Acute Weakness Or NumbnessAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

634 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Transient Neurologic Deficits Acute Aphasia And Speech Disturbance Acute Confusion And Delirium Postictal State And Seizure Recurrence Concern Seizure Acute Vision Loss New Tremor And Involuntary Movements Headache Vertigo Acute Weakness Or Numbness Gait Instability And Ataxia

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx90

Presenting syndrome framing

›Pattern and timing

›Sudden onset deficit

›Progressive over hours to days

›Fluctuating or episodic

›Recurrent stereotyped episodes

›Distribution

›Unilateral face, arm, leg

›Bilateral legs

›Distal stocking glove

›Single nerve or dermatomal

›Baseline and change

›Baseline neurologic deficits

›Baseline mobility and ADLs

›Time last known well

OPQRST

›Onset

›Exact time last known well

›Wake up with symptoms

›During exertion

›During Valsalva

›Provocation/Palliation

›Worse with neck movement

›Worse with back movement

›Worse with exertion

›Worse with heat or fever

›Better with rest

›Better with positional change

›Quality

›Weakness

›Numbness

›Tingling

›Burning pain

›Heaviness

›Region/Radiation

›Face involvement

›Arm involvement

›Leg involvement

›Trunk sensory level

›Perineal saddle region

›Severity

›Inability to walk

›Inability to use hand

›Dropping objects

›Falls

›Timing

›Minutes to hours

›Hours to days

›Days to weeks

›Intermittent with full resolution

Associated symptoms

›Central nervous system red flags

›Speech disturbance

›Visual loss

›Diplopia

›Dysphagia

›Vertigo with focal deficits

›New severe headache

›Seizure

›Altered mental status

›Spinal cord red flags

›Back pain

›Neck pain

›Sensory level

›Urinary retention

›Fecal incontinence

›Saddle anesthesia

›Peripheral and systemic clues

›Myalgias

›Muscle cramps

›Dyspnea

›Palpitations

›Fever

›Rash

›Weight loss

Precipitating context

›Vascular context

›Recent transient episodes

›Atrial fibrillation symptoms

›Recent surgery or immobilization

›Toxic metabolic context

›Recent vomiting or diarrhea

›Poor intake

›New insulin or hypoglycemia risk

›Alcohol binge

›Infectious and inflammatory context

›Recent URI or gastroenteritis

›Tick exposure

›Recent vaccination

›Trauma and procedure context

›Minor trauma

›Recent lumbar puncture

›Neuraxial anesthesia

›Recent spinal manipulation

02Alarm Features/alarm43

Immediate time critical triggers

›Activate resuscitation and urgent neuro pathway

›Suspected acute stroke

›Suspected spinal cord compression

›Suspected epidural hematoma or abscess

›Rapidly ascending weakness

›Respiratory muscle involvement

›Hyperkalemia pattern with weakness

›Airway and breathing threats

›Inability to count to 20 in one breath

›Weak cough

›Pooling secretions

›Bulbar dysfunction

›Circulation threats

›SBP < 90

›Persistent tachycardia

›New arrhythmia

High risk historical features

›Stroke high risk

›Last known well within thrombolysis window local protocol dependent

›Anticoagulant use

›Severe headache with deficit

›Spinal cord high risk

›Cancer history

›Immunocompromised state

›IV drug use

›Fever with back pain

›Neuromuscular respiratory high risk

›Rapid progression over hours

›Recent GI illness with ascending weakness

›Fluctuating fatigable weakness

High risk exam and vital signs

›Exam danger findings

›New focal deficit

›New aphasia

›New gaze deviation

›New facial droop

›New sensory level

›New areflexia with weakness

›New hyperreflexia with clonus

›Vital sign danger thresholds

›Glucose < 3.0 mmol/L

›Glucose > 25 mmol/L with dehydration

›Temperature >= 38.0 C with neurologic deficit

›SBP >= 220

›DBP >= 120

03Medications/meds37

Medication exposures relevant to weakness or numbness

›Anticoagulants and antiplatelets

›Warfarin

›DOACs

›Heparin

›Aspirin

›P2Y12 inhibitors

›Neuroactive medications

›Sedatives

›Antipsychotics

›Antiepileptics

›Opioids

›Metabolic and electrolyte affecting medications

›Diuretics

›Insulin

›Sulfonylureas

›Beta agonists

›ACE inhibitors

›ARBs

›Myopathy and neuropathy associated medications

›Statins

›Colchicine

›Fluoroquinolones

›Amiodarone

›Chemotherapy agents

›Recent medication change

›Dose increase

›New start

›Missed doses

Contraindications and interactions to anticipate

›Thrombolysis and bleeding risk

›DOAC timing unknown

›Recent major surgery

›Contrast imaging risk

›Prior contrast reaction

›Severe CKD

›Steroid risks for suspected cord compression

›Active uncontrolled infection

›GI bleed history

04Diet/diet16

Intake and metabolic triggers

›Reduced intake and dehydration

›Poor oral intake

›Prolonged fasting

›Weight loss

›High carbohydrate load and glycemic swings

›Sugary beverages

›Skipped meals with diabetes meds

›Alcohol exposure

›Recent binge

›Withdrawal risk

›Caffeine and energy drinks

›High dose stimulant exposure

›Sleep deprivation association

›Electrolyte risk context

›Excess free water intake

›Low solute diet

05Review of Systems/ros28

Neurologic

›Neurologic symptom screen

›Headache

›Vision change

›Speech change

›Dysphagia

›Dizziness

›Ataxia

›Seizure

Cardiopulmonary

›Cardiopulmonary symptom screen

›Chest pain

›Dyspnea

›Palpitations

›Syncope

Infectious and inflammatory

›Infection and inflammation screen

›Fever

›Chills

›Neck stiffness

›Rash

Musculoskeletal and systemic

›Systemic symptom screen

›Myalgias

›Arthralgias

›Proximal muscle weakness

›Dark urine

Genitourinary and bowel

›Bladder and bowel screen

›Urinary retention

›Urinary incontinence

›Fecal incontinence

›Constipation

06Collateral History and Family History/chafh15

Collateral and baseline function

›Collateral source and reliability

›Witnessed onset

›Family report

›EMS report

›Baseline function

›Independent ambulation baseline

›Baseline speech and cognition

Family history

›Vascular and neurologic family history

›Early stroke or MI

›Aneurysm history

›Migraine with aura

›Neuromuscular and inherited conditions

›Neuropathy

›Myopathy

›Multiple sclerosis family history

07Risk Factors/rf29

Cerebrovascular risk

›Atherosclerotic risk factors

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Hyperlipidemia (E78.5)

›Tobacco use

›Cardioembolic risk factors

›Atrial fibrillation (I48.91)

›Recent MI

›Valvular disease

›Hypercoagulable risk factors

›Active malignancy

›Pregnancy and postpartum

›Estrogen therapy

Spinal cord compression and infection risk

›Epidural abscess risk

›IV drug use

›Indwelling catheter

›Diabetes mellitus

›Epidural hematoma risk

›Anticoagulation

›Recent neuraxial procedure

›Coagulopathy

Peripheral neuropathy and metabolic risk

›Neuropathy risk factors

›Diabetes mellitus

›Alcohol use disorder (F10.20)

›B12 deficiency risk

›Electrolyte and endocrine risk factors

›CKD

›Adrenal insufficiency risk

›Thyroid disease

08Differential Diagnosis/ddx64

Life threatening

›Acute ischemic stroke (I63.9)

›Sudden focal deficit

›Cortical signs

›Intracerebral hemorrhage (I61.9)

›Severe headache with deficit

›Marked hypertension

›Subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Meningismus

›Spinal cord compression

›Metastatic cord compression (G95.20)

›Epidural abscess (G06.1)

›Epidural hematoma (G95.19)

›Guillain Barre syndrome (G61.0)

›Ascending weakness

›Areflexia

›Autonomic instability

›Myasthenic crisis (G70.01)

›Bulbar weakness

›Respiratory fatigue

›Severe electrolyte disorder

›Hyperkalemic paralysis (E87.5)

›Hypokalemic paralysis (E87.6)

›Severe hypophosphatemia (E83.39)

›Hypoglycemia (E16.2)

›Diaphoresis or confusion

›Rapid improvement with glucose

Common

›Transient ischemic attack (G45.9)

›Focal deficit resolves within 24 hours

›High early stroke risk

›Radiculopathy

›Dermatomal sensory symptoms

›Radiating pain

›Peripheral nerve entrapment

›Median neuropathy

›Ulnar neuropathy

›Peroneal neuropathy

›Peripheral polyneuropathy

›Stocking glove sensory loss

›Reduced reflexes

›Migraine with aura (G43.109)

›Gradual spread of symptoms

›Headache association

›Functional neurologic disorder (F44.4)

›Inconsistent exam findings

›Non anatomic distribution

Less common

›Multiple sclerosis relapse (G35)

›Subacute deficit over days

›Prior episodes

›Transverse myelitis (G37.3)

›Sensory level

›Bladder involvement

›Spinal cord infarction (G95.11)

›Sudden deficit with back pain

›Vascular risk

›Vasculitic neuropathy

›Painful asymmetric neuropathy

›Systemic symptoms

›Periodic paralysis

›Episodic weakness

›Triggered by exertion or meals

›Conversion to toxic neuropathy

›Heavy metal exposure

›Industrial solvent exposure

09Past Medical History/pmh25

Relevant neurologic and vascular history

›Prior stroke or TIA

›Residual deficits

›Prior imaging findings

›Seizure disorder

›Typical semiology

›Last seizure date

›Migraine history

›Typical aura pattern

›Typical duration

Relevant spine and neuromuscular history

›Known spinal stenosis

›Prior MRI results

›Prior surgery

›Known neuropathy

›Etiology

›Baseline distribution

›Myasthenia gravis

›Baseline meds

›Prior crisis

Comorbidities affecting evaluation

›Bleeding and thrombosis history

›Prior GI bleed

›Prior DVT or PE

›Immunosuppression

›HIV

›Transplant

›Steroid use

10Physical Exam/exam54

General and vitals interpretation

›General appearance

›Toxic appearance

›Distress

›Airway secretion handling

›Vitals pattern

›Fever

›Severe hypertension

›Hypoxia

›Tachycardia

Focused neurologic exam

›Mental status and language

›Orientation

›Aphasia

›Neglect

›Cranial nerves

›Pupils and fields

›Facial symmetry

›Dysarthria

›Palate elevation

›Motor

›Drift

›Proximal strength

›Distal strength

›Symmetry

›Sensory

›Light touch

›Pinprick

›Vibration

›Sensory level

›Reflexes

›Areflexia

›Hyperreflexia

›Clonus

›Babinski

›Coordination and gait

›Finger nose

›Heel shin

›Truncal ataxia

›Gait assessment if safe

Spine and peripheral nerve exam

›Spine red flags

›Midline tenderness

›Percussion tenderness

›Step off

›Radicular and entrapment maneuvers

›Straight leg raise

›Spurling maneuver

›Tinel signs

›Autonomic and sphincter clues

›Bladder distension

›Perineal sensation

›Anal tone

Respiratory muscle screening

›Bedside respiratory assessment

›Single breath count

›Accessory muscle use

›Paradoxical breathing

11Lab Studies/labs30

Core labs for most ED presentations

›Baseline labs

›CBC

›Electrolytes

›Creatinine

›Glucose

›Coagulation if stroke or bleeding concern

›INR

›aPTT

›Platelets

Targeted metabolic and neuromuscular labs

›Electrolyte and endocrine evaluation

›Magnesium

›Phosphate

›Calcium

›TSH

›Myopathy evaluation

›CK

›AST and ALT

›Urinalysis for heme with few RBC

›Infection and inflammation evaluation when indicated

›CRP

›ESR

Interpretation and pitfalls

›Glucose pitfalls

›Focal deficits can mimic stroke in hypoglycemia

›Repeat glucose after treatment

›Potassium pitfalls

›Hemolysis false elevation

›Repeat potassium if discordant

›CK pitfalls

›Early rhabdomyolysis can have normal CK

›Repeat CK if high suspicion

12Imaging/img35

Scoring Systems

›Stroke and TIA risk tools

›NIHSS for acute stroke severity

›ABCD2 for short term stroke risk after TIA

›Limitations

›Do not delay imaging and reperfusion decisions

›Local protocol dependent pathways

MRI

›Brain MRI indications

›Posterior circulation symptoms with nondiagnostic CT

›Suspected demyelination

›Persistent deficit with unclear etiology

›Spine MRI indications

›Suspected cord compression

›Suspected epidural abscess

›Suspected transverse myelitis

›MRI cautions

›Implanted device compatibility

›Need for sedation or monitoring

›Noncontrast CT head

›Suspected acute stroke or hemorrhage

›Thunderclap headache with deficit

›CT angiography head and neck

›Suspected large vessel occlusion

›Suspected cervical artery dissection

›CT spine when MRI unavailable

›Trauma with neurologic deficit

›Bony compression concern

›CT cautions

›Contrast reaction history

›CKD risk for contrast nephropathy local protocol dependent

Ultrasound

›POCUS adjuncts

›Bladder volume for retention

›DVT evaluation if limb symptoms and thrombosis concern

›Ultrasound limitations

›Does not exclude stroke

›Does not exclude cord compression

13Special Tests/spec19

Bedside neurologic localization and mimics

›Stroke mimic screen

›Glucose point of care

›Seizure with postictal deficits

›Migraine aura pattern

›Functional exam signs

›Inconsistency on distraction

›Give way weakness

Neuromuscular respiratory testing

›Respiratory function testing

›FVC trending if available

›Negative inspiratory force if available

›Autonomic instability screening

›Orthostatic vitals

›Cardiac monitoring need

Lumbar puncture pathways when indicated

›CSF indications

›Suspected CNS infection

›Suspected inflammatory demyelination

›CSF cautions

›Suspected epidural abscess needs imaging first

›Coagulopathy increases risk

14ECG/ecg15

ECG indications and patterns relevant to weakness

›ECG indications

›Electrolyte disorder concern

›Syncope or palpitations

›Stroke evaluation baseline

›Hyperkalemia patterns

›Peaked T waves

›PR prolongation

›QRS widening

›Hypokalemia patterns

›U waves

›ST depression

›Ventricular ectopy

›Arrhythmias

›Atrial fibrillation

›Bradyarrhythmia

15Assessment/ax33

Localization based working problem

›Central nervous system pattern

›Cortical signs

›Cranial nerve involvement

›Visual field deficit

›Spinal cord pattern

›Sensory level

›Upper motor neuron signs below level

›Bladder dysfunction

›Peripheral nerve pattern

›Dermatomal symptoms

›Focal nerve distribution

›Reduced reflexes

›Neuromuscular junction or muscle pattern

›Fatigable weakness

›Proximal weakness

›CK elevation

Severity and risk stratification

›Stroke severity

›NIHSS score documentation

›Large vessel occlusion concern

›Respiratory failure risk

›Bulbar weakness presence

›Declining single breath count

›Cord compression risk

›Progressive deficit

›Sphincter symptoms

Key uncertainties and alternatives

›Mimics and confounders

›Hypoglycemia

›Seizure with Todd paralysis

›Drug intoxication

›Functional symptoms

›Coexisting diagnoses

›Infection with delirium and weakness

›Rhabdomyolysis with electrolyte derangement

16Plan/plan47

First 5 minutes and stabilization

›Immediate stabilization

›Airway if bulbar dysfunction

›Oxygen if hypoxemia

›Cardiac monitor

›Two IV lines if unstable or thrombolysis pathway

›Point of care tests

›Glucose immediate

›ECG immediate if electrolyte concern

›Time critical pathways

›Stroke alert for suspected acute stroke local protocol dependent

›Emergent MRI spine for suspected cord compression

›Broad spectrum antibiotics after cultures for suspected epidural abscess local protocol dependent

Diagnostic sequencing

›Imaging sequence for suspected stroke

›Noncontrast CT head immediate

›CTA head and neck if LVO concern

›Imaging sequence for suspected cord compression

›MRI spine with and without contrast if infection concern

›CT spine if MRI unavailable

›Lab sequence for metabolic causes

›Electrolytes and glucose

›Magnesium and phosphate

›CK if myopathy concern

Therapeutics

›Hypoglycemia treatment

›Dextrose IV per local protocol

›Recheck glucose within 15 minutes

›Hyperkalemia with weakness or ECG changes

›Calcium gluconate IV local protocol dependent

›Insulin with glucose IV local protocol dependent

›Nebulized beta agonist local protocol dependent

›Dialysis consult if refractory or ESRD

›Suspected metastatic cord compression

›Dexamethasone IV or PO local protocol dependent

›Neurosurgery and oncology consult

›Suspected epidural abscess

›Vancomycin plus broad gram negative coverage local protocol dependent

›Emergent neurosurgery consult

›Suspected Guillain Barre syndrome

›ICU evaluation if respiratory risk

›Neurology consult for IVIG or plasma exchange

Monitoring and reassessment loop

›Reassessment timing

›Neuro checks every 30 to 60 minutes if evolving deficit

›Vitals every 15 to 30 minutes if unstable

›Triggered escalation

›Worsening weakness

›New bulbar symptoms

›New urinary retention

›New hypoventilation

17Disposition/dispo23

Level of care criteria

›ICU or high acuity

›Respiratory muscle weakness

›Bulbar dysfunction

›Autonomic instability

›Rapidly progressive weakness

›Large vessel occlusion concern

›Inpatient admission

›New stroke or TIA requiring workup

›Suspected cord compression

›Suspected CNS infection

›Significant electrolyte abnormality

›Observation pathway

›Resolved TIA with rapid access pathway local protocol dependent

›Mild stable deficits with completed imaging and plan

Discharge criteria and follow up

›Discharge criteria

›Benign peripheral entrapment pattern

›Normal neuro exam or baseline confirmed

›No red flags

›Reliable follow up

›Follow up timing

›TIA or minor stroke follow up within 24 to 72 hours local protocol dependent

›Neurology follow up for suspected demyelination

›Primary care follow up for neuropathy workup

18Discharge Instructions/di22

Copy discharge instructions

›Summary

›You were seen for weakness or numbness

›Your testing today did not show an emergency cause

›Medications

›Take your usual medications as prescribed

›Avoid alcohol or sedating drugs until symptoms resolve

›Activity

›Do not drive if you still feel weak or numb

›Avoid heavy lifting until follow up

›Follow up

›Follow up with your doctor within 2 to 3 days

›Return sooner if symptoms worsen

›Return to ED now for

›New trouble speaking

›New facial droop

›New vision loss

›New severe headache

›New trouble breathing

›New inability to walk

›New urinary retention

›New loss of bowel control

›Fever with back pain

19References/r9

Guidelines and key sources

›Stroke guidelines

›AHA and ASA guideline for early management of acute ischemic stroke 2019 update

›AHA and ASA guideline for prevention of stroke in patients with stroke and TIA 2021

›Spinal emergencies

›IDSA guideline for diagnosis and treatment of native vertebral osteomyelitis 2015

›Review guidance for spinal epidural abscess evaluation and management local protocol dependent

›Neuromuscular emergencies

›AAN guideline and evidence report for Guillain Barre syndrome management most recent local protocol dependent

›International consensus guidance for management of myasthenia gravis 2020

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Acute Weakness Or NumbnessAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

634 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx90

Presenting syndrome framing

›Pattern and timing

›Sudden onset deficit

›Progressive over hours to days

›Fluctuating or episodic

›Recurrent stereotyped episodes

›Distribution

›Unilateral face, arm, leg

›Bilateral legs

›Distal stocking glove

›Single nerve or dermatomal

›Baseline and change

›Baseline neurologic deficits

›Baseline mobility and ADLs

›Time last known well

OPQRST

›Onset

›Exact time last known well

›Wake up with symptoms

›During exertion

›During Valsalva

›Provocation/Palliation

›Worse with neck movement

›Worse with back movement

›Worse with exertion

›Worse with heat or fever

›Better with rest

›Better with positional change

›Quality

›Weakness

›Numbness

›Tingling

›Burning pain

›Heaviness

›Region/Radiation

›Face involvement

›Arm involvement

›Leg involvement

›Trunk sensory level

›Perineal saddle region

›Severity

›Inability to walk

›Inability to use hand

›Dropping objects

›Falls

›Timing

›Minutes to hours

›Hours to days

›Days to weeks

›Intermittent with full resolution

Associated symptoms

›Central nervous system red flags

›Speech disturbance

›Visual loss

›Diplopia

›Dysphagia

›Vertigo with focal deficits

›New severe headache

›Seizure

›Altered mental status

›Spinal cord red flags

›Back pain

›Neck pain

›Sensory level

›Urinary retention

›Fecal incontinence

›Saddle anesthesia

›Peripheral and systemic clues

›Myalgias

›Muscle cramps

›Dyspnea

›Palpitations

›Fever

›Rash

›Weight loss

Precipitating context

›Vascular context

›Recent transient episodes

›Atrial fibrillation symptoms

›Recent surgery or immobilization

›Toxic metabolic context

›Recent vomiting or diarrhea

›Poor intake

›New insulin or hypoglycemia risk

›Alcohol binge

›Infectious and inflammatory context

›Recent URI or gastroenteritis

›Tick exposure

›Recent vaccination

›Trauma and procedure context

›Minor trauma

›Recent lumbar puncture

›Neuraxial anesthesia

›Recent spinal manipulation

02Alarm Features/alarm43

Immediate time critical triggers

›Activate resuscitation and urgent neuro pathway

›Suspected acute stroke

›Suspected spinal cord compression

›Suspected epidural hematoma or abscess

›Rapidly ascending weakness

›Respiratory muscle involvement

›Hyperkalemia pattern with weakness

›Airway and breathing threats

›Inability to count to 20 in one breath

›Weak cough

›Pooling secretions

›Bulbar dysfunction

›Circulation threats

›SBP < 90

›Persistent tachycardia

›New arrhythmia

High risk historical features

›Stroke high risk

›Last known well within thrombolysis window local protocol dependent

›Anticoagulant use

›Severe headache with deficit

›Spinal cord high risk

›Cancer history

›Immunocompromised state

›IV drug use

›Fever with back pain

›Neuromuscular respiratory high risk

›Rapid progression over hours

›Recent GI illness with ascending weakness

›Fluctuating fatigable weakness

High risk exam and vital signs

›Exam danger findings

›New focal deficit

›New aphasia

›New gaze deviation

›New facial droop

›New sensory level

›New areflexia with weakness

›New hyperreflexia with clonus

›Vital sign danger thresholds

›Glucose < 3.0 mmol/L

›Glucose > 25 mmol/L with dehydration

›Temperature >= 38.0 C with neurologic deficit

›SBP >= 220

›DBP >= 120

03Medications/meds37

Medication exposures relevant to weakness or numbness

›Anticoagulants and antiplatelets

›Warfarin

›DOACs

›Heparin

›Aspirin

›P2Y12 inhibitors

›Neuroactive medications

›Sedatives

›Antipsychotics

›Antiepileptics

›Opioids

›Metabolic and electrolyte affecting medications

›Diuretics

›Insulin

›Sulfonylureas

›Beta agonists

›ACE inhibitors

›ARBs

›Myopathy and neuropathy associated medications

›Statins

›Colchicine

›Fluoroquinolones

›Amiodarone

›Chemotherapy agents

›Recent medication change

›Dose increase

›New start

›Missed doses

Contraindications and interactions to anticipate

›Thrombolysis and bleeding risk

›DOAC timing unknown

›Recent major surgery

›Contrast imaging risk

›Prior contrast reaction

›Severe CKD

›Steroid risks for suspected cord compression

›Active uncontrolled infection

›GI bleed history

04Diet/diet16

Intake and metabolic triggers

›Reduced intake and dehydration

›Poor oral intake

›Prolonged fasting

›Weight loss

›High carbohydrate load and glycemic swings

›Sugary beverages

›Skipped meals with diabetes meds

›Alcohol exposure

›Recent binge

›Withdrawal risk

›Caffeine and energy drinks

›High dose stimulant exposure

›Sleep deprivation association

›Electrolyte risk context

›Excess free water intake

›Low solute diet

05Review of Systems/ros28

Neurologic

›Neurologic symptom screen

›Headache

›Vision change

›Speech change

›Dysphagia

›Dizziness

›Ataxia

›Seizure

Cardiopulmonary

›Cardiopulmonary symptom screen

›Chest pain

›Dyspnea

›Palpitations

›Syncope

Infectious and inflammatory

›Infection and inflammation screen

›Fever

›Chills

›Neck stiffness

›Rash

Musculoskeletal and systemic

›Systemic symptom screen

›Myalgias

›Arthralgias

›Proximal muscle weakness

›Dark urine

Genitourinary and bowel

›Bladder and bowel screen

›Urinary retention

›Urinary incontinence

›Fecal incontinence

›Constipation

06Collateral History and Family History/chafh15

Collateral and baseline function

›Collateral source and reliability

›Witnessed onset

›Family report

›EMS report

›Baseline function

›Independent ambulation baseline

›Baseline speech and cognition

Family history

›Vascular and neurologic family history

›Early stroke or MI

›Aneurysm history

›Migraine with aura

›Neuromuscular and inherited conditions

›Neuropathy

›Myopathy

›Multiple sclerosis family history

07Risk Factors/rf29

Cerebrovascular risk

›Atherosclerotic risk factors

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Hyperlipidemia (E78.5)

›Tobacco use

›Cardioembolic risk factors

›Atrial fibrillation (I48.91)

›Recent MI

›Valvular disease

›Hypercoagulable risk factors

›Active malignancy

›Pregnancy and postpartum

›Estrogen therapy

Spinal cord compression and infection risk

›Epidural abscess risk

›IV drug use

›Indwelling catheter

›Diabetes mellitus

›Epidural hematoma risk

›Anticoagulation

›Recent neuraxial procedure

›Coagulopathy

Peripheral neuropathy and metabolic risk

›Neuropathy risk factors

›Diabetes mellitus

›Alcohol use disorder (F10.20)

›B12 deficiency risk

›Electrolyte and endocrine risk factors

›CKD

›Adrenal insufficiency risk

›Thyroid disease

08Differential Diagnosis/ddx64

Life threatening

›Acute ischemic stroke (I63.9)

›Sudden focal deficit

›Cortical signs

›Intracerebral hemorrhage (I61.9)

›Severe headache with deficit

›Marked hypertension

›Subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Meningismus

›Spinal cord compression

›Metastatic cord compression (G95.20)

›Epidural abscess (G06.1)

›Epidural hematoma (G95.19)

›Guillain Barre syndrome (G61.0)

›Ascending weakness

›Areflexia

›Autonomic instability

›Myasthenic crisis (G70.01)

›Bulbar weakness

›Respiratory fatigue

›Severe electrolyte disorder

›Hyperkalemic paralysis (E87.5)

›Hypokalemic paralysis (E87.6)

›Severe hypophosphatemia (E83.39)

›Hypoglycemia (E16.2)

›Diaphoresis or confusion

›Rapid improvement with glucose

Common

›Transient ischemic attack (G45.9)

›Focal deficit resolves within 24 hours

›High early stroke risk

›Radiculopathy

›Dermatomal sensory symptoms

›Radiating pain

›Peripheral nerve entrapment

›Median neuropathy

›Ulnar neuropathy

›Peroneal neuropathy

›Peripheral polyneuropathy

›Stocking glove sensory loss

›Reduced reflexes

›Migraine with aura (G43.109)

›Gradual spread of symptoms

›Headache association

›Functional neurologic disorder (F44.4)

›Inconsistent exam findings

›Non anatomic distribution

Less common

›Multiple sclerosis relapse (G35)

›Subacute deficit over days

›Prior episodes

›Transverse myelitis (G37.3)

›Sensory level

›Bladder involvement

›Spinal cord infarction (G95.11)

›Sudden deficit with back pain

›Vascular risk

›Vasculitic neuropathy

›Painful asymmetric neuropathy

›Systemic symptoms

›Periodic paralysis

›Episodic weakness

›Triggered by exertion or meals

›Conversion to toxic neuropathy

›Heavy metal exposure

›Industrial solvent exposure

09Past Medical History/pmh25

Relevant neurologic and vascular history

›Prior stroke or TIA

›Residual deficits

›Prior imaging findings

›Seizure disorder

›Typical semiology

›Last seizure date

›Migraine history

›Typical aura pattern

›Typical duration

Relevant spine and neuromuscular history

›Known spinal stenosis

›Prior MRI results

›Prior surgery

›Known neuropathy

›Etiology

›Baseline distribution

›Myasthenia gravis

›Baseline meds

›Prior crisis

Comorbidities affecting evaluation

›Bleeding and thrombosis history

›Prior GI bleed

›Prior DVT or PE

›Immunosuppression

›HIV

›Transplant

›Steroid use

10Physical Exam/exam54

General and vitals interpretation

›General appearance

›Toxic appearance

›Distress

›Airway secretion handling

›Vitals pattern

›Fever

›Severe hypertension

›Hypoxia

›Tachycardia

Focused neurologic exam

›Mental status and language

›Orientation

›Aphasia

›Neglect

›Cranial nerves

›Pupils and fields

›Facial symmetry

›Dysarthria

›Palate elevation

›Motor

›Drift

›Proximal strength

›Distal strength

›Symmetry

›Sensory

›Light touch

›Pinprick

›Vibration

›Sensory level

›Reflexes

›Areflexia

›Hyperreflexia

›Clonus

›Babinski

›Coordination and gait

›Finger nose

›Heel shin

›Truncal ataxia

›Gait assessment if safe

Spine and peripheral nerve exam

›Spine red flags

›Midline tenderness

›Percussion tenderness

›Step off

›Radicular and entrapment maneuvers

›Straight leg raise

›Spurling maneuver

›Tinel signs

›Autonomic and sphincter clues

›Bladder distension

›Perineal sensation

›Anal tone

Respiratory muscle screening

›Bedside respiratory assessment

›Single breath count

›Accessory muscle use

›Paradoxical breathing

11Lab Studies/labs30

Core labs for most ED presentations

›Baseline labs

›CBC

›Electrolytes

›Creatinine

›Glucose

›Coagulation if stroke or bleeding concern

›INR

›aPTT

›Platelets

Targeted metabolic and neuromuscular labs

›Electrolyte and endocrine evaluation

›Magnesium

›Phosphate

›Calcium

›TSH

›Myopathy evaluation

›CK

›AST and ALT

›Urinalysis for heme with few RBC

›Infection and inflammation evaluation when indicated

›CRP

›ESR

Interpretation and pitfalls

›Glucose pitfalls

›Focal deficits can mimic stroke in hypoglycemia

›Repeat glucose after treatment

›Potassium pitfalls

›Hemolysis false elevation

›Repeat potassium if discordant

›CK pitfalls

›Early rhabdomyolysis can have normal CK

›Repeat CK if high suspicion

12Imaging/img35

Scoring Systems

›Stroke and TIA risk tools

›NIHSS for acute stroke severity

›ABCD2 for short term stroke risk after TIA

›Limitations

›Do not delay imaging and reperfusion decisions

›Local protocol dependent pathways

MRI

›Brain MRI indications

›Posterior circulation symptoms with nondiagnostic CT

›Suspected demyelination

›Persistent deficit with unclear etiology

›Spine MRI indications

›Suspected cord compression

›Suspected epidural abscess

›Suspected transverse myelitis

›MRI cautions

›Implanted device compatibility

›Need for sedation or monitoring

›Noncontrast CT head

›Suspected acute stroke or hemorrhage

›Thunderclap headache with deficit

›CT angiography head and neck

›Suspected large vessel occlusion

›Suspected cervical artery dissection

›CT spine when MRI unavailable

›Trauma with neurologic deficit

›Bony compression concern

›CT cautions

›Contrast reaction history

›CKD risk for contrast nephropathy local protocol dependent

Ultrasound

›POCUS adjuncts

›Bladder volume for retention

›DVT evaluation if limb symptoms and thrombosis concern

›Ultrasound limitations

›Does not exclude stroke

›Does not exclude cord compression

13Special Tests/spec19

Bedside neurologic localization and mimics

›Stroke mimic screen

›Glucose point of care

›Seizure with postictal deficits

›Migraine aura pattern

›Functional exam signs

›Inconsistency on distraction

›Give way weakness

Neuromuscular respiratory testing

›Respiratory function testing

›FVC trending if available

›Negative inspiratory force if available

›Autonomic instability screening

›Orthostatic vitals

›Cardiac monitoring need

Lumbar puncture pathways when indicated

›CSF indications

›Suspected CNS infection

›Suspected inflammatory demyelination

›CSF cautions

›Suspected epidural abscess needs imaging first

›Coagulopathy increases risk

14ECG/ecg15

ECG indications and patterns relevant to weakness

›ECG indications

›Electrolyte disorder concern

›Syncope or palpitations

›Stroke evaluation baseline

›Hyperkalemia patterns

›Peaked T waves

›PR prolongation

›QRS widening

›Hypokalemia patterns

›U waves

›ST depression

›Ventricular ectopy

›Arrhythmias

›Atrial fibrillation

›Bradyarrhythmia

15Assessment/ax33

Localization based working problem

›Central nervous system pattern

›Cortical signs

›Cranial nerve involvement

›Visual field deficit

›Spinal cord pattern

›Sensory level

›Upper motor neuron signs below level

›Bladder dysfunction

›Peripheral nerve pattern

›Dermatomal symptoms

›Focal nerve distribution

›Reduced reflexes

›Neuromuscular junction or muscle pattern

›Fatigable weakness

›Proximal weakness

›CK elevation

Severity and risk stratification

›Stroke severity

›NIHSS score documentation

›Large vessel occlusion concern

›Respiratory failure risk

›Bulbar weakness presence

›Declining single breath count

›Cord compression risk

›Progressive deficit

›Sphincter symptoms

Key uncertainties and alternatives

›Mimics and confounders

›Hypoglycemia

›Seizure with Todd paralysis

›Drug intoxication

›Functional symptoms

›Coexisting diagnoses

›Infection with delirium and weakness

›Rhabdomyolysis with electrolyte derangement

16Plan/plan47

First 5 minutes and stabilization

›Immediate stabilization

›Airway if bulbar dysfunction

›Oxygen if hypoxemia

›Cardiac monitor

›Two IV lines if unstable or thrombolysis pathway

›Point of care tests

›Glucose immediate

›ECG immediate if electrolyte concern

›Time critical pathways

›Stroke alert for suspected acute stroke local protocol dependent

›Emergent MRI spine for suspected cord compression

›Broad spectrum antibiotics after cultures for suspected epidural abscess local protocol dependent

Diagnostic sequencing

›Imaging sequence for suspected stroke

›Noncontrast CT head immediate

›CTA head and neck if LVO concern

›Imaging sequence for suspected cord compression

›MRI spine with and without contrast if infection concern

›CT spine if MRI unavailable

›Lab sequence for metabolic causes

›Electrolytes and glucose

›Magnesium and phosphate

›CK if myopathy concern

Therapeutics

›Hypoglycemia treatment

›Dextrose IV per local protocol

›Recheck glucose within 15 minutes

›Hyperkalemia with weakness or ECG changes

›Calcium gluconate IV local protocol dependent

›Insulin with glucose IV local protocol dependent

›Nebulized beta agonist local protocol dependent

›Dialysis consult if refractory or ESRD

›Suspected metastatic cord compression

›Dexamethasone IV or PO local protocol dependent

›Neurosurgery and oncology consult

›Suspected epidural abscess

›Vancomycin plus broad gram negative coverage local protocol dependent

›Emergent neurosurgery consult

›Suspected Guillain Barre syndrome

›ICU evaluation if respiratory risk

›Neurology consult for IVIG or plasma exchange

Monitoring and reassessment loop

›Reassessment timing

›Neuro checks every 30 to 60 minutes if evolving deficit

›Vitals every 15 to 30 minutes if unstable

›Triggered escalation

›Worsening weakness

›New bulbar symptoms

›New urinary retention

›New hypoventilation

17Disposition/dispo23

Level of care criteria

›ICU or high acuity

›Respiratory muscle weakness

›Bulbar dysfunction

›Autonomic instability

›Rapidly progressive weakness

›Large vessel occlusion concern

›Inpatient admission

›New stroke or TIA requiring workup

›Suspected cord compression

›Suspected CNS infection

›Significant electrolyte abnormality

›Observation pathway

›Resolved TIA with rapid access pathway local protocol dependent

›Mild stable deficits with completed imaging and plan

Discharge criteria and follow up

›Discharge criteria

›Benign peripheral entrapment pattern

›Normal neuro exam or baseline confirmed

›No red flags

›Reliable follow up

›Follow up timing

›TIA or minor stroke follow up within 24 to 72 hours local protocol dependent

›Neurology follow up for suspected demyelination

›Primary care follow up for neuropathy workup

18Discharge Instructions/di22

Copy discharge instructions

›Summary

›You were seen for weakness or numbness

›Your testing today did not show an emergency cause

›Medications

›Take your usual medications as prescribed

›Avoid alcohol or sedating drugs until symptoms resolve

›Activity

›Do not drive if you still feel weak or numb

›Avoid heavy lifting until follow up

›Follow up

›Follow up with your doctor within 2 to 3 days

›Return sooner if symptoms worsen

›Return to ED now for

›New trouble speaking

›New facial droop

›New vision loss

›New severe headache

›New trouble breathing

›New inability to walk

›New urinary retention

›New loss of bowel control

›Fever with back pain

19References/r9

Guidelines and key sources

›Stroke guidelines

›AHA and ASA guideline for early management of acute ischemic stroke 2019 update

›AHA and ASA guideline for prevention of stroke in patients with stroke and TIA 2021

›Spinal emergencies

›IDSA guideline for diagnosis and treatment of native vertebral osteomyelitis 2015

›Review guidance for spinal epidural abscess evaluation and management local protocol dependent

›Neuromuscular emergencies

›AAN guideline and evidence report for Guillain Barre syndrome management most recent local protocol dependent

›International consensus guidance for management of myasthenia gravis 2020

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.