By Aayushi Pandya (4th year Medical Student)
Name
David Doose
DOB
05/09/1966 (50 years)
Occupation
Chef
History
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.
Past Medical History
Nil
Drug History
Paracetamol for stress headaches
Family History
Adopted so unknown.
Social History
Non-smoker, drinks a few times a week with his wife (a couple of glasses of wine with dinner), no recreational drug use
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)

Previous episodes or recent illnesses

Any associated features (tremor, weakness, wasting, fasciculation, swallowing/speech problems, falls, neuro symptoms – headaches, seizures, LOC, sphincter control, sensory changes, visual/speech disturbances)

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, 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 (MND, bulbar palsy, multiple sclerosis, MG) and appropriate follow up (full neurological examination, bloods, nerve conduction tests)