History Physical

History Physical neuropathy

Peripheral Neuropathy guidelines, most of neuropathy is inflammatory

Table 7. Key Findings from History and Physical Examination: Pattern Recognition for Generalized Neuropathies
Pattern	Classification/possible diagnoses	Comments
Symmetric proximal and distal weakness with sensory loss	Inflammatory demyelinating polyneuropathy Guillain-Barre syndrome (GBS) Chronic inflammatory demyelinating polyneuropathy	Patient complaints include: difficulty raising arms to brush teeth and comb hair, problems climbing stairs, difficulty rising from a seated position, sensory loss, and sensory ataxia
Symmetric distal weakness with sensory loss	Metabolic disorders (e.g., amyloidosis, diabetes, Sjogrens syndrome) Drugs (amitriptyline, chloroquine, dapsone) and toxins Hereditary neuropathies (Charcot-Marie-Tooth disease, amyloidosis)	Underlying conditions may be axonal or demyelinating; therefore, laboratory investigations (e.g., fasting blood sugar, hemoglobin A_1C, vitamin B₁₂ levels, molecular genetic blood tests) are recommended based on initial suspicions
Asymmetric distal weakness with sensory loss	Vasculitis Hereditary neuropathy with predisposition to pressure palsies Infectious diseases (leprosy, Lyme, HIV) Sarcoidosis Compression and entrapment neuropathies	Vasculitis is the most common diagnosis when multiple nerves not normally subject to compression are involved. Compressive mononeuropathy, radiculopathy should be considered with single nerve/region involvement.
Asymmetric distal weakness without sensory loss	Upper-motor-neuron disease Generalized: multifocal motor neuropathy (MMP)	Bulbar findings (i.e., slurred or nasal speech, drooling, nasal regurgitation of liquids, difficulty whistling, swallowing), fasciculations,and hyperreflexia suggest upper-motor-neuron disease, and are rare with MMP
Asymmetric proximal and distal weakness with sensory loss	Polyradiculopathy Plexopathy (brachial or lumbar) Meningeal carcinomatosis or lymphomatosis	In diabetic plexopathy, pain typically precedes weakness
Symmetric sensory loss without weakness	Cryptogenic sensory polyneuropathy (CSPN) Metabolic derangements (diabetes, alcohol), drugs, toxins	CSPN is primarily observed in older adults. Diabetic and alcoholic neuropathies may present with few or no motor signs.
Asymmetric proprioceptive sensory loss without weakness	Sensory neuropathy (ganglionopathy) Paraneoplastic syndrome Sjogrens syndrome Idiopathic sensory neuropathy Drug (e.g., cisplatin and its analogues) or vitamin B₆ toxicity HIV sensory neuropathy	Primarily affects large fibers. May warrant a cancer workup.
Autonomic symptoms	Generalized - diseases affecting small fibers: e.g., acute dysautonomia, familial/ primary amyloidosis, GBS, diabetes, Chagas disease, porphyria, HIV-related autonomic neuropathy, idiopathic pandysautonomia	Typically associated with other types of neuropathy. Conduct autonomic testing (e.g., Valsalva heart rate response to pressure changes). May be an early or sole presentation of alcoholic or diabetic neuropathy.
Based on Barohn [6], Kowalske [13].

Table 8. Assessment of Muscle-Group Weakness
Symptoms	Likely source of weakness
Slurred/nasal speech Drooling Nasal regurgitation of liquids Difficulty whistling, smiling Difficulty swallowing, weight loss	Bulbar muscles
Diplopia Ptosis	Extraocular muscles
Trouble reaching Difficulty holding razor, comb, hair dryer Difficulty placing things in high cabinets	Proximal upper-extremity muscles
Difficulty opening jars, doors, using keys, silverware Trouble buttoning clothing	Distal upper-extremity muscles
Trouble rising from chairs, sofas Trouble getting out of car, bath, or off toilet Difficulty climbing stairs	Proximal lower-extremity muscles
Tripping Sprained ankles	Distal lower-extremity muscles

Table 9. Principal Motor Innervation of Peripheral Nerves: Localizing Muscle Weakness
Nerves	Muscles	Action
Axillary	Deltoid	Shoulder abduction
Musculocutaneous	Biceps, brachialis	Flexion of elbow
Median	Flexor carpi radialis	Radial flexion of wrist
	Flexor digitorum sublimis	Flexion of middle phalanges (digiti II-V)
	Flexor digitorum profundus (lateral half)	Flexion of distal phalanges (digiti II, III)
	Pronator teres, pronator quadratus	Pronation of forearm
	Abductor pollicis brevis	Abduction of thumb
	Opponens pollicis brevis	Opposition of thumb
	Flexor pollicis longus	Flexion of distal phalanx of thumb
	Flexor pollicis brevis	Flexion of proximal phalanx of thumb
Ulnar	Flexor carpi ulnaris	Ulnar flexion of wrist
	Flexor digitorum profundus (medial half)	Flexion of distal phalanges (digiti IV, V)
	Abductor digiti minimi	Abduction of digiti V
	All other intrinsics of hand	Finger abduction/adduction
Radial	Triceps	Extension at elbow
	Brachioradialis	Flexion of forearm
	Extensor carpi radialis/ulnaris	Extension at wrist with radial/ulnar deviation
	Supinator	Supination of forearm
	Extensor pollicis brevis	Extension of thumb (proximal)
	Extensor pollicis longus	Extension of thumb (distal)
	Extensor indicis proprius	Extension of index (proximal)
	Extensor digiti V proprius	Extension of little finger (proximal)
	Extensor digiti communis	Extension of digits (II-V, proximal)
Femoral	Iliopsoas	Flexion of thigh at hip
Femoral	Quadriceps	Extension of leg at knee
Obturator	Adductor longus, adductor brevis, adductor magnus	Adduction of thigh at hip
Superior gluteal	Gluteus medius, gluteus minimus, gluteus maximus	Abduction of thigh at hip
Sciatic	Biceps femoris, semitendinosus, semimembranosus	Flexion of leg at knee
Sciatic branches: fibular (deep)	Tibialis anterior	Dorsiflexion of foot
	Extensor digitorum longus	Extension of toes
	Extensor hallucis longus	Extension of great toe
Sciatic branches: fibular (superficial)	Peroneus	Everts foot
Tibial	Gastrocnemius, soleus	Plantar flexion of foot
	Flexor digitorum longus	Flexion of distal phalanges (II-IV)
	Flexor hallucis longus	Flexion of distal phalanges (I)
	Flexor digitorum brevis	Flexion of middle phalanges (II-V)
	Flexor hallucis brevis	Flexion of middle phalanges (I)
Pudendal	Perineal and sphincters	Closure of sphincters, contraction of pelvic floor
From Ronthal [14].

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History Physical neuropathy