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