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Name
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Barbara Boss
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DOB
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30/03/1981 (35 years)
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Occupation
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Secretary
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History
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I have been feeling very
tired over the past month or so and it is making me miserable. I just feel
more and more worn out as the day progresses, with my arms getting weaker and
less able to get jobs done at work. I’m also finding it difficult to work at
my computer screen as my eyes feel very heavy and keep closing. I thought I
might be coming down with something as I’m also finding it difficult to
swallow my food. I don’t however have a sore throat or a high temperature.
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Past Medical History
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Nil
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Drug History
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OCP, NKDA
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Family History
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Dad had a heart attack at
74 years. Mum and younger brother have Type 1 DM.
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Social History
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Smokes 15-20/day (15
years), drinks a glass of red wine with dinner daily, no recreational drug
use. Single.
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Introduction and consent
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Name, age, occupation
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Presenting complaint
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History of Presenting Complaint (duration,
onset, any triggers, progression, worse at a specific time of the day)
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Previous episodes or recent illnesses
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Any associated features (sensory loss, lower
limb weakness, muscle twitching, breathing/swallowing difficulties, changes
in vision/speech, motor difficulties)
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Red flags: headache (worse on
coughing/bending/with vomiting), loss of consciousness, trauma
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Constitutional symptoms (fever, weight loss,
malaise, loss of appetite)
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Past Medical History
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Family History
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Drug History and allergies
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Social History (smoking, alcohol, drugs)
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Ideas e.g. “Was there anything you thought it
might be?”
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Concerns e.g. “What about it is worrying you
in particular?”
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Expectations e.g. “Is there anything in
particular you’re hoping we could do for you?”
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Summarises and thanks patient
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Offer differentials (MG, LEMS, MND, MS) and
appropriate follow up (motor examinations, nerve studies, tensilon test etc.)
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