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Name
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Charlotte Coombs
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DOB
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03/04/1961 (64 years)
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Occupation
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Housewife
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History
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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.
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Past Medical History
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Hypertension
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Drug History
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Amlodipine, allergic to
peanuts
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Family History
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Mum has Alzheimer’s
disease, Dad died of an MI (70 years)
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Social History
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Non-smoker, drinks rarely –
at Christmas etc., no recreational drug use. Lives with spouse, has 2
children.
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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, bilateral)
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Previous episodes or recent illnesses
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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
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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 & withdrawal, 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 (Parkinson’s, LWBD, essential tremor, anxiety, MSA,
supranuclear palsy, hyperthyroidism) and appropriate follow up
(imaging, neurology clinic)
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