Polyneuropathy
HISTORY:
for
Location:
Onset:
Pattern: , worse during the
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Neurologic:
- Mental status: , oriented in , speech
- Cranial nerves:
- Strength: upper extremities -R /5 , -L /5
lower extremities -R /5 , -L /5
- Sensation: upper extremities -R , -L ,
lower extremities -R , -L
- Reflexes: triceps -R , -L , biceps -R , -L , brachioradialis -R , -L
patellar -R , -L , achilles -R , -L , plantar -R , -L
- Cerebellar function: , finger-nose , rapid alternating movements , heel-knee , Romberg , Dix-Hallpike ,
- Gait: , tandem walking , heel and toe walking
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , , , , , , , , , , ,
- Nerve conduction study
- EMG
- MRI of the spine
- Lumbar puncture
-
-
- Physical therapy
- Occupational therapy
- Vitamin supplementation
- Optimize glycemic control if diabetic
- Smoking cessation
- Alcohol reduction
- Referral to neurologist
- Follow-up in
- Return if symptoms worsen, if new symptoms develop such as muscle weakness or autonomic dysfunction, or if symptoms do not improve with treatment