Browse categories and answer follow-up questions to refine your symptom profile.
History
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
Alarm Features
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
Medications
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
Diet
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
Review of Systems
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
Collateral History and Family History
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
Risk Factors
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
Differential Diagnosis
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
Past Medical History
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
Physical Exam
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
Lab Studies
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
Imaging
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
CT
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
Special Tests
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
ECG
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
Assessment
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
Plan
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.