Gait Instability and AtaxiaAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

584 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/hx69

Presenting pattern

›Symptom characterization

›Gait instability description

›Ataxia description

›Falls

›Near falls

›Assistive device requirement

OPQRST

›OPQRST framework

›Onset

›Sudden

›Subacute

›Progressive

›Provocation and palliation

›Worse with eyes closed

›Worse in the dark

›Worse with head movement

›Worse with standing

›Improves with support

›Improves sitting or lying

›Quality

›Unsteadiness

›Swaying

›Veering

›Leg clumsiness

›Truncal instability

›Region and radiation

›Truncal predominant

›Lower limb predominant

›Upper limb incoordination

›Severity

›Unable to ambulate

›Requires assistance to ambulate

›Falls frequency

›Timing

›Constant

›Episodic

›Fluctuating

›Stepwise

Associated neurologic symptoms

›Associated symptoms

›Vertigo

›Diplopia

›Dysarthria

›Dysphagia

›New headache

›Nausea

›Vomiting

›Limb weakness

›Limb numbness

›Vision loss

›New tremor

›Myoclonus

›Seizure

Context and triggers

›Precipitating context

›Recent infection

›Recent vaccination

›Recent head trauma

›Recent neck manipulation

›New rash

›Fever

›Heat exposure

Baseline and functional impact

›Baseline status

›Prior gait baseline

›Prior neurologic deficits

›Baseline mobility aids

›Baseline cognition

Prior episodes

›Prior episodes

›Similar episodes

›Prior stroke or TIA history

›Prior vertigo syndromes

›Prior intoxication episodes

02Alarm Features/alarm33

Immediate life threats

›Time critical diagnoses

›Posterior circulation ischemic stroke

›Cerebellar hemorrhage

›Subdural hematoma after fall

›Spinal cord compression

›Wernicke encephalopathy

›Toxic ingestion

High risk symptoms

›High risk symptoms

›Sudden onset inability to walk

›New severe headache

›Persistent vomiting

›Chest pain

›Syncope

›Acute confusion

›Seizure

High risk exam findings

›High risk findings

›New cranial nerve palsy

›Direction changing nystagmus

›Skew deviation

›New limb weakness

›New sensory level

›Hyperreflexia with clonus

›Fever with neck stiffness

Vital sign danger thresholds

›Vital sign danger

›Hypotension

›Hypoxia

›Fever 38.0 C or higher

›Severe hypertension with neurologic deficit

Escalation triggers

›Escalation logic

›If glucose low, immediate dextrose per protocol

›If unable to protect airway, airway management pathway

›If suspected stroke with disabling deficit, activate stroke pathway

›If suspected CNS infection, antibiotics after cultures when feasible

03Medications/meds30

Medication reconciliation

›Medication list

›Anticoagulants

›Antiplatelets

›Antihypertensives

›Antiepileptics

›Psychotropics

›Parkinson therapies

›Insulin and glucose agents

High risk medication effects

›Medication adverse effects

›Sedatives and hypnotics

›Opioids

›Anticholinergics

›Antipsychotics

›Antidepressants

›Anticonvulsants

›Lithium

Recent changes and adherence

›Recent changes

›Dose increase

›New start within 30 days

›Withdrawal within 14 days

›Missed doses

Toxin exposures

›Substances

›Alcohol

›Cannabis

›Stimulants

›Sedative misuse

Therapy interaction traps

›Interaction considerations

›Anticoagulation and head trauma risk

›QT prolonging combinations

›Serotonergic combinations

04Diet/diet16

Intake and nutrition

›Intake pattern

›Poor oral intake

›Prolonged vomiting

›Weight loss

›Malnutrition risk

Alcohol and thiamine risk

›Alcohol related nutrition risk

›Daily heavy alcohol use

›Recent binge

›Prolonged fasting

Hydration and electrolytes

›Hydration pattern

›Dehydration symptoms

›Excess free water intake

›Diuretic associated fluid shifts

Dietary triggers

›Trigger exposures

›Energy drinks

›Excess caffeine

05Review of Systems/ros27

Neurologic

›Neurologic ROS

›Headache

›Vertigo

›Visual symptoms

›Dysarthria

›Dysphagia

›Weakness

›Numbness

›Tremor

›Seizure

›Confusion

Infectious and inflammatory

›Constitutional ROS

›Fever

›Chills

›Night sweats

›Rash

›Neck pain

Cardiopulmonary

›Cardiopulmonary ROS

›Chest pain

›Palpitations

›Dyspnea

›Syncope

Endocrine and metabolic

›Metabolic ROS

›Polyuria

›Polydipsia

›Heat intolerance

›Cold intolerance

06Collateral History and Family History/chafh12

Collateral source

›Collateral reliability

›Witnessed gait change

›Witnessed fall or head strike

›Time last known well

Family history

›Inherited risk

›Hereditary ataxias

›Early stroke or thrombosis

›Migraine with brainstem aura history

Social support

›Home safety

›Lives alone

›Supervision available

›Fall hazards at home

07Risk Factors/rf24

Cerebrovascular risk

›Vascular risk

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Dyslipidemia (E78.5)

›Tobacco use

›Atrial fibrillation (I48.91)

›Prior stroke (I63.9)

Bleeding and trauma risk

›Hemorrhage risk

›Anticoagulant use

›Thrombocytopenia history

›Recent fall

Infection risk

›Infection risk

›Immunocompromised state

›Recent sinus or ear infection

›Endocarditis risk factors

Nutritional risk

›Deficiency risk

›Alcohol use disorder (F10.20)

›Bariatric surgery history

›Malabsorption history

Special populations

›Population modifiers

›Pregnancy

›Pediatrics

›Older adult frailty

›Chronic dialysis

08Differential Diagnosis/ddx77

Life threatening

›Life threatening causes

›Posterior circulation ischemic stroke (I63.9)

›Sudden onset

›Brainstem symptoms

›Cerebellar hemorrhage (I61.4)

›Severe headache

›Vomiting

›Subdural hematoma (S06.5)

›Fall or head strike

›Anticoagulant use

›CNS infection

›Meningitis (G00.9)

›Encephalitis (G04.90)

›Cerebellitis

›Spinal cord compression

›Epidural abscess (G06.1)

›Cauda equina syndrome (G83.4)

›Wernicke encephalopathy (E51.2)

›Malnutrition risk

›Oculomotor findings

›Severe hypoglycemia (E16.2)

›Diaphoresis

›Altered mental status

›Toxic alcohol or sedative intoxication

›Depressed level of consciousness

›Respiratory depression

Common

›Common causes

›Benign paroxysmal positional vertigo (H81.1)

›Brief positional episodes

›Triggered by head movement

›Vestibular neuritis (H81.2)

›Acute prolonged vertigo

›Unidirectional nystagmus

›Medication adverse effect

›Sedatives

›Anticonvulsants

›Alcohol intoxication (F10.129)

›Slurred speech

›Wide based gait

›Peripheral neuropathy (G62.9)

›Stocking sensory loss

›Worse in the dark

›Orthostatic hypotension (I95.1)

›Lightheadedness on standing

›Medication triggers

›Normal pressure hydrocephalus (G91.2)

›Gait apraxia pattern

›Cognitive symptoms

Less common

›Less common causes

›Multiple sclerosis (G35)

›Prior neurologic episodes

›Young adult onset

›Cerebellar tumor or mass effect (C71.6)

›Progressive symptoms

›Morning headache

›Paraneoplastic cerebellar degeneration

›Subacute progression

›Cancer history

›Thyroid disease

›Hypothyroidism (E03.9)

›Hyperthyroidism (E05.90)

›Vitamin B12 deficiency (E53.8)

›Posterior column signs

›Macrocytosis

›Miller Fisher syndrome variant (G61.0)

›Ophthalmoplegia

›Areflexia

Mimics and pitfalls

›Mimics

›Functional gait disorder

›Inconsistency

›Distractibility

›Severe anxiety with hyperventilation

›Perioral tingling

›Carpopedal spasm

›Musculoskeletal pain gait limitation

›Focal joint pain

›Normal coordination seated

09Past Medical History/pmh23

Neurologic history

›Neurologic conditions

›Prior stroke or TIA

›Seizure disorder (G40.909)

›Migraine (G43.909)

›Multiple sclerosis (G35)

›Parkinson disease (G20)

Cardiometabolic

›Vascular comorbidities

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Coronary artery disease (I25.10)

›Atrial fibrillation (I48.91)

Substance and nutrition

›Substance and nutrition history

›Alcohol use disorder (F10.20)

›Eating disorder history

›Bariatric surgery

Prior procedures and devices

›Procedures and devices

›Ventriculoperitoneal shunt

›Pacemaker or ICD

›Recent lumbar puncture

Baseline function

›Baseline function

›Independent ambulation

›Walker or cane baseline

›Prior falls frequency

10Physical Exam/exam46

General and vitals

›General status

›Mental status level

›Speech clarity

›Intoxication signs

›Trauma signs

›Vitals interpretation

›Fever

›Orthostatic change

›Hypoxia

Neurologic screening

›Key neuro exam

›NIHSS elements when stroke concern

›Cranial nerves

›Motor strength

›Sensory exam

›Reflexes

›Plantar response

Cerebellar exam

›Coordination

›Finger to nose

›Heel to shin

›Rapid alternating movements

›Dysmetria

›Intention tremor

Gait and balance

›Gait assessment

›Stance width

›Veering direction

›Tandem gait

›Romberg

›Turns and freezing

Oculomotor and vestibular

›Eye findings

›Nystagmus pattern

›Skew deviation

›Head impulse response

›Test of gaze holding

Cardiovascular

›Cardiovascular

›Murmur

›Irregularly irregular rhythm

›Signs of endocarditis

Spine and peripheral nerves

›Spine and neuroaxis

›Neck stiffness

›Back pain

›Sensory level

›Saddle anesthesia

›Peripheral neuropathy signs

›Vibration sense loss

›Proprioception loss

›Distal weakness

11Lab Studies/labs25

Core labs

›Initial labs

›Glucose point of care

›CBC

›Electrolytes

›Creatinine

›Liver enzymes

›Magnesium

›Phosphate

Stroke and hemorrhage adjuncts

›Coagulation and stroke adjuncts

›INR

›aPTT

›Troponin

›Lipids local protocol dependent

Toxic and metabolic

›Toxic metabolic evaluation

›Ethanol level

›Acetaminophen level when indicated

›Salicylate level when indicated

›VBG when respiratory depression concern

Nutritional and endocrine

›Deficiency endocrine evaluation

›Vitamin B12

›TSH

›Thiamine deficiency risk marker support

Infection evaluation

›Infection evaluation

›Blood cultures when febrile or endocarditis concern

›CRP or ESR when inflammatory concern

12Imaging/img47

Scoring Systems

›Clinical decision tools

›HINTS exam for acute vestibular syndrome

›Use when continuous vertigo with spontaneous nystagmus and gait unsteadiness

›Do not use when symptoms episodic or examiner not trained

›Central pattern triggers neuroimaging

›NIHSS for suspected stroke

›Baseline severity communication

›Does not exclude posterior circulation stroke

MRI

›MRI brain and neuroaxis

›Indications

›Suspected posterior fossa stroke with negative CT

›Demyelinating disease concern

›Cerebellar mass concern

›Protocol considerations

›DWI for acute ischemia

›Contrast for tumor or inflammation when indicated

›Limitations

›Early DWI false negative possible in posterior circulation

›Motion artifact in vomiting or agitation

›CT strategies

›Noncontrast CT head

›Indications

›Head trauma

›Anticoagulated patient with fall

›Thunderclap headache

›Strengths

›Hemorrhage detection

›Mass effect screening

›Limitations

›Low sensitivity for acute posterior fossa ischemia

›CTA head and neck

›Indications

›Suspected large vessel occlusion

›Suspected vertebral artery dissection

›Contrast cautions

›CKD risk stratification local protocol dependent

›Prior contrast reaction history

Ultrasound

›Ultrasound applications

›Cardiac POCUS

›Gross ventricular function

›Pericardial effusion

›Carotid duplex

›Anterior circulation symptoms correlation

›Limited value in isolated posterior circulation syndrome

›Ocular ultrasound when indicated

›Elevated optic nerve sheath diameter adjunct

›Not diagnostic alone

13Special Tests/spec24

Bedside vestibular testing

›Bedside tests

›HINTS components

›Head impulse

›Nystagmus direction

›Test of skew

›Dix Hallpike

›Use when episodic positional vertigo pattern

›Contraindications

›Suspected cervical instability

›Severe carotid stenosis history local protocol dependent

Lumbar puncture

›CSF evaluation

›Indications

›Suspected meningitis or encephalitis

›Suspected subarachnoid hemorrhage with negative CT and persistent concern

›Safety checks

›Coagulopathy correction

›Mass effect exclusion when indicated

Toxicology adjuncts

›Toxicology adjuncts

›Urine drug screen limited utility

›Serum osmolality and anion gap for toxic alcohol concern

Gait and functional testing

›Functional measures

›Timed up and go

›Sit to stand

›Physical therapy assessment when disposition uncertain

14ECG/ecg13

Indications and patterns

›ECG indications

›Syncope

›Palpitations

›Chest pain

›Stroke evaluation baseline

›High risk ECG findings

›Atrial fibrillation

›High grade AV block

›Ventricular tachyarrhythmia

›Acute ischemia pattern

Monitoring logic

›Rhythm monitoring

›Continuous monitoring when syncope or suspected arrhythmia

›Serial ECG when ongoing chest pain or ischemia concern

15Assessment/ax20

Problem representation

›Syndrome classification

›Acute vestibular syndrome

›Episodic positional vertigo syndrome

›Cerebellar ataxia syndrome

›Sensory ataxia syndrome

›Frontal gait disorder pattern

Severity and risk stratification

›Severity stratification

›Unable to ambulate

›New focal neurologic deficit

›Persistent vomiting with dehydration

›Recurrent falls

Complications to exclude

›Must exclude

›Intracranial hemorrhage after fall

›Posterior circulation stroke

›CNS infection

›Wernicke encephalopathy

Diagnostic uncertainty

›Alternate diagnoses

›Medication toxicity

›Metabolic derangement

›Functional disorder

16Plan/plan36

First 5 minutes

›Immediate stabilization

›Airway protection assessment

›Oxygen if hypoxic

›Cardiac monitor if syncope or arrhythmia concern

›IV access criteria

›Unable to tolerate oral intake

›Persistent vomiting

›Point of care glucose within minutes

Time critical pathways

›Activation pathways

›If disabling deficit and within reperfusion window, stroke activation per local protocol

›If suspected CNS infection, antibiotics within 60 minutes after cultures when feasible

Targeted therapy

›Directed treatments

›Suspected Wernicke risk

›Thiamine IV 500 mg every 8 hours initial dosing example

›Give thiamine before glucose when feasible

›Nausea and vomiting control

›Ondansetron ODT 4 mg once

›Ondansetron IV 4 mg once

›Suspected vestibular neuritis

›Short course steroids local protocol dependent

›Vestibular suppressants only short term

›Suspected BPPV

›Epley maneuver if Dix Hallpike consistent and no contraindications

Diagnostic sequencing

›Sequencing logic

›If fall with head strike or anticoagulated, CT head first

›If acute vestibular syndrome with central signs, MRI DWI preferred and CTA when vascular concern

›If fever and meningismus, imaging before LP when mass effect risk

Reassessment loop

›Reassessment

›Neuro exam repeat every 30 to 60 minutes when evolving symptoms

›Ambulation trial after symptom control

›Orthostatic vitals repeat after fluids when indicated

Consultation

›Consult triggers

›Neurology for suspected central cause

›Neurosurgery for hemorrhage or mass effect

›Internal medicine for metabolic or toxic causes requiring admission

›Physical therapy for gait safety planning

17Disposition/dispo27

ICU criteria

›ICU indications

›Declining mental status

›Airway risk

›Hemodynamic instability

›Large cerebellar stroke with edema risk

›Intracranial hemorrhage with mass effect

Inpatient admission criteria

›Admission indications

›Suspected stroke or TIA

›Suspected CNS infection

›Persistent inability to ambulate safely

›Recurrent falls with injury risk

›Severe metabolic derangement

›Concern for Wernicke encephalopathy requiring IV therapy

Observation pathway criteria

›Observation candidates

›Stable vitals

›No focal deficit after evaluation

›Symptom improvement with treatment

›Pending MRI or PT assessment

Discharge criteria

›Discharge requirements

›Stable vitals

›Ambulates safely with plan

›No central signs on exam

›No dangerous cause found after appropriate testing

›Reliable supervision and follow up

Follow up timing

›Follow up

›Neurology within 1 to 2 weeks for unexplained ataxia

›Primary care within 3 to 7 days for medication review and fall risk

18Discharge Instructions/di28

Copy discharge instructions

›Summary

›You were seen for unsteadiness and trouble walking

›Testing today did not show an emergency cause that requires hospital treatment

›Safety

›Use a cane or walker if recommended

›Avoid driving until symptoms are gone

›Avoid alcohol and sedating medicines unless prescribed

›Medications

›Take medicines as prescribed

›If given nausea medicine, take only as directed

›Hydration and nutrition

›Drink fluids regularly

›Eat regular meals

›Follow up

›See your doctor within the recommended time

›Neurology follow up if arranged

›Return to ED now for

›New weakness

›New numbness

›Trouble speaking

›Trouble swallowing

›New double vision

›Severe headache

›Fever

›Fainting

›Chest pain

›Worsening inability to walk

›Repeated vomiting

19References/r7

Guidelines and key sources

›Reference set

›American Heart Association American Stroke Association guidelines for early management of acute ischemic stroke 2019 update

›American Heart Association American Stroke Association guideline for spontaneous intracerebral hemorrhage 2022

›Infectious Diseases Society of America guidelines for bacterial meningitis 2004

›Centers for Disease Control and Prevention clinical guidance for Wernicke encephalopathy and thiamine deficiency risk in alcohol use disorder local protocol dependent

›GRACE 3 guideline for acute dizziness and vertigo in the emergency department 2023

›Newman Toker acute vestibular syndrome bedside diagnosis evidence base HINTS validation studies 2009 to 2013

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.

Gait Instability and AtaxiaAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

584 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/hx69

Presenting pattern

›Symptom characterization

›Gait instability description

›Ataxia description

›Falls

›Near falls

›Assistive device requirement

OPQRST

›OPQRST framework

›Onset

›Sudden

›Subacute

›Progressive

›Provocation and palliation

›Worse with eyes closed

›Worse in the dark

›Worse with head movement

›Worse with standing

›Improves with support

›Improves sitting or lying

›Quality

›Unsteadiness

›Swaying

›Veering

›Leg clumsiness

›Truncal instability

›Region and radiation

›Truncal predominant

›Lower limb predominant

›Upper limb incoordination

›Severity

›Unable to ambulate

›Requires assistance to ambulate

›Falls frequency

›Timing

›Constant

›Episodic

›Fluctuating

›Stepwise

Associated neurologic symptoms

›Associated symptoms

›Vertigo

›Diplopia

›Dysarthria

›Dysphagia

›New headache

›Nausea

›Vomiting

›Limb weakness

›Limb numbness

›Vision loss

›New tremor

›Myoclonus

›Seizure

Context and triggers

›Precipitating context

›Recent infection

›Recent vaccination

›Recent head trauma

›Recent neck manipulation

›New rash

›Fever

›Heat exposure

Baseline and functional impact

›Baseline status

›Prior gait baseline

›Prior neurologic deficits

›Baseline mobility aids

›Baseline cognition

Prior episodes

›Prior episodes

›Similar episodes

›Prior stroke or TIA history

›Prior vertigo syndromes

›Prior intoxication episodes

02Alarm Features/alarm33

Immediate life threats

›Time critical diagnoses

›Posterior circulation ischemic stroke

›Cerebellar hemorrhage

›Subdural hematoma after fall

›Spinal cord compression

›Wernicke encephalopathy

›Toxic ingestion

High risk symptoms

›High risk symptoms

›Sudden onset inability to walk

›New severe headache

›Persistent vomiting

›Chest pain

›Syncope

›Acute confusion

›Seizure

High risk exam findings

›High risk findings

›New cranial nerve palsy

›Direction changing nystagmus

›Skew deviation

›New limb weakness

›New sensory level

›Hyperreflexia with clonus

›Fever with neck stiffness

Vital sign danger thresholds

›Vital sign danger

›Hypotension

›Hypoxia

›Fever 38.0 C or higher

›Severe hypertension with neurologic deficit

Escalation triggers

›Escalation logic

›If glucose low, immediate dextrose per protocol

›If unable to protect airway, airway management pathway

›If suspected stroke with disabling deficit, activate stroke pathway

›If suspected CNS infection, antibiotics after cultures when feasible

03Medications/meds30

Medication reconciliation

›Medication list

›Anticoagulants

›Antiplatelets

›Antihypertensives

›Antiepileptics

›Psychotropics

›Parkinson therapies

›Insulin and glucose agents

High risk medication effects

›Medication adverse effects

›Sedatives and hypnotics

›Opioids

›Anticholinergics

›Antipsychotics

›Antidepressants

›Anticonvulsants

›Lithium

Recent changes and adherence

›Recent changes

›Dose increase

›New start within 30 days

›Withdrawal within 14 days

›Missed doses

Toxin exposures

›Substances

›Alcohol

›Cannabis

›Stimulants

›Sedative misuse

Therapy interaction traps

›Interaction considerations

›Anticoagulation and head trauma risk

›QT prolonging combinations

›Serotonergic combinations

04Diet/diet16

Intake and nutrition

›Intake pattern

›Poor oral intake

›Prolonged vomiting

›Weight loss

›Malnutrition risk

Alcohol and thiamine risk

›Alcohol related nutrition risk

›Daily heavy alcohol use

›Recent binge

›Prolonged fasting

Hydration and electrolytes

›Hydration pattern

›Dehydration symptoms

›Excess free water intake

›Diuretic associated fluid shifts

Dietary triggers

›Trigger exposures

›Energy drinks

›Excess caffeine

05Review of Systems/ros27

Neurologic

›Neurologic ROS

›Headache

›Vertigo

›Visual symptoms

›Dysarthria

›Dysphagia

›Weakness

›Numbness

›Tremor

›Seizure

›Confusion

Infectious and inflammatory

›Constitutional ROS

›Fever

›Chills

›Night sweats

›Rash

›Neck pain

Cardiopulmonary

›Cardiopulmonary ROS

›Chest pain

›Palpitations

›Dyspnea

›Syncope

Endocrine and metabolic

›Metabolic ROS

›Polyuria

›Polydipsia

›Heat intolerance

›Cold intolerance

06Collateral History and Family History/chafh12

Collateral source

›Collateral reliability

›Witnessed gait change

›Witnessed fall or head strike

›Time last known well

Family history

›Inherited risk

›Hereditary ataxias

›Early stroke or thrombosis

›Migraine with brainstem aura history

Social support

›Home safety

›Lives alone

›Supervision available

›Fall hazards at home

07Risk Factors/rf24

Cerebrovascular risk

›Vascular risk

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Dyslipidemia (E78.5)

›Tobacco use

›Atrial fibrillation (I48.91)

›Prior stroke (I63.9)

Bleeding and trauma risk

›Hemorrhage risk

›Anticoagulant use

›Thrombocytopenia history

›Recent fall

Infection risk

›Infection risk

›Immunocompromised state

›Recent sinus or ear infection

›Endocarditis risk factors

Nutritional risk

›Deficiency risk

›Alcohol use disorder (F10.20)

›Bariatric surgery history

›Malabsorption history

Special populations

›Population modifiers

›Pregnancy

›Pediatrics

›Older adult frailty

›Chronic dialysis

08Differential Diagnosis/ddx77

Life threatening

›Life threatening causes

›Posterior circulation ischemic stroke (I63.9)

›Sudden onset

›Brainstem symptoms

›Cerebellar hemorrhage (I61.4)

›Severe headache

›Vomiting

›Subdural hematoma (S06.5)

›Fall or head strike

›Anticoagulant use

›CNS infection

›Meningitis (G00.9)

›Encephalitis (G04.90)

›Cerebellitis

›Spinal cord compression

›Epidural abscess (G06.1)

›Cauda equina syndrome (G83.4)

›Wernicke encephalopathy (E51.2)

›Malnutrition risk

›Oculomotor findings

›Severe hypoglycemia (E16.2)

›Diaphoresis

›Altered mental status

›Toxic alcohol or sedative intoxication

›Depressed level of consciousness

›Respiratory depression

Common

›Common causes

›Benign paroxysmal positional vertigo (H81.1)

›Brief positional episodes

›Triggered by head movement

›Vestibular neuritis (H81.2)

›Acute prolonged vertigo

›Unidirectional nystagmus

›Medication adverse effect

›Sedatives

›Anticonvulsants

›Alcohol intoxication (F10.129)

›Slurred speech

›Wide based gait

›Peripheral neuropathy (G62.9)

›Stocking sensory loss

›Worse in the dark

›Orthostatic hypotension (I95.1)

›Lightheadedness on standing

›Medication triggers

›Normal pressure hydrocephalus (G91.2)

›Gait apraxia pattern

›Cognitive symptoms

Less common

›Less common causes

›Multiple sclerosis (G35)

›Prior neurologic episodes

›Young adult onset

›Cerebellar tumor or mass effect (C71.6)

›Progressive symptoms

›Morning headache

›Paraneoplastic cerebellar degeneration

›Subacute progression

›Cancer history

›Thyroid disease

›Hypothyroidism (E03.9)

›Hyperthyroidism (E05.90)

›Vitamin B12 deficiency (E53.8)

›Posterior column signs

›Macrocytosis

›Miller Fisher syndrome variant (G61.0)

›Ophthalmoplegia

›Areflexia

Mimics and pitfalls

›Mimics

›Functional gait disorder

›Inconsistency

›Distractibility

›Severe anxiety with hyperventilation

›Perioral tingling

›Carpopedal spasm

›Musculoskeletal pain gait limitation

›Focal joint pain

›Normal coordination seated

09Past Medical History/pmh23

Neurologic history

›Neurologic conditions

›Prior stroke or TIA

›Seizure disorder (G40.909)

›Migraine (G43.909)

›Multiple sclerosis (G35)

›Parkinson disease (G20)

Cardiometabolic

›Vascular comorbidities

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Coronary artery disease (I25.10)

›Atrial fibrillation (I48.91)

Substance and nutrition

›Substance and nutrition history

›Alcohol use disorder (F10.20)

›Eating disorder history

›Bariatric surgery

Prior procedures and devices

›Procedures and devices

›Ventriculoperitoneal shunt

›Pacemaker or ICD

›Recent lumbar puncture

Baseline function

›Baseline function

›Independent ambulation

›Walker or cane baseline

›Prior falls frequency

10Physical Exam/exam46

General and vitals

›General status

›Mental status level

›Speech clarity

›Intoxication signs

›Trauma signs

›Vitals interpretation

›Fever

›Orthostatic change

›Hypoxia

Neurologic screening

›Key neuro exam

›NIHSS elements when stroke concern

›Cranial nerves

›Motor strength

›Sensory exam

›Reflexes

›Plantar response

Cerebellar exam

›Coordination

›Finger to nose

›Heel to shin

›Rapid alternating movements

›Dysmetria

›Intention tremor

Gait and balance

›Gait assessment

›Stance width

›Veering direction

›Tandem gait

›Romberg

›Turns and freezing

Oculomotor and vestibular

›Eye findings

›Nystagmus pattern

›Skew deviation

›Head impulse response

›Test of gaze holding

Cardiovascular

›Cardiovascular

›Murmur

›Irregularly irregular rhythm

›Signs of endocarditis

Spine and peripheral nerves

›Spine and neuroaxis

›Neck stiffness

›Back pain

›Sensory level

›Saddle anesthesia

›Peripheral neuropathy signs

›Vibration sense loss

›Proprioception loss

›Distal weakness

11Lab Studies/labs25

Core labs

›Initial labs

›Glucose point of care

›CBC

›Electrolytes

›Creatinine

›Liver enzymes

›Magnesium

›Phosphate

Stroke and hemorrhage adjuncts

›Coagulation and stroke adjuncts

›INR

›aPTT

›Troponin

›Lipids local protocol dependent

Toxic and metabolic

›Toxic metabolic evaluation

›Ethanol level

›Acetaminophen level when indicated

›Salicylate level when indicated

›VBG when respiratory depression concern

Nutritional and endocrine

›Deficiency endocrine evaluation

›Vitamin B12

›TSH

›Thiamine deficiency risk marker support

Infection evaluation

›Infection evaluation

›Blood cultures when febrile or endocarditis concern

›CRP or ESR when inflammatory concern

12Imaging/img47

Scoring Systems

›Clinical decision tools

›HINTS exam for acute vestibular syndrome

›Use when continuous vertigo with spontaneous nystagmus and gait unsteadiness

›Do not use when symptoms episodic or examiner not trained

›Central pattern triggers neuroimaging

›NIHSS for suspected stroke

›Baseline severity communication

›Does not exclude posterior circulation stroke

MRI

›MRI brain and neuroaxis

›Indications

›Suspected posterior fossa stroke with negative CT

›Demyelinating disease concern

›Cerebellar mass concern

›Protocol considerations

›DWI for acute ischemia

›Contrast for tumor or inflammation when indicated

›Limitations

›Early DWI false negative possible in posterior circulation

›Motion artifact in vomiting or agitation

›CT strategies

›Noncontrast CT head

›Indications

›Head trauma

›Anticoagulated patient with fall

›Thunderclap headache

›Strengths

›Hemorrhage detection

›Mass effect screening

›Limitations

›Low sensitivity for acute posterior fossa ischemia

›CTA head and neck

›Indications

›Suspected large vessel occlusion

›Suspected vertebral artery dissection

›Contrast cautions

›CKD risk stratification local protocol dependent

›Prior contrast reaction history

Ultrasound

›Ultrasound applications

›Cardiac POCUS

›Gross ventricular function

›Pericardial effusion

›Carotid duplex

›Anterior circulation symptoms correlation

›Limited value in isolated posterior circulation syndrome

›Ocular ultrasound when indicated

›Elevated optic nerve sheath diameter adjunct

›Not diagnostic alone

13Special Tests/spec24

Bedside vestibular testing

›Bedside tests

›HINTS components

›Head impulse

›Nystagmus direction

›Test of skew

›Dix Hallpike

›Use when episodic positional vertigo pattern

›Contraindications

›Suspected cervical instability

›Severe carotid stenosis history local protocol dependent

Lumbar puncture

›CSF evaluation

›Indications

›Suspected meningitis or encephalitis

›Suspected subarachnoid hemorrhage with negative CT and persistent concern

›Safety checks

›Coagulopathy correction

›Mass effect exclusion when indicated

Toxicology adjuncts

›Toxicology adjuncts

›Urine drug screen limited utility

›Serum osmolality and anion gap for toxic alcohol concern

Gait and functional testing

›Functional measures

›Timed up and go

›Sit to stand

›Physical therapy assessment when disposition uncertain

14ECG/ecg13

Indications and patterns

›ECG indications

›Syncope

›Palpitations

›Chest pain

›Stroke evaluation baseline

›High risk ECG findings

›Atrial fibrillation

›High grade AV block

›Ventricular tachyarrhythmia

›Acute ischemia pattern

Monitoring logic

›Rhythm monitoring

›Continuous monitoring when syncope or suspected arrhythmia

›Serial ECG when ongoing chest pain or ischemia concern

15Assessment/ax20

Problem representation

›Syndrome classification

›Acute vestibular syndrome

›Episodic positional vertigo syndrome

›Cerebellar ataxia syndrome

›Sensory ataxia syndrome

›Frontal gait disorder pattern

Severity and risk stratification

›Severity stratification

›Unable to ambulate

›New focal neurologic deficit

›Persistent vomiting with dehydration

›Recurrent falls

Complications to exclude

›Must exclude

›Intracranial hemorrhage after fall

›Posterior circulation stroke

›CNS infection

›Wernicke encephalopathy

Diagnostic uncertainty

›Alternate diagnoses

›Medication toxicity

›Metabolic derangement

›Functional disorder

16Plan/plan36

First 5 minutes

›Immediate stabilization

›Airway protection assessment

›Oxygen if hypoxic

›Cardiac monitor if syncope or arrhythmia concern

›IV access criteria

›Unable to tolerate oral intake

›Persistent vomiting

›Point of care glucose within minutes

Time critical pathways

›Activation pathways

›If disabling deficit and within reperfusion window, stroke activation per local protocol

›If suspected CNS infection, antibiotics within 60 minutes after cultures when feasible

Targeted therapy

›Directed treatments

›Suspected Wernicke risk

›Thiamine IV 500 mg every 8 hours initial dosing example

›Give thiamine before glucose when feasible

›Nausea and vomiting control

›Ondansetron ODT 4 mg once

›Ondansetron IV 4 mg once

›Suspected vestibular neuritis

›Short course steroids local protocol dependent

›Vestibular suppressants only short term

›Suspected BPPV

›Epley maneuver if Dix Hallpike consistent and no contraindications

Diagnostic sequencing

›Sequencing logic

›If fall with head strike or anticoagulated, CT head first

›If acute vestibular syndrome with central signs, MRI DWI preferred and CTA when vascular concern

›If fever and meningismus, imaging before LP when mass effect risk

Reassessment loop

›Reassessment

›Neuro exam repeat every 30 to 60 minutes when evolving symptoms

›Ambulation trial after symptom control

›Orthostatic vitals repeat after fluids when indicated

Consultation

›Consult triggers

›Neurology for suspected central cause

›Neurosurgery for hemorrhage or mass effect

›Internal medicine for metabolic or toxic causes requiring admission

›Physical therapy for gait safety planning

17Disposition/dispo27

ICU criteria

›ICU indications

›Declining mental status

›Airway risk

›Hemodynamic instability

›Large cerebellar stroke with edema risk

›Intracranial hemorrhage with mass effect

Inpatient admission criteria

›Admission indications

›Suspected stroke or TIA

›Suspected CNS infection

›Persistent inability to ambulate safely

›Recurrent falls with injury risk

›Severe metabolic derangement

›Concern for Wernicke encephalopathy requiring IV therapy

Observation pathway criteria

›Observation candidates

›Stable vitals

›No focal deficit after evaluation

›Symptom improvement with treatment

›Pending MRI or PT assessment

Discharge criteria

›Discharge requirements

›Stable vitals

›Ambulates safely with plan

›No central signs on exam

›No dangerous cause found after appropriate testing

›Reliable supervision and follow up

Follow up timing

›Follow up

›Neurology within 1 to 2 weeks for unexplained ataxia

›Primary care within 3 to 7 days for medication review and fall risk

18Discharge Instructions/di28

Copy discharge instructions

›Summary

›You were seen for unsteadiness and trouble walking

›Testing today did not show an emergency cause that requires hospital treatment

›Safety

›Use a cane or walker if recommended

›Avoid driving until symptoms are gone

›Avoid alcohol and sedating medicines unless prescribed

›Medications

›Take medicines as prescribed

›If given nausea medicine, take only as directed

›Hydration and nutrition

›Drink fluids regularly

›Eat regular meals

›Follow up

›See your doctor within the recommended time

›Neurology follow up if arranged

›Return to ED now for

›New weakness

›New numbness

›Trouble speaking

›Trouble swallowing

›New double vision

›Severe headache

›Fever

›Fainting

›Chest pain

›Worsening inability to walk

›Repeated vomiting

19References/r7

Guidelines and key sources

›Reference set

›American Heart Association American Stroke Association guidelines for early management of acute ischemic stroke 2019 update

›American Heart Association American Stroke Association guideline for spontaneous intracerebral hemorrhage 2022

›Infectious Diseases Society of America guidelines for bacterial meningitis 2004

›Centers for Disease Control and Prevention clinical guidance for Wernicke encephalopathy and thiamine deficiency risk in alcohol use disorder local protocol dependent

›GRACE 3 guideline for acute dizziness and vertigo in the emergency department 2023

›Newman Toker acute vestibular syndrome bedside diagnosis evidence base HINTS validation studies 2009 to 2013

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.