Peripheral Neuropathy/Radiculopathy Evaluation Note

Date/Time: [Date and time of encounter]
Author: [Clinician name and credentials]
Location: [Clinic/site]
Encounter Type: [new / follow-up]; [consult / established]
Referring Clinician: [Name, specialty, contact] (Only include if consult)
Clinical Question: [Reason for consult] (Only include if consult)
Information Sources: [patient / family / caregiver / interpreter / outside records]
Limitations: [Description of limitation] (Only include if applicable)

Chief Complaint

[Patient's primary concern in their own words] (If patient cannot report, identify the source and state the clinical concern.)

History of Present Illness

[One-sentence summary: patient age, key comorbidities, symptom tempo, distribution pattern, and leading syndrome]

[Narrative of symptom evolution including onset, tempo, progression pattern, and precipitating events]

• Distribution: [Laterality, symmetry, length-dependent vs non–length-dependent, dermatomal vs single nerve vs multifocal vs generalized, proximal involvement]
• Primary symptoms: [Numbness, tingling, pain quality/severity/timing, weakness with functional tasks affected, atrophy, fasciculations, imbalance, falls]
• Autonomic symptoms: [Orthostatic lightheadedness, sweating changes, GI/GU dysfunction] (Omit if not assessed)
• Spine-associated features: [Neck/back pain, radicular radiation, positional provocation, bowel/bladder symptoms, upper motor neuron signs]
• Functional impact: [Walking tolerance, ADLs, work, sleep, falls history with dates]
• Prior evaluation and treatment: [Key prior labs/imaging/EMG with dates and findings, medications tried with response, procedures]
• Pertinent negatives: [Targeted negatives that inform localization or rule out red flags]

(Omit elements not assessed. If critical information is unobtainable, document why.)

Red Flags

(For new evaluations, document explicit positives or negatives. May abbreviate or omit for stable follow-up with recent screening.)

• Cauda equina/conus signs: urinary retention/incontinence [present / absent]; saddle anesthesia [present / absent]; rapid bilateral leg weakness [present / absent]
• Myelopathy signs: gait spasticity [present / absent]; hand clumsiness [present / absent]; hyperreflexia/Babinski [present / absent]; sensory level [present / absent]
• Rapid progression: weakness over days–weeks [present / absent]; bulbar/respiratory symptoms [present / absent]
• Infection/malignancy indicators: fever [present / absent]; weight loss [present / absent]; immunosuppression [present / absent]; known cancer [present / absent]; severe nocturnal pain [present / absent]
• Vascular/structural concerns: acute pain after trauma [present / absent]; anticoagulation with neurologic deficit [present / absent]

[Disposition plan and patient instructions if any red flags present] (Only include if applicable)

Relevant Background

• Medical history: [Diabetes/prediabetes status and control, thyroid disease, renal/hepatic disease, autoimmune conditions, malignancy and chemotherapy exposure, HIV/hepatitis risk, B12 deficiency risk or bariatric surgery, spine disease/surgery]
• Medication/toxin exposure: [Neurotoxic medications, excess vitamin B6, alcohol pattern, occupational/environmental toxins] (Include if relevant)
• Family history: [Neuropathy, high arches, hammer toes, early gait difficulty, known hereditary neuropathy]
• Social history: [Alcohol quantity, substance use, occupational factors, home fall risks/supports]

Medications and Allergies

• Current medications: [Medication list with dose/frequency, emphasizing neuropathic pain agents, sedatives, anticoagulants, diabetes medications]
• Allergies: [Allergen and reaction type]

Review of Systems

(Targeted to neuropathy/radiculopathy; omit systems not discussed)

• Constitutional: [Fever, weight loss]
• Skin: [Rash]
• Sicca symptoms: [Dry eyes, dry mouth]
• Neurologic: [Diplopia, dysphagia, dyspnea, bladder/bowel changes]
• Autonomic: [Orthostasis, sweating changes, GI/GU dysfunction] (If not covered in HPI)

Physical Examination

(Document only elements performed. Use standardized grading: Strength 0–5; Reflexes 0–4+ with symmetry; Sensory as intact/diminished/absent. If exam limited, state why.)

• Vital signs: [BP, HR, RR, Temp, SpO2, Weight/BMI]
• General: [Appearance, distress, assistive devices]
• Spine/MSK: [Alignment, range of motion, focal tenderness]; Spurling [positive / negative / not done]; Straight Leg Raise [positive / negative / not done] (Include if radiculopathy suspected)
• Motor: Bulk [normal / atrophy]; Tone [normal / increased / decreased]; Fasciculations [present / absent]; Strength [by myotome/nerve with 0–5 grades]
• Reflexes: [Biceps, brachioradialis, triceps, patellar, Achilles with 0–4+ grades and side comparison]; Hoffmann [present / absent]; Babinski [present / absent]; Clonus [present / absent] (Include pathologic reflexes if indicated)
• Sensory: Small fiber [pin/temperature]; Large fiber [vibration/proprioception]; [Map deficits: length-dependent gradient vs dermatomal vs focal nerve territory]; Allodynia [present / absent]
• Coordination: Finger-to-nose [intact / dysmetric]; Heel-to-shin [intact / dysmetric] (Include when ataxia suspected)
• Gait and station: [Base, speed, stability]; Heel walk [intact / impaired]; Toe walk [intact / impaired]; Tandem [intact / impaired]; Romberg [positive / negative]
• Peripheral nerve maneuvers: Tinel [location and result]; Phalen [result] (Include when relevant)
• Foot exam: [Skin integrity, ulcers, deformities]; Distal pulses [present / diminished / absent] (Include for neuropathy evaluation)

Data Reviewed

• Laboratory: [Test name, date, key findings]
• Imaging: [Study, date, findings relevant to localization]
• EMG/NCS: [Date, summary: axonal vs demyelinating, distribution, severity]
• Outside records: [Source, date, salient points]

(State "None available" if no pertinent data)

Assessment

• Problem 1: [Localization statement: e.g., length-dependent polyneuropathy, L5 radiculopathy, ulnar neuropathy at elbow] — Certainty: [high / moderate / low]
  Supporting features: [1–3 key findings from history and exam]
  Differential: [Most likely, must not miss, less likely] (Include if diagnosis uncertain or high-stakes alternatives exist)
• Problem 2: [Additional problem with localization, supporting features, and differential] (Include if applicable)
• Severity/functional status: [Motor deficit, falls risk, functional limitations, impact on sleep/mood]

Plan

(Organize by problem. Include rationale when ordering or deferring studies.)

Problem 1: [Problem name]

Diagnostics:

• Laboratory: [Glycemic assessment, B12 with metabolites, monoclonal protein screen, targeted labs with rationale] (For polyneuropathy workup)
• EMG/NCS: Clinical question: [radiculopathy vs entrapment vs polyneuropathy / axonal vs demyelinating / severity]; Suspected levels/nerves: [specify]; Limbs: [symptomatic limbs] (If not ordering, document why)
• Imaging: [MRI region] for [indication: red flags / objective deficits / procedural planning] (If deferring, document conservative management plan)
• Small fiber testing: [Skin biopsy / autonomic testing] (Include when small fiber symptoms with unrevealing large-fiber studies)

Treatment:

• Etiology-directed: [Glycemic optimization, B12 replacement, discontinue offending agent, address compressive lesion, or document as idiopathic pending evaluation]
• Pain management: Functional goal: [sleep / walking / work tolerance]; Medication: [class, titration plan, adverse effect counseling]; Opioids: [indication and risk mitigation if used / nonopioid multimodal therapy prioritized if not used]
• Nonpharmacologic: [PT/exercise, CBT-based strategies, sleep hygiene, lifestyle modifications]
• Rehabilitation/DME: [PT/OT, bracing/orthotics, assistive devices, fall prevention]
• Patient education: [Working diagnosis, medication counseling including sedation/fall risk, red flag return precautions]
• Follow-up: [Timeline for results review, triggers for earlier contact, next visit timing]

Problem 2: [Problem name]

(Repeat Diagnostics and Treatment structure as above)

Orders Placed

• Laboratory: [Tests ordered]
• Imaging: [Studies ordered]
• EMG/NCS: [Study and region]
• Referrals: [PT/OT, pain management, subspecialty]
• DME: [Braces/orthotics/assistive devices]