Neuromuscular Weakness Evaluation Note

Date/Time: [Encounter date and time]

Patient: [Age], [sex], [handedness]

Encounter Type: [new consult / follow-up] — [clinic / inpatient / ED]

Referring Clinician: [Name and specialty] (Include only if applicable.)

Information Sources: [patient / caregiver / interpreter] (Specify interpreter language if used.)

External Records Reviewed: [Prior EMG/NCS, imaging, labs, genetic testing, other records reviewed] (Note whether original data vs summaries were available. List important missing records and retrieval plan.)

Chief Concern

[Patient-reported concern in their own words] — [Clinical problem statement specifying true weakness vs fatigability vs pain-limited function vs impaired motor control] (Include referral question if consultation. Limit to 1–2 sentences.)

History of Present Illness

[Single-sentence summary encoding time course (acute/subacute/chronic; progressive vs episodic), distribution (proximal/distal; symmetric/asymmetric; axial/bulbar/respiratory/ocular involvement), and key modifiers (fatigability, pain, sensory symptoms)]

Timeline and tempo: [Onset date or best estimate; progression rate; stepwise vs steady vs relapsing pattern; triggers (infection, exertion, fasting, heat, new medications, anesthesia)] (Explicitly document uncertainty if onset is unclear.)

Weakness characterization: [True weakness / fatigability / pain inhibition / impaired motor control / deconditioning; factors affecting exam validity such as pain, poor participation, or language barriers]

Distribution pattern: [Symmetry (symmetric/asymmetric/multifocal); proximal/distal; functional correlates (transfers, stairs, overhead activity, grip, foot drop, head control); laterality]

Bulbar, ocular, and respiratory screen: [Dysarthria; dysphagia (solids vs liquids); choking; chewing fatigue; ptosis; diplopia; diurnal variation; dyspnea (exertional/rest); orthopnea; morning headaches; weak cough; aspiration events] (Document presence or absence for each. If positive, note severity and safety impact.)

Sensory and autonomic features: [Sensory loss; paresthesias; neuropathic pain; muscle cramps; subjective fasciculations; orthostasis; bowel/bladder symptoms] (Include myelopathy red flags when relevant.)

Systemic features: [Weight loss; fevers; rash; Raynaud phenomenon; sicca symptoms; thyroid dysfunction; cardiac symptoms; dark urine suggestive of rhabdomyolysis] (Include when present.)

Prior workup: [Prior labs with dates and key values (especially CK); imaging; EMG/NCS; genetic tests; biopsies; treatments tried with responses] (Differentiate tests performed, results known, and reports unavailable.)

Functional History

Mobility and ADLs: [Ambulation status (independent/cane/walker/wheelchair); distance tolerance; transfers; fall frequency and injuries; stair climbing; upper extremity function (overhead reach, fine motor, grip); impact on work/school/driving; current level vs baseline]

Therapy and equipment: [PT/OT/SLP involvement; orthotics/bracing; respiratory devices (BiPAP/cough assist); home supports]

Standardized measures: [Instrument name, version, score, date] (Include only if formally administered.)

Pediatric History

(Include this section only when the patient is a child or when hypotonia is the primary concern. Omit entirely for adult patients without hypotonia.)

Perinatal history: [Gestational age; pregnancy/delivery complications; NICU course; hypotonia at birth; feeding or respiratory support; newborn screening results]

Developmental milestones: [Gross motor (head control, rolling, sitting, crawling, walking); fine motor; speech/language] Regression: [yes / no / uncertain] (Document explicitly.)

Feeding and growth: [Latch/suck quality; fatigue with feeds; aspiration signs; weight gain trajectory]

Family pedigree: [Three-generation history; similarly affected relatives; early deaths; miscarriages] Consanguinity: [yes / no / unknown]

Past Medical History

• [Medical conditions with dates]
• [Prior neurologic diagnoses (stroke, seizures, neuropathy, myopathy)]
• [Autoimmune/rheumatologic disease; cancer and treatments]
• [Surgeries and hospitalizations with dates]

Medications and Allergies

Current medications: [Prescription, OTC, supplements, recent changes] (Flag agents associated with myopathy, neuropathy, or NMJ dysfunction: statins, steroids, immune therapies.)

Allergies: [Medication allergies with reaction type (rash vs anaphylaxis)]

Exposures: [Alcohol; recreational drugs; occupational exposures; travel; tick exposure] (Include when relevant to differential. State "not assessed" if not evaluated.)

Family History

[Neuromuscular disease; unexplained weakness; early wheelchair use; cardiomyopathy; arrhythmias; sudden death; known genetic diagnoses; carrier status] (Include relation and age at onset when known.)

Social History

[Living situation; caregiver support; occupation and functional demands; smoking; alcohol quantity; substance use]

Review of Systems

[Neuromuscular-focused ROS: constitutional; skin/rash; ocular; respiratory; cardiac; GI (swallowing); GU (bowel/bladder); musculoskeletal (myalgias); neurologic (sensory symptoms, cramps); endocrine] (Document pertinent positives and negatives actually reviewed.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2, weight, height, BMI, weight trend] (For pediatric hypotonia: include growth percentiles and dysmorphology observations.)

General and targeted exam: [Appearance; body habitus (cachexia/Cushingoid); joint hypermobility; contractures; scoliosis; skin findings; respiratory effort/accessory muscle use; edema; murmurs; scapular winging; calf hypertrophy or atrophy]

Neurologic examination:

• Mental status and speech: [Findings relevant to presentation]
• Cranial nerves: [Ptosis; extraocular movements; facial strength; palate elevation; tongue bulk and fasciculations]
• Motor: [Bulk (atrophy/hypertrophy, fasciculation locations); tone (hypotonia/spasticity/rigidity); strength with MRC grades and laterality] (Note pain limitation or inconsistent effort.)
• Functional maneuvers: [Rise from chair; squat; heel/toe walk; single-leg stance; Gowers maneuver]
• Reflexes: [0–4+ by site; plantar responses; clonus]
• Sensory: [Light touch; pin; vibration; proprioception by distribution]
• Coordination: [Finger-nose; heel-shin; rapid alternating movements]
• Gait and station: [Pattern (waddling/steppage/spastic); tandem gait; Romberg]
• Fatigability testing: [Specific maneuvers and observed changes] (Include when NMJ disorder is in the differential.)

Respiratory bedside assessment: [Cough strength; single-breath count; ability to lie flat; paradoxical breathing] (Include when respiratory symptoms, significant axial weakness, or known neuromuscular disorder is present.)

Data Reviewed

Laboratory

[Key values with dates, especially CK]

Imaging

[Modality, date, body region; personally reviewed vs report only]

Electrodiagnostic Studies

[Date, facility, summary impression; raw waveforms available vs report only]

Genetic Testing

[Test type, lab, date, result classification (pathogenic/VUS/negative)]

Pathology

[Biopsy site, date, key findings]

Cardiopulmonary

[ECG, echocardiogram, PFTs, sleep study results]

Pending/Requested: [Data mentioned but not yet available with retrieval plan]

Assessment

Problem representation: [1–3 sentence synthesis of phenotype, tempo, key positives and negatives, and suspected anatomic level(s)]

Localization: [Central (brain/spinal cord) / anterior horn cell / motor neuron / root / plexus / peripheral nerve / neuromuscular junction / muscle / mixed / systemic] (State most likely level(s) with brief rationale.)

Differential diagnosis:

• Most likely: [Diagnoses grouped by localization with supporting and refuting features]
• Less likely but important: [Diagnoses with reasoning]
• Cannot miss: [Urgent or dangerous causes; include iatrogenic/toxic when exposure suggests]

Plan

[Problem name]

Status: [new / worsening / stable]

Immediate safety triage: [ED evaluation / inpatient admission / urgent respiratory assessment / swallow evaluation / urgent imaging] (Include only if indicated.)

Diagnostic workup:

• Laboratory: [Tests with rationale—baseline screening (CBC, CMP, CK); inflammatory/autoimmune markers; neuropathy labs; NMJ antibodies; metabolic evaluation]
• Genetic testing: [Pretest counseling status; test type (targeted gene/panel/CMA/exome/genome) with rationale; variant interpretation plan] (If not pursued, document why.)
• Electrodiagnostic: [NCS + needle EMG / repetitive stimulation / single-fiber; clinical question; factors affecting interpretation]
• Imaging: [Brain/spine MRI; muscle MRI; chest imaging; contrast considerations]
• Biopsy: [Target site, rationale; pathology coordination; medication holds] (Include only when results will change management.)
• Other: [Swallow evaluation; sleep study; ECG/echo; PFTs as indicated]

Management: [Rehabilitation referrals; mobility and fall prevention; symptom management (pain/cramps/spasticity); respiratory care and vaccinations; swallow/nutrition support; psychosocial services; genetic counseling] (Use conditional language when workup is pending.)

Return precautions: [Rapid progression; new respiratory distress; inability to handle secretions; new/worsening dysphagia; new bowel/bladder dysfunction with weakness; dark urine with severe myalgias; marked fatigable bulbar weakness]

Referrals: [Service, reason, urgency, specific question for consultant]

Follow-up: [Interval and modality; pending results with responsible party; contingency if testing delayed]

(Repeat problem-based structure for additional issues as needed.)