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Pfizer Pharmaceuticals Group
APPENDIX B:
Diagnostic Worksheet for Diabetic Peripheral Neuropathy:
A.
NEUROLOGICAL HISTORY
Your standard neurological history should be performed. This history should include an inquiry into possible exposure to neurotoxic
drugs or chemicals, and a family history of neurologic disease, weakness, or arthritis and joint deformities. Also make specific and
detailed inquiry about symptoms of sensory, motor, and autonomic dysfunction.
1. Based on your history, does the patient have:
No
Yes
a) A condition other than diabetes which could cause neuropathy?
b )
Exposure to known neurotoxins?
0
c) A family history of neuromuscular disorders?
If Yes to any of the above, reconsider the diagnosis of diabetic peripheral neuropathy. Patient is not allowed to enter study if
there is doubt about the diagnosis or a concomitant condition is present which could confuse the assessment of pain due to
diabetic peripheral neuropathy.
Are any of the following sensory symptoms present in the hands or feet?
No
Both Hands
Feet Only . Hands Only
and Feet
) Numbness
b)
Dysesthesias, paresthesias
Allodynia
d) Burning/aching stabbing pain
m
0 0 0 0
Note: If symptoms present in hands only, consider alternative diagnosis!
- . .
. .
. . . :
3.
Are any of the following motor symptoms present? .
No
Yes
a) Ankle weakness
. .
. ..: .
O
b) Cramps
4. Are any of the following autonomic symptoms present?
. . .
No
Yes
. . ..
Postural Hypotension
a) Weakness on standing relieved by lying down
b) Fainting on standing relieved by lying down
- :
Gastroparesis
c) Dysphagia (difficulty in swallowing)
d) Anorexia
:. A
e)
Nausea
f) Vomiting
g) . Vague fullness after meal
Diabetic Diarrhea
h) Nocturnal diarrhea
i)
Fecal incontinence
j) More than 20 bowel movements/day
. '. " ... . .
Colonic Atony
k) Less than 2 bowel movements/week
1) Less than 1 bowel movement/3 days
Protocol ID A945-1008
40
Working Protocol inc. Amendment #2: August 7, 2002
CONFIDENTIAL
Pfizer_MPatel_0203749
Source: https://www.industrydocuments.uesf.edu/docs/lpjm0223

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