By Aayushi Pandya (4th year Medical Student)
Name
Charlotte Coombs
DOB
03/04/1961 (64 years)
Occupation
Housewife
History
My husband wanted me to come in today because he was worried about me. I’ve had some difficulty moving around the house and I think I might have arthritis, as I feel quite stiff. My husband says I have become ‘slower’ but I am not too sure what he means. My main issue is that my hands keep shaking when I am relaxing, which is quite embarrassing as people, including my husband, ask me if I am anxious. I’ve noticed this for a few months now, but it seems to have gotten worse. It doesn’t seem to be an issue when I am trying to cook or do things around the house though.
Past Medical History
Hypertension
Drug History
Amlodipine, allergic to peanuts
Family History
Mum has Alzheimer’s disease, Dad died of an MI (70 years)
Social History
Non-smoker, drinks rarely – at Christmas etc., no recreational drug use. Lives with spouse, has 2 children.
Introduction and consent

Name, age, occupation

Presenting complaint

History of Presenting Complaint (duration, onset, any triggers, progression, worse at a specific time of the day, bilateral)

Previous episodes or recent illnesses

Any associated features (tremor, rigidity, bradykinesia, falls, sleep disturbance, smaller writing, hallucinations/memory problems, dizziness on standing up, falls/visual disturbance, loss of sensation/weakness/headaches), palpitations/heat intolerance

Red flags: headache (worse on coughing/bending/with vomiting), loss of consciousness, recent trauma

Constitutional symptoms (fever, weight loss, malaise, loss of appetite)

Past Medical History

Family History

Drug History and allergies

Social History (smoking, alcohol & withdrawal, drugs)

Ideas e.g. “Was there anything you thought it might be?”

Concerns e.g. “What about it is worrying you in particular?”

Expectations e.g. “Is there anything in particular you’re hoping we could do for you?”

Summarises and thanks patient

Offer differentials (Parkinson’s, LWBD, essential tremor, anxiety, MSA, supranuclear palsy, hyperthyroidism) and appropriate follow up (imaging, neurology clinic)