History and physical examination remain the key in evaluation of ataxia and gait disorders. If other symptoms or signs are present in addition to ataxia or gait disturbance, then the diagnostic approach might follow that clinical pathway. When the predominant complaint is ataxia or gait disturbance, determine whether ataxia is sensory or motor. Attempt to determine whether the primary process is systemic or within the nervous system. If within the nervous system, the next question is one of localization to the peripheral nervous system versus the CNS and perhaps to a more specific anatomic location. Finally, the tempo of the illness, comorbid diseases, and other clinical findings guide investigations and may allow a disease-specific diagnosis.
A patient with acute gait failure over hours to days needs thorough evaluation in the emergency department, consultation if available, and possible admission, in contrast to a patient with gradual loss of abilities over weeks or months, where outpatient referral and evaluation may be appropriate.
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