History

Onset? Progression (Table 18.2)? Fluctuating? Intermittent? Recurrent? Aggravating/relieving factors? Triggers?

Character (Table 18.3) and distribution (Table 18.4, Figure 18.2)?

Associated weakness (Chapter 17)? Headache (Chapter 15)?

Sphincter disturbance? Dysphasia/cortical symptoms/hemianopia?

Functional impairment? Sensory ataxia (worse in dark/eyes closed)?

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

Background

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

Past neurological or systemic disease?

Diabetes? Vascular risk factors?

Examination

Even with a predominantly (or purely) sensory presentation, it is almost always advisable to leave the sensory examination until last, having already developed a clear hypothesis regarding the expected abnormality.

Rapid assessment of ABC/vital signs/glucose

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

Assess for any weakness, and alteration of tone, and reflexes (Chapter 17)

Assess visual function and cranial nerves

Check vital capacity if GBS possible

Perform sensory testing with a prior hypothesis/expected distribution (Table 18.4; Figure 18.2). Use unaffected region to check patient appreciates what normal sensation is and understands the response expected. Proceed from abnormal to normal areas, mapping out the borders between areas of abnormal and normal sensation.

• Check spinothalamic (pain/temperature) and dorsal column (vibration/proprioception/light touch) modalities
• Look for other signs if proprioceptive loss. Rombergism? Pseudoathetosis?
• Look for parietal signs if appropriate. Two-point discrimination? Astereognosis? Agraphesthesia? Extinction?

General examination to look for cause: Bruit? AF? Rash? Cachexia? Lymphadenopathy? Organomegaly?