History

Time and speed of onset and progression (instant, seconds, hours, days, weeks; resolving, stable, fluctuating/fatigable, worsening)?

Distribution? (hemi-, quadri-, para-, monoplegia, localized, proximal, distal, axial)

Cranial nerve distribution involvement? (facial, bulbar, ocular/diplopia)

Headache?

Other associated pain? Character? Myelopathic (constricting)? Radicular (shooting/deep ache)? Localized to entrapment sites or plexus? Neuropathic (paraesthesia)? Myalgic?

Sensory loss (Chapter 18)? Distribution? Saddle?

Sphincter disturbance? Dysphasia/hemianopia/other cortical symptoms?

Functional impairment? Walking? Stairs/chairs? Fine motor tasks? Breathing?

Prodromal illness/infection? Trauma? Compression? Arising from sleep?

Systemic upset? Weight loss? Diet/malnutrition? Alcohol/drug/toxin exposure?

Vascular risk factors?

Past neurological or systemic disease?

Examination

Rapid assessment of ABC/vital signs/glucose

If acute stroke, possible CT scanning +/– thrombolysis now takes priority

Assess distribution of weakness, tone and reflex pattern as per Table 3.1

Check for cranial nerve and higher mental dysfunction. Is there dysphasia?

Perform sensory testing with a hypothesis in mind:

• Hemisensory loss? Sensory level? Suspended? Dissociated/crossed? (Check both spinothalamic and dorsal column modalities) Saddle? Dermatomal? Glove and stocking? In territory of single peripheral nerve? Normal? (See Chapter 18)

Ptosis +/– diplopia developing or worsening with prolonged upgaze? Reduction in power after repetitive muscle contraction?

Check vital capacity if neuromuscular respiratory failure possible

General examination to look for cause

• Bruit? AF? Rash? Cachexia? Lymphadenopathy? Organomegaly?