Can you create a SOAP note for an adult patient on chronic statin therapy who consumes about ten standard alcoholic drinks per week, has a family history of rheumatoid arthritis, diabetes mellitus, and alcohol abuse, and presents with a new painless symmetric distal neuropathy of the upper extremities?

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SOAP Note: New Symmetric Distal Neuropathy of Upper Extremities

SUBJECTIVE

Chief Complaint: New onset numbness and tingling in both hands, symmetric distribution, without pain.

History of Present Illness: Patient reports gradual onset of symmetric sensory changes in distal upper extremities over [specify timeframe]. Denies pain, weakness, or functional impairment. No recent trauma, fever, or systemic symptoms.

Medications: Currently on statin therapy [specify agent, dose, duration].

Alcohol Use: Consumes approximately 10 standard drinks per week (below threshold for significant alcohol consumption per NAFLD guidelines, which define significant use as >21 drinks/week in men or >14 drinks/week in women) 1.

Family History:

  • Rheumatoid arthritis
  • Diabetes mellitus
  • Alcohol abuse

Review of Systems: Denies lower extremity symptoms, muscle pain, weakness, fatigue, cold intolerance, weight changes, or urinary symptoms.

OBJECTIVE

Vital Signs: [Document BP, HR, temp, weight, BMI]

Physical Examination:

  • Neurological: Symmetric decreased sensation to light touch and pinprick in bilateral hands in glove distribution. Intact motor strength 5/5 throughout upper extremities. Deep tendon reflexes [document]. Gait normal. No lower extremity sensory deficits.
  • Musculoskeletal: No joint swelling, erythema, or deformity. No muscle tenderness or atrophy.
  • Skin: No rashes or lesions.

Laboratory Studies Ordered:

  • Creatine kinase (CK) – to evaluate for statin-induced myopathy 1
  • TSH – to exclude hypothyroidism as contributor to neuropathy 1
  • Vitamin D (25-OH) – deficiency increases risk of statin-related symptoms 1
  • Comprehensive metabolic panel – assess renal and hepatic function 1
  • Hemoglobin A1C and fasting glucose – screen for diabetes given family history and neuropathy presentation
  • Vitamin B12 level – common reversible cause of neuropathy
  • Urinary ethyl glucuronide (EtG) – objective marker to detect alcohol intake within previous 90 hours, as patient history often underestimates consumption 2
  • Liver enzymes (AST, ALT, GGT), uric acid, triglycerides, magnesium, folate – markers of excessive alcohol intake that may be contributing to neuropathy 2

ASSESSMENT

New symmetric distal sensory neuropathy of upper extremities, etiology undetermined.

Differential Diagnosis (in order of likelihood based on clinical context):

  1. Alcohol-related neuropathy – Despite reporting only 10 drinks/week (below guideline thresholds for "significant" consumption), alcohol remains the most common cause of distal symmetric polyneuropathy after diabetes 2. Alcohol consumption as a causative factor is regularly overlooked in clinical practice 2. Biochemical screening with urinary EtG and indirect markers (elevated liver enzymes, uric acid, triglycerides, low magnesium/folate) is essential, as patient-reported intake frequently underestimates actual consumption 2.

  2. Statin-induced neuropathy – While statins demonstrate neuroprotective properties in diabetic models, extended duration of statin treatment is minimally associated with development of non-diabetic idiopathic neuropathy 3. However, this patient presents with sensory symptoms rather than the typical muscle pain/weakness pattern of statin myopathy 1.

  3. Prediabetes/early diabetes mellitus – Strong family history warrants screening. Neuropathy can precede overt diabetes diagnosis.

  4. Vitamin B12 deficiency – Common and reversible cause requiring evaluation.

  5. Hypothyroidism – Can contribute to neuropathy and increases risk for statin-related symptoms 1.

  6. Early rheumatoid arthritis – Family history present, though absence of joint symptoms makes this less likely. Statins may actually reduce RA risk (hazard ratio 0.58 in highly persistent users) 4.

PLAN

Diagnostic Workup

Obtain comprehensive laboratory panel as outlined above to identify reversible causes and assess for alcohol-related markers 1, 2.

Statin Management

Continue current statin therapy pending laboratory results 1. The patient lacks typical statin-associated muscle symptoms (pain, tenderness, weakness, fatigue), which would warrant temporary discontinuation 1. Sensory neuropathy alone, without myopathic features, does not meet criteria for immediate statin cessation 5, 6.

Alcohol Counseling

Strongly advise complete alcohol cessation 2, 7. Even moderate alcohol consumption (10 drinks/week) significantly worsens symptomatic peripheral neuropathy in susceptible individuals 7. If alcohol consumption is not discontinued, distal symmetric polyneuropathy—whatever the etiology—will not improve 2. The prevalence of symptomatic neuropathy is substantially higher in patients who drink excessively, and alcohol may be the predominant causative factor even when other conditions (diabetes, statin use) are present 7.

Medication Safety

Do not prescribe symptomatic neuropathy treatments (tricyclics, gabapentinoids, SNRIs, opioid analgesics) if alcohol use continues, as these agents in combination with alcohol can excessively suppress respiration and cognitive function 2.

Follow-Up

  • Return in 2 weeks to review laboratory results and reassess symptoms.
  • If urinary EtG is positive or indirect alcohol markers are elevated, provide structured alcohol cessation counseling and consider referral to addiction services given family history of alcohol abuse.
  • If statin-related myopathy is confirmed (elevated CK with muscle symptoms), implement ACC/AHA algorithm: temporarily discontinue statin, wait for symptom resolution, then rechallenge with lower dose or alternative agent (pitavastatin or fluvastatin preferred) 5, 6.
  • If diabetes or prediabetes is diagnosed, initiate appropriate glycemic management and counsel that statins demonstrate favorable neurological effects in diabetic neuropathy through anti-inflammatory and antioxidant properties 3.
  • If vitamin B12 or vitamin D deficiency is identified, initiate replacement therapy 1.

Patient Education

  • Explained that alcohol is the second most common cause of peripheral neuropathy after diabetes and is frequently underrecognized 2.
  • Discussed importance of complete alcohol cessation for neuropathy improvement.
  • Reviewed that statin continuation is appropriate unless myopathic symptoms develop.
  • Advised to report any new muscle pain, weakness, or dark urine immediately.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Alcohol Consumption as a Causator and/or an Accelerator of Neuropathy in People With Diabetes Is Regularly Overlooked.

Diabetes therapy : research, treatment and education of diabetes and related disorders, 2021

5
Guideline

Alternative Statin Options for Managing Muscle Aches

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Guideline

Management of Rosuvastatin Discontinuation

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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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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