What history of present illness (HPI) and physical examination (PE) should be performed on a patient with right arm numbness and tingling?

History of Present Illness (HPI) for Right Arm Numbness and Tingling

For a patient presenting with right arm numbness and tingling, obtain a detailed HPI focusing on distribution pattern, temporal profile, associated symptoms, and red flag features that distinguish benign from urgent neurological conditions. 1, 2

Critical HPI Components

Symptom Characterization

• Distribution mapping: Document whether symptoms are dermatomal (suggesting radiculopathy), peripheral nerve territory (median/ulnar/radial nerve), or non-anatomic patterns 1, 3
• Temporal profile: Determine if onset was acute (hours), subacute (days to weeks), or chronic (months), as acute rapidly progressive symptoms require urgent evaluation for Guillain-Barré syndrome or vasculitis 2
• Quality of sensation: Distinguish between pure numbness (negative symptom indicating sensory loss) versus tingling/pins-and-needles (positive symptom indicating paresthesia from ectopic nerve activity) 1

Red Flag Assessment

• Motor involvement: Ask specifically about weakness, as the combination of paresthesias with predominant motor weakness signals urgent conditions requiring immediate workup 2
• Asymmetry and progression: Rapidly progressive, asymmetric, proximal, or multifocal patterns mandate urgent evaluation 2
• Associated symptoms: Screen for dysautonomia (orthostatic symptoms, bowel/bladder dysfunction), respiratory difficulty, or swallowing problems 4

Etiologic Clues

• Metabolic risk factors: Document diabetes history and glycemic control status, as diabetic neuropathy is a leading cause requiring annual screening 2
• Medication history: Specifically ask about metformin (especially ≥2g daily), chemotherapy agents, and statins, which commonly cause peripheral neuropathy 2
• Infectious exposures: Inquire about hepatitis C, as up to 50% develop peripheral neuropathy 2
• Cardiovascular risk factors: In patients over 50 with hemibody sensory symptoms, assess stroke risk factors (hypertension, diabetes, smoking, atrial fibrillation) 2

Functional Impact

• Activities of daily living: Determine if symptoms interfere with function (grade 3 severity), as this significantly impacts quality of life and treatment urgency 1
• Occupational factors: Document repetitive activities or positions that may suggest compressive neuropathies 5, 6

Physical Examination

Neurological Examination

• Sensory testing: Perform objective documentation using light touch, pinprick, vibration (128-Hz tuning fork), and temperature testing in the affected distribution 1, 2
• Motor examination: Test strength systematically, as weakness on examination increases likelihood of abnormal electrodiagnostic findings by five-fold 3
• Reflex assessment: Check biceps, triceps, and brachioradialis reflexes, as reduced reflexes combined with weakness strongly predict abnormal studies 3
• Provocative maneuvers: Perform Spurling's test for cervical radiculopathy, Tinel's and Phalen's signs for carpal tunnel syndrome 6

Pattern Recognition

• Dermatomal mapping: C6 (thumb/index finger), C7 (middle finger), C8 (ring/little finger) distributions suggest radiculopathy 3, 6
• Peripheral nerve territories: Median (thumb/index/middle/radial half of ring), ulnar (little/ulnar half of ring), radial (dorsal first web space) 6
• Stocking-glove pattern: Bilateral distal symmetric involvement suggests length-dependent polyneuropathy from metabolic or toxic causes 2

Vascular Assessment

• Pulse examination: Palpate radial and ulnar pulses, as vascular insufficiency can mimic neuropathic symptoms 7
• Allen test: Assess collateral circulation if radial artery pathology is suspected 7

Systemic Examination

• Vital signs: Document blood pressure in both arms, as asymmetry may indicate vascular pathology 5
• Skin inspection: Look for trophic changes, color changes, or temperature differences suggesting autonomic involvement 4
• Cervical spine: Assess range of motion and palpate for tenderness suggesting radiculopathy 6

Critical Clinical Pitfalls

Note that normal physical examination does not exclude significant pathology—almost half of patients with normal neurological exams have abnormal electrodiagnostic findings 3. Conversely, isolated subjective symptoms (numbness, tingling, weakness) without objective findings have poor predictive value for specific diagnoses 3. The combination of any abnormal neurological sign increases sensitivity to 84% for detecting pathology, though specificity remains low at 44% 3.