses

Laboratory and Diagnostic Testing

Initial Testing

  • Document pertinent laboratory results:
    • Blood glucose/A1C
    • Complete blood count
    • Comprehensive metabolic panel
    • Vitamin B12 levels
    • Thyroid function tests

Advanced Testing (if performed)

  • Electrophysiological studies
  • Autonomic function tests
  • Skin or nerve biopsy results

Treatment Plan Documentation

Glycemic Control (for Diabetic Neuropathy)

  • Target A1C goals
  • Medication adjustments

Pain Management

  • First-line agents (gabapentin, pregabalin, duloxetine) 2
  • Topical treatments
  • Non-pharmacologic approaches

Preventive Care

  • Foot care instructions
  • Follow-up schedule based on risk classification 1
  • Referrals to specialists as needed

Common Pitfalls to Avoid

  1. Incomplete sensory testing: Always assess both small and large fiber function using multiple modalities (not just monofilament testing alone).

  2. Missing non-diabetic causes: Remember that diabetic neuropathy is a diagnosis of exclusion; document consideration of other etiologies.

  3. Overlooking autonomic symptoms: Specifically ask about and document orthostatic symptoms, gastrointestinal issues, and genitourinary problems.

  4. Inadequate foot examination: For diabetic patients, a thorough foot exam is essential at every visit if neuropathy is present.

  5. Failure to classify severity: Document risk classification to guide follow-up frequency and preventive measures.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Diabetic Shoulder Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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