Browse categories and answer follow-up questions to refine your symptom profile.
History
HPI snapshot
Symptom characterization
Primary deficit pattern
Witnessed language disturbance versus dysarthria versus confusion
Time last known well
OPQRST Onset
Onset
Exact time last known normal
Sudden maximal at onset versus gradual progression
Wake up symptoms
OPQRST Provocation/Palliation
Provocation and palliation
Fluctuating deficits
Triggered by exertion
Triggered by posture change
Triggered by Valsalva
OPQRST Quality
Quality
Expressive aphasia
Receptive aphasia
Global aphasia
Anomia
Paraphasic errors
OPQRST Region/Radiation
Region and associated neurologic territory clues
Right sided weakness or sensory loss
Gaze deviation
Visual field loss
OPQRST Severity
Severity
Complete inability to produce language
Mild word finding difficulty
Functional impact on safety
OPQRST Timing
Timing
Persistent deficit duration
Resolved deficit duration
Recurrent stereotyped episodes
Associated symptoms
Associated symptoms
Headache
Seizure activity
Fever
Neck pain
Chest pain
Palpitations
Hypoglycemia symptoms
Baseline and prior episodes
Baseline neurologic and language function
Prior stroke or TIA baseline
Baseline dementia or primary progressive aphasia history
Baseline hearing or vision impairment
Time critical treatment modifiers
Reperfusion eligibility modifiers
Recent major surgery or trauma
Recent intracranial hemorrhage history
Anticoagulant use and last dose time
Pregnancy status
Alarm Features
First 5 minutes triggers
Immediate escalation triggers
Airway risk
Hypoxia
Hypotension
Refractory seizure
Rapidly worsening mental status
Stroke and hemorrhage red flags
Life threatening neurologic triggers
Sudden aphasia with unilateral weakness
Sudden aphasia with gaze deviation
Severe thunderclap headache
Meningismus
Anticoagulated with new neurologic deficit
Vital sign danger thresholds
Vital sign danger thresholds
Glucose less than 3.0 mmol/L
Oxygen saturation less than 92 percent
SBP less than 90 mmHg
SBP greater than 220 mmHg
Temperature 38.0 C or higher
Exam danger findings
High risk exam findings
Depressed level of consciousness
New anisocoria
Cushing response pattern
Papilledema
Do not delay pathways
Do not delay
Noncontrast CT head for suspected stroke or hemorrhage
Point of care glucose
Stroke team activation local protocol dependent
Medications
Current and recent exposures
Medication reconciliation
Anticoagulants
Antiplatelets
Antiseizure medications
Insulin or sulfonylureas
Sedatives
Antipsychotics
High risk interactions and reversals
High risk medication implications
DOAC last dose time and renal function dependence
Warfarin with INR relevance
Opioids or sedatives contributing to delirium
Contraindications to common therapies
Contraindications and cautions
Contrast allergy history for CTA
Metformin with severe renal dysfunction context for contrast local protocol dependent
Pregnancy considerations for radiation imaging
Diet
Intake and metabolic risk
Intake pattern
Poor oral intake
Recent vomiting or dehydration
Alcohol binge exposure
Energy drink or caffeine excess
Glucose and electrolyte triggers
Metabolic triggers
Prolonged fasting
Recent insulin dosing change
Recent diarrhea with electrolyte loss
Review of Systems
Neurologic
Neurologic symptoms
Weakness
Numbness
Vision loss
Diplopia
Vertigo
Ataxia
Headache
Seizure
Infectious and inflammatory
Systemic symptoms
Fever
Chills
Rash
Recent infection
Cardiopulmonary
Cardiopulmonary symptoms
Chest pain
Dyspnea
Palpitations
Syncope
Toxic exposures
Exposure symptoms
Substance use
Carbon monoxide exposure risk
Recent medication overdose risk
Collateral History and Family History
Collateral source
Collateral and reliability
Witness account of last known well
EMS report timeline
Baseline language function confirmation
Family history
Family history
Early stroke or MI
Inherited thrombophilia history
Epilepsy history
Risk Factors
Cerebrovascular
Stroke and TIA risk factors
Atrial fibrillation
Hypertension (I10)
Diabetes mellitus type 2 (E11.9)
Hyperlipidemia (E78.5)
Smoking
Prior stroke (I63.9) or TIA (G45.9)
Hemorrhage
Intracranial hemorrhage risk factors
Anticoagulant use
Thrombocytopenia history
Liver disease
Uncontrolled hypertension
Seizure and metabolic
Seizure and mimic risks
Known epilepsy (G40.909)
Alcohol withdrawal
Hypoglycemia risk
Infection and endocarditis
Embolic and infectious risks
Endocarditis risk factors
IV drug use
Prosthetic valve
Special populations
Population specific risks
Pregnancy and postpartum hypercoagulability
Cancer associated thrombosis
Sickle cell disease (D57.1)
Differential Diagnosis
Life threatening
Life threatening causes
Acute ischemic stroke (I63.9)
Sudden onset focal deficit
Cortical signs
Intracerebral hemorrhage (I61.9)
Headache
Vomiting
Decreased level of consciousness
Subarachnoid hemorrhage (I60.9)
Thunderclap headache
Meningismus
Large vessel occlusion
Gaze deviation
Dense hemiparesis
Nonconvulsive status epilepticus (G41.90)
Fluctuating aphasia
Unexplained altered mental status
Hypoglycemia (E16.2)
Diaphoresis
Tremor
CNS infection
Fever
Neck stiffness
Common
Common causes
TIA (G45.9)
Resolved deficit
High short term stroke risk
Postictal aphasia
Witnessed seizure
Gradual recovery
Migraine with aura (G43.109)
Gradual spread of symptoms
Headache association
Toxic metabolic encephalopathy
Medication effect
Renal failure
Hepatic failure
Less common
Less common causes
Brain tumor or mass lesion (C71.9)
Subacute progression
Morning headache
Brain abscess (G06.0)
Fever
Immunocompromise
Cerebral venous sinus thrombosis (I67.6)
Headache
Pregnancy postpartum
Demyelinating disease
Prior neurologic episodes
Young adult presentation
Functional neurologic symptom disorder (F44.4)
Inconsistent exam
Nonanatomic features
Past Medical History
Neurologic and vascular history
Relevant comorbidities
Prior stroke or TIA details
Carotid stenosis history
Atrial fibrillation history
Seizure disorder history
Procedures and devices
Procedures and devices
Mechanical heart valve
Pacemaker or ICD
Recent cardiac ablation
Baseline function
Baseline function
Independent activities of daily living
Baseline speech or language impairment
Baseline mobility limitations
Physical Exam
General and vitals interpretation
General and vitals
Temperature pattern
Oxygenation status
Perfusion status
BP pattern relevant to stroke treatment thresholds
Neurologic rapid screen
Focused neurologic exam
Level of consciousness
Gaze and visual fields
Facial symmetry
Arm drift
Leg drift
Sensation asymmetry
Language and speech breakdown
Language versus speech differentiation
Aphasia features
Naming
Repetition
Comprehension
Fluency
Dysarthria features
Slurred articulation
Normal comprehension and naming
Apraxia of speech features
Effortful groping
Inconsistent sound errors
NIH Stroke Scale elements
NIHSS relevant elements
Language item scoring impact
Neglect assessment
Limb ataxia assessment
Cardiovascular
Cardiovascular exam
Irregularly irregular rhythm
New murmur
Signs of endocarditis
Head and neck
Head and neck
Carotid bruit
Meningismus
Tongue bite evidence
Pitfalls
Pitfalls and subtle findings
Hearing loss mimicking comprehension deficit
Delirium or intoxication confounding language testing
Lab Studies
Point of care and immediate labs
Immediate tests
Point of care glucose
Electrolytes
CBC
Creatinine and eGFR
PT INR
aPTT
Stroke pathway labs
Stroke pathway labs
Troponin
Lipids local protocol dependent
HbA1c local protocol dependent
Infection and mimic labs
Mimic evaluation labs
Blood cultures if febrile with embolic concern
CRP or ESR local protocol dependent
Toxicology screen local protocol dependent
Interpretation pearls and limitations
Limitations and pitfalls
Normal labs do not exclude ischemic stroke
Early infection markers may be normal
Anticoagulant effect may not be captured by PT INR for some DOACs
Imaging
Scoring Systems
Imaging based risk and selection tools
ASPECTS for anterior circulation ischemic stroke
Lower scores correlate with larger core infarct
Interrater variability limitation
ABCD2 score for TIA risk stratification
Use for short term stroke risk estimation
Do not use to exclude need for urgent imaging
MRI
MRI brain pathways
DWI MRI for acute ischemia
Higher sensitivity than CT for early infarct
False negative possible early or posterior circulation
MRI contraindications screen
Non MRI compatible implants
Severe agitation requiring airway risk sedation
CT
CT based acute stroke imaging
Noncontrast CT head
Primary role hemorrhage exclusion
Early ischemic change may be subtle
CTA head and neck
Large vessel occlusion detection
Contrast nephropathy risk low but local protocol dependent
CT perfusion local protocol dependent
Selection for late window thrombectomy
Software and thresholds vary
Ultrasound
Ultrasound and POCUS adjuncts
Carotid duplex local protocol dependent
Stenosis assessment for secondary prevention
Operator dependence limitation
TTE or TEE local protocol dependent
Cardioembolic source evaluation
Not a substitute for emergent CT or CTA
Special Tests
Bedside differentiation tests
Bedside language testing
Picture description
Object naming
Repetition phrase testing
Simple command following
Seizure evaluation
EEG considerations
Persistent aphasia with normal imaging
Fluctuating deficits with altered awareness
Nonconvulsive status epilepticus suspicion
Lumbar puncture indications
CSF evaluation indications
Suspected meningitis or encephalitis
Suspected SAH with negative CT and ongoing high suspicion local protocol dependent
Swallow assessment
Aspiration risk screening
NPO until swallow screen completed
Early speech language pathology involvement local protocol dependent
ECG
Rhythm and ischemia evaluation
ECG role
Atrial fibrillation detection
Acute ischemia screening
QT prolongation for toxicologic concerns
Cardioembolic source clues
ECG findings and implications
New atrial fibrillation
Recent MI pattern
Frequent ectopy as arrhythmia marker
Serial and monitoring logic
Monitoring
Continuous telemetry for suspected cardioembolic stroke local protocol dependent
Repeat ECG if chest pain or troponin rise
Assessment
Problem representation
Acute aphasia or speech disturbance
Suspected cortical syndrome
Time last known well defined versus unknown
Persistent versus resolved deficit
Severity and risk stratification
Severity and risk
NIHSS language component influence on reperfusion decisions
High risk TIA features
Posterior circulation concern features
Key must not miss complications
Complications to rule out
Intracranial hemorrhage
Large vessel occlusion
Hypoglycemia
Seizure or status epilepticus
Diagnostic uncertainty and mimics
Mimic framework
Toxic metabolic encephalopathy
Migraine aura
Functional symptoms
CNS infection
Plan
First 5 minutes
Time critical workflow
Stroke activation local protocol dependent
Glucose correction if low
Oxygen for hypoxia
Two IV lines if candidate for thrombolysis or thrombectomy
Noncontrast CT head target within 20 minutes local protocol dependent
Acute stroke pathway
Reperfusion decision workflow
Noncontrast CT head for hemorrhage exclusion
CTA head and neck for large vessel occlusion when eligible local protocol dependent
Thrombolysis eligibility screen local protocol dependent
Thrombectomy eligibility screen local protocol dependent
Blood pressure targets
Blood pressure management local protocol dependent
If thrombolysis planned maintain BP below 185 over 110 mmHg
After thrombolysis maintain BP below 180 over 105 mmHg
If no thrombolysis and BP greater than 220 over 120 mmHg consider cautious reduction
Glucose and temperature
Physiologic targets
Glucose target 7 to 10 mmol/L local protocol dependent
Treat hypoglycemia immediately
Treat fever and search source
Antithrombotic therapy
Antiplatelet and anticoagulation local protocol dependent
Aspirin after hemorrhage excluded
Dual antiplatelet for high risk TIA or minor stroke when appropriate local protocol dependent
Anticoagulation timing for atrial fibrillation stroke depends on infarct size local protocol dependent
Seizure management
Seizure treatment if present
Lorazepam IV 2 mg
Repeat 2 mg every 2 minutes up to 8 mg total local protocol dependent
Airway risk monitoring
Levetiracetam IV 60 mg per kg
Maximum 4500 mg
Renal adjustment local protocol dependent
Reassessment loop
Reassessment loop
Neuro checks frequency local protocol dependent
Repeat glucose after correction
Repeat vitals after BP interventions
Escalate for worsening NIHSS or declining consciousness
Disposition
Level of care criteria
ICU or higher acuity criteria
Intracranial hemorrhage
Large vessel occlusion awaiting intervention
Airway compromise
Refractory seizure
Severe BP instability
Admission and observation
Admission criteria
Persistent neurologic deficit
TIA with high short term stroke risk features
Need for urgent carotid or cardioembolic workup
Anticoagulation management complexity
Observation pathway criteria local protocol dependent
Resolved deficit with rapid access imaging and neurology follow up
Stable vitals and reliable supervision
Transfer criteria
Transfer to thrombectomy capable center local protocol dependent
Suspected large vessel occlusion
Within endovascular time window per protocol
No prohibitive comorbidity or goals of care limitations
Discharge criteria
Discharge criteria
Stroke and hemorrhage excluded with appropriate imaging
Mimic identified and treated
Normal neurologic exam at baseline
Reliable follow up within 24 to 72 hours for TIA pathway local protocol dependent
Discharge Instructions
Copy discharge instructions
Summary
You were seen for a sudden change in speech or language
Your tests today did not show bleeding in the brain
A stroke can still happen even if symptoms improve
Medications
Take medications exactly as prescribed
Do not stop blood thinners without medical advice
Activity
Do not drive until cleared if you had a seizure or stroke concern
Avoid alcohol and sedating substances until symptoms fully resolved
Follow up
Return for urgent follow up within 24 to 72 hours if advised
Neurology or stroke clinic follow up timing as arranged
Return to ED now for
Any new or worsening weakness
Any new or worsening speech or understanding problems
Severe sudden headache
Seizure
Confusion or fainting
Chest pain or trouble breathing
References
Guidelines and key sources
Evidence based references
American Heart Association American Stroke Association guidelines for early management of acute ischemic stroke 2019 update
American Heart Association American Stroke Association guideline for the prevention of stroke in patients with stroke and TIA 2021
European Stroke Organisation guidelines for management of acute ischemic stroke and TIA 2021 to 2023 local protocol dependent
Society of NeuroInterventional Surgery recommendations for endovascular thrombectomy systems of care 2021 local protocol dependent
NIH Stroke Scale training and certification materials current version local protocol dependent
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.