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Name
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David Doose
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DOB
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05/09/1966 (50 years)
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Occupation
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Chef
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History
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I have had trouble opening
the door and writing recently as my right hand feels very weak. My left arm
has been quite stiff and I can’t bend it properly. If asked specifically,
this is progressive and the right hand started first. This means I have had
to call in sick for two weeks now, and the restaurant business just cannot
run for longer without me. I want to know if I am going to die soon because I
have no energy and my wife thinks I am wasting away. Just look at me! I’ve
also noticed my muscles twitching, and am very anxious.
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Past Medical History
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Nil
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Drug History
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Paracetamol for stress
headaches
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Family History
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Adopted so unknown.
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Social History
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Non-smoker, drinks a few
times a week with his wife (a couple of glasses of wine with dinner), no
recreational drug use
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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 (tremor, weakness,
wasting, fasciculation, swallowing/speech problems, falls, neuro symptoms –
headaches, seizures, LOC, sphincter control, sensory changes, visual/speech
disturbances)
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Red flags: headache (worse on
coughing/bending/with vomiting), loss of consciousness, recent 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 (MND, bulbar palsy,
multiple sclerosis, MG) and appropriate follow up (full neurological
examination, bloods, nerve conduction tests)
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