Clinical Commander

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symptom.weakness.ed.v1

Acute weakness (ED workup — focal + generalized + fluctuating)

symptomacuteundifferentiatedadultacute
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym wave-9 expansion (2026-05-15) — pattern-matches symptom.chest_pain.ed_undifferentiated.v1 (be7b7d2f), symptom.gi_bleed.ed.v1 / symptom.altered_mental_status.ed.v1 (2ce6d299 wave-8). Engine scope: ED triage + risk-stratification + disposition for the adult acute weakness presentation, covering focal (stroke), generalized (GBS / myopathy / electrolyte), fluctuating (MG), descending (botulism), and cord-level (TM / cauda equina) phenotypes. Downstream confirmed diagnoses route to: neuro.ischaemic-stroke.v1, neuro.tia.v1, neuro.ich.core.v1, neuro.sah.core.v1, neuro.gbs.core.v1, neuro.mg-crisis.core.v1, neuro.transverse-myelitis.v1, syndrome.hyperkalemia.core.v1, syndrome.hyponatremia.core.v1, renal.aki.intrinsic.atn.v1. Bayesian linkage (LR+, LR−, T_treat, T_test, pre-test priors by pattern + age, NIHSS / ABCD2 / EGRIS thresholds) lives in companion depth bundle _briefs/symptom.weakness.ed.v1.depth.md — schema has no first-class likelihood-ratio field. 11 sibling-differentiation rows cover the key look-alikes (ischemic stroke / TIA / ICH / SAH / GBS / MG crisis / transverse myelitis / hyperkalemia / hyponatremia / rhabdo AKI / falls overlay). 15 severity triggers (≥10 per spec): focal_weakness_acute_stroke_window + large_vessel_occlusion + transient_ischemic_attack + gbs_ascending + myasthenic_crisis + cord_compression + transverse_myelitis + botulism + periodic_paralysis_channelopathy + rhabdomyolysis_aki + severe_hyponatremia + hypoglycemia_stroke_mimic + drug_induced_myopathy + critical_illness_neuropathy_myopathy + functional_neurologic_weakness. Calculators wired (3): calc.nihss (RISK_STRATIFICATION), calc.abcd2 (RISK_STRATIFICATION), calc.cha2ds2vasc (RISK_STRATIFICATION). EGRIS / MGFA class / Tomita / Tokuhashi — schema-blocked; ticketed in shard-3 state file. Schema-blocked: workup.weakness / workup.neuro_exam — NOT in clinical-tools-registry; manual application in setting playbook required_assessments + ticketed in shard-3 state file. Regimen_axes intentionally empty — engine is triage-only. Supportive drug actions (D50, alteplase/tenecteplase, labetalol/nicardipine, dexamethasone, IVIG/PLEX, pyridostigmine, HBAT, Ca/insulin/D50 for hyperK, KCl for hypoK, LR for rhabdo, methylprednisolone for TM) live in setting_playbooks.ed.drug_actions; definitive treatment is owned by downstream routed engines. Setting playbook: single `ed` per user spec — outpatient weakness workup (chronic myopathy, polyneuropathy) is a future engine. SCAFFOLDED status: no workup.weakness in clinical-tools-registry; PRODUCTION audit would fail. Will promote once registry entries land.

Entry points (13)

  • symptom
    Focal weakness (hemiparesis / monoparesis / facial droop / dysarthria) — stroke until proven otherwise (Powers AHA/ASA 2019 PMID 31662037; Saver NEJM 2019)
    focal_weakness
  • symptom
    Generalized symmetric weakness, often ascending — GBS / myopathy / electrolyte / botulism (van den Berg Brighton GBS PMID 24163275)
    generalized_weakness
  • symptom
    Fatigable / fluctuating weakness + ptosis / diplopia / dysphagia / dysarthria — myasthenic crisis (Sanders MGFA 2016 PMID 27358333)
    fluctuating_weakness_with_bulbar
  • symptom
    Episodic / periodic paralysis — channelopathies (hypokalemic, hyperkalemic, thyrotoxic) — K-based phenotype
    episodic_paralysis
  • symptom
    Descending weakness + dilated/fixed pupils + cranial nerves — botulism (Sobel CDC 2015 PMID 33956777)
    descending_weakness_with_cranial_nerves
  • symptom
    Bilateral weakness + sensory level + bladder/bowel dysfunction — cord compression / transverse myelitis STAT MRI (Greenberg AAN PMID 12236201)
    cord_level_weakness_with_sensory_level
  • symptom
    Bilateral leg weakness + saddle anesthesia + urinary retention — cauda equina syndrome STAT MRI (Greenhalgh Spine 2015)
    lower_extremity_weakness_with_saddle_anesthesia
  • lab_abnormality
    K <2.5 OR >6.5 with weakness — periodic paralysis OR hyperkalemic paralysis (Khan 2008)
    severe_potassium_derangement
  • lab_abnormality
    CK >5000 with myalgia/weakness — rhabdomyolysis → AKI risk (Bosch NEJM 2009 PMID 19571284)
    ck_above_5000
  • lab_abnormality
    Na <120 with weakness/AMS — severe hyponatremia route (syndrome.hyponatremia.core.v1)
    severe_hyponatremia_with_weakness
  • history
    Viral illness 1-3 wks prior then ascending weakness + areflexia — GBS (van den Berg 2014)
    recent_viral_illness_then_ascending_weakness
  • history
    Statin / colchicine / steroid use + proximal weakness — drug-induced myopathy (Stroes EAS 2015 PMID 25694464)
    statin_or_colchicine_use
  • history
    Known malignancy + back pain + leg weakness — epidural spinal cord compression STAT MRI + dexamethasone (Loblaw NEJM 2003)
    malignancy_with_back_pain_weakness

Required inputs (41)

  • agerequired
    demographic • used at CONTEXT
    Age shifts priors: stroke risk doubles each decade after 55; GBS bimodal (young + elderly); MG peaks 20s women, 60s men (Powers 2019; van den Berg 2014; Sanders 2016)
  • sexrequired
    demographic • used at CONTEXT
    MG women > men in young adulthood; periodic paralysis (thyrotoxic) Asian males; PPM > women for stroke until 75
  • weakness_distributionrequired
    symptom • used at FRAME
    Focal vs generalized vs proximal vs distal vs ascending vs descending vs fluctuating — anchors phenotype (Powers 2019; van den Berg 2014; Sanders 2016)
  • weakness_onset_timerequired
    symptom • used at FRAME
    Last-known-well + onset tempo (seconds-stroke; hours-cord; days-GBS; weeks-MG; sudden-recurrent-channelopathy) drives thrombolysis window + workup tempo (Powers 2019)
  • weakness_progressionrequired
    symptom • used at FRAME
    Static (stroke) vs progressive (GBS, cord) vs fluctuating (MG) vs episodic (channelopathy) — anchors mechanism
  • associated_facial_or_speech_findingsrequired
    symptom • used at ENTRY
    Facial droop + dysarthria + arm drift = FAST screen for stroke; bulbar findings (dysphagia, dysarthria, dysphonia) raise MG/GBS/botulism prior
  • associated_sensory_findingsrequired
    symptom • used at ENTRY
    Sensory level → cord; stocking-glove → polyneuropathy / GBS; cortical sensory loss → stroke; saddle anesthesia → cauda equina
  • associated_bowel_bladderrequired
    symptom • used at ENTRY
    Urinary retention + saddle anesthesia → cauda equina STAT; bladder dysfunction + sensory level → cord lesion
  • associated_diplopia_ptosisrequired
    symptom • used at ENTRY
    Diplopia + ptosis + fatigability → MG; fixed dilated pupils + descending → botulism
  • associated_back_painrequired
    symptom • used at ENTRY
    Back pain + leg weakness + sensory level → cord compression / cauda equina → route symptom.back_pain.ed.v1
  • associated_myalgia_dark_urinerequired
    symptom • used at ENTRY
    Myalgia + cola-colored urine + weakness → rhabdomyolysis (Bosch 2009 PMID 19571284)
  • recent_viral_illnessrequired
    symptom • used at ENTRY
    Viral illness 1-3 wks prior + ascending weakness + areflexia → GBS (Brighton criteria PMID 24163275)
  • recent_canned_food_wound
    symptom • used at ENTRY
    Canned/home-canned food OR wound + descending weakness + cranial nerves + dilated pupils → botulism (CDC PMID 33956777)
  • sbprequired
    vital • used at CONTEXT
    BP extremes drive stroke vs hypoperfusion; hypertensive urgency in stroke; orthostatic in hypoadrenalism / dehydration
  • hrrequired
    vital • used at CONTEXT
    Brady (channelopathy, hypothyroid, MG vagal); tachy (thyrotoxic paralysis, GBS dysautonomia)
  • rrrequired
    vital • used at CONTEXT
    Tachypnea early respiratory failure in GBS / MG crisis / botulism — pCO2 lags
  • spo2required
    vital • used at CONTEXT
    Hypoxia from neuromuscular respiratory failure (GBS, MG, botulism) — late finding (FVC drop precedes)
  • temprequired
    vital • used at CONTEXT
    Fever raises infection prior (transverse myelitis post-infectious; epidural abscess); hypothermia → severe hypothyroid
  • afib_or_cardio_embolic_sourcerequired
    history • used at CONTEXT
    AFib / mechanical valve / recent MI → cardioembolic stroke (CHA2DS2-VASc); raises stroke prior with focal deficit
  • htn_dm_smoking_dyslipidemiarequired
    history • used at CONTEXT
    Atherosclerotic vascular risk factors raise stroke prior; metabolic syndrome → small-vessel disease
  • prior_stroke_tiarequired
    history • used at CONTEXT
    Prior stroke/TIA → recurrence risk + ABCD2 prior; chronic deficits may mimic acute deficit
  • known_mg_or_myopathyrequired
    history • used at CONTEXT
    Known MG → crisis trigger search; known myopathy → exacerbation vs new disease
  • known_malignancy_metastasesrequired
    history • used at CONTEXT
    Known cancer + back pain + neuro deficit → epidural cord compression STAT MRI + dexamethasone
  • statin_colchicine_steroid_userequired
    history • used at CONTEXT
    Statin / colchicine / chronic steroid → drug-induced myopathy (Stroes EAS 2015 PMID 25694464)
  • anticoag_antiplatelet_userequired
    history • used at CONTEXT
    Anticoag/antiplatelet shifts hemorrhagic vs ischemic stroke prior; thrombolysis contraindication if recent anticoag
  • thyroid_diseaserequired
    history • used at CONTEXT
    Hyperthyroid → thyrotoxic periodic paralysis (Asian males) + storm myopathy; hypothyroid → myopathy + myxedema
  • recent_tick_exposure
    history • used at CONTEXT
    Tick attachment 4-7 days → tick paralysis (ascending) — remove tick + observe
  • recent_canned_food_or_wound
    history • used at CONTEXT
    Canned food / IV drug use → botulism (food / wound); descending + cranial nerves + autonomic
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis with infection (transverse myelitis, abscess); anemia in chronic disease
  • bmprequired
    lab • used at INITIAL_WORKUP
    K (periodic paralysis), Na (hyponatremia weakness/AMS), glucose (hypoglycemia stroke mimic), BUN/Cr (AKI in rhabdo)
  • ck_serumrequired
    lab • used at INITIAL_WORKUP
    CK >5000 → rhabdomyolysis; mild elevation in myopathy; high in MG crisis is rare
  • tsh_t4_freerequired
    lab • used at INITIAL_WORKUP
    Thyroid screen — hyper (thyrotoxic paralysis, storm myopathy), hypo (myopathy, myxedema)
  • troponin_hs
    lab • used at INITIAL_WORKUP
    Demand ischemia in stroke / severe weakness + CAD; cardio-embolic source workup
  • coags_inr_pttrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy → hemorrhagic stroke risk; thrombolysis contraindication if INR >1.7 (warfarin)
  • urinalysis_myoglobinrequired
    lab • used at INITIAL_WORKUP
    Heme-positive dipstick without RBCs → myoglobinuria → rhabdo
  • fingerstick_glucose_statrequired
    imaging • used at INITIAL_WORKUP
    STAT glucose — hypoglycemia is the #1 stroke mimic; ALWAYS check before thrombolysis
  • ct_head_noncontrast_strokerequired
    imaging • used at INITIAL_WORKUP
    NCCT — rule out hemorrhage before thrombolysis; ASPECTS score for LVO (Powers 2019 PMID 31662037)
  • cta_head_neck_for_lvo
    imaging • used at BRANCHING_WORKUP
    CTA head/neck — LVO detection within thrombectomy window (Saver NEJM 2019); collateral score
  • mri_spine_stat_cord_cauda
    imaging • used at BRANCHING_WORKUP
    STAT MRI spine with contrast if cord compression / cauda equina / transverse myelitis suspected (Greenberg 2015 PMID 12236201)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    AFib detection (cardio-embolic stroke); hyperkalemic peaked T-waves; hypokalemic U-waves; long QT in channelopathy
  • fvc_nif_bedside
    imaging • used at INITIAL_WORKUP
    Bedside FVC + NIF — falling FVC <20 mL/kg or NIF less negative than -30 cm H2O → intubation prep in GBS/MG/botulism

12-phase flow (12)

  1. 1FRAME
    Distribution (focal / generalized / proximal / distal / ascending / descending / fluctuating), onset tempo, progression — anchors phenotype (stroke / GBS / MG / cord / channelopathy / botulism / myopathy) (Powers 2019)
    inputs: weakness_distribution, weakness_onset_time, weakness_progression
    advance: pattern characterized + tempo anchored
  2. 2ENTRY
    Associated facial/speech, sensory level, bowel/bladder, diplopia/ptosis, back pain, myalgia/dark urine, recent viral illness, canned food/wound exposure
    inputs: associated_facial_or_speech_findings, associated_sensory_findings, associated_bowel_bladder, associated_diplopia_ptosis, associated_back_pain, associated_myalgia_dark_urine, recent_viral_illness
    advance: phenotype-defining features captured
  3. 3CONTEXT
    Age, sex, vitals, AFib/cardioembolic source, vascular risk factors, prior stroke/TIA, known MG/myopathy, malignancy, drug exposures (statin/colchicine/steroid), thyroid, tick/canned food (Powers 2019; van den Berg 2014; Sanders 2016)
    inputs: age, sex, sbp, hr, rr, spo2, temp, afib_or_cardio_embolic_source, htn_dm_smoking_dyslipidemia, prior_stroke_tia, known_mg_or_myopathy, known_malignancy_metastases, statin_colchicine_steroid_use, anticoag_antiplatelet_use, thyroid_disease
    advance: context complete
  4. 4RED_FLAGS
    Stroke (LVO, IV alteplase / thrombectomy window); cord compression / cauda equina (STAT MRI); myasthenic crisis / GBS with FVC<20; botulism (descending + cranial); severe hyperkalemia + paralysis; rhabdo with AKI; severe hyponatremia with weakness/AMS
    inputs: weakness_onset_time, associated_facial_or_speech_findings, associated_bowel_bladder, spo2, fvc_nif_bedside
    advance: no immediate life-threat OR emergent intervention activated
  5. 5INITIAL_WORKUP
    STAT glucose, NCCT head, ECG, CBC, BMP, CK, TSH, INR/PTT, troponin (selective), UA for myoglobin, bedside FVC/NIF if neuromuscular concern (Powers 2019; Bosch 2009)
    inputs: fingerstick_glucose_stat, ct_head_noncontrast_stroke, ecg_12_lead, cbc_with_diff, bmp, ck_serum, tsh_t4_free, coags_inr_ptt, urinalysis_myoglobin, fvc_nif_bedside
    actions: calc.nihss, panel.cbc, panel.renal, panel.thyroid, panel.coag, panel.cardiac
    advance: initial workup reviewed + phenotype narrowed
  6. 6BRANCHING_WORKUP
    Stroke: CTA head/neck for LVO + perfusion (DEFUSE-3 / DAWN extended window) → IV alteplase + endovascular. Cord/cauda: STAT MRI with contrast + dexamethasone. GBS: LP (albumin-cytologic dissociation) + NCS/EMG (subacute). MG: edrophonium/ice-pack (historical) → bedside FVC + AChR Ab + EMG repetitive nerve stim. Channelopathy: K trending + thyroid panel. Botulism: serum/stool toxin + antitoxin (CDC). Rhabdo: aggressive IVF
    inputs: cta_head_neck_for_lvo, mri_spine_stat_cord_cauda
    advance: definitive pathway selected
  7. 7DIFFERENTIAL
    Focal: ischemic stroke (LVO vs small vessel) ~75%, hemorrhagic stroke ~15%, mass/abscess ~5%, post-ictal (Todd) ~5%. Generalized: GBS (post-infectious ascending areflexic), MG crisis (fatigable + bulbar), botulism (descending + autonomic), channelopathy (recurrent), rhabdo, severe electrolyte derangement, hypoglycemia (stroke mimic), functional neurologic disorder, critical illness polyneuropathy in admitted/ICU patients. Cord: TM / cord compression (mass, abscess, hematoma), cauda equina
    advance: phenotype ranked with pre-test priors
  8. 8RISK_STRATIFICATION
    Stroke: NIHSS for severity + LVO suspicion (NIHSS ≥6 raises LVO prior); ABCD2 for TIA short-term stroke risk; CHA2DS2-VASc for stroke risk on AFib. GBS: Erasmus GBS Respiratory Insufficiency Score (EGRIS) for intubation risk. MG: MGFA class. Cord/cauda: Tomita/Tokuhashi for spine metastasis (out of scope here). Rhabdo: CK trend + AKI staging (KDIGO)
    actions: calc.nihss, calc.abcd2, calc.cha2ds2vasc
    advance: risk scores documented
  9. 9TREATMENT
    Stroke: IV alteplase ≤4.5 h (or tenecteplase) + endovascular thrombectomy for LVO ≤24 h (DEFUSE-3 / DAWN) + permissive BP <185/110 pre-tPA. ICH: reverse anticoag + BP control + neurosurgery consult. Cord/cauda: dexamethasone 10 mg IV bolus + STAT neurosurgery / radiation oncology. GBS: IVIG 0.4 g/kg/day × 5 days or PLEX; intubation if FVC<20. MG crisis: IVIG or PLEX + pyridostigmine + steroids; intubation if FVC<20 or NIF >-30. Botulism: equine antitoxin (HBAT for adults from CDC); supportive ventilation. Channelopathy: replete K (hypoK), kayexalate/insulin-D50/Ca-gluconate (hyperK). Rhabdo: aggressive IVF (LR 1.5-2 mL/kg/h) + correct electrolytes
    inputs: fingerstick_glucose_stat, ct_head_noncontrast_stroke, fvc_nif_bedside
    advance: definitive intervention initiated
  10. 10DISPOSITION
    Stroke: stroke unit / NSICU / endovascular suite. ICH: NSICU. Cord/cauda: OR or RT suite + admit. GBS / MG crisis / botulism: ICU. Hyperkalemic paralysis: monitored bed + telemetry. Rhabdo: admit for IVF until CK trending; ICU if AKI or hyperK. Hypoglycemia stroke mimic: observe + cause workup. Channelopathy: short stay + outpatient neuro
    advance: disposition assigned + downstream handoff complete
  11. 11MONITORING
    Stroke: NIHSS q1h × 24 h then q4h; BP q15 min post-tPA × 2 h; serial neuro exams. GBS/MG/botulism: FVC + NIF q2-4h; arrhythmia monitoring (dysautonomia); aspiration precautions. Rhabdo: CK q6h; BMP q4-6h until K + Cr stable. Cord: serial neuro + dexamethasone taper plan
    inputs: sbp, spo2, fvc_nif_bedside
    advance: stability achieved or escalation triggered
  12. 12FOLLOWUP
    Stroke: secondary prevention (antiplatelet OR anticoag for AFib, statin, BP control, dysphagia screen, rehab); dual-antiplatelet for high-risk TIA (CHANCE/POINT). GBS: outpatient neuro + rehab. MG: chronic immunosuppression + crisis prevention. Cord/cauda: spine surgery + radiation; rehab. Rhabdo: cause workup + electrolyte monitoring. Channelopathy: chronic K replacement + trigger avoidance
    advance: discharge bundle prescribed + follow-up scheduled